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  • Summary
    • Distal radius fractures are the most common orthopaedic injury and generally result from fall on an outstretched hand.
    • Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist
    • Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands 
  • Epidemiology
    • Incidence
      • accounts for 17.5% of all fractures in adults
    • Demographics
      • more common in females (2-3:1)
      • bimodal distribution
        • younger patients due to high energy mechanisms
        • older patients due to low energy mechanisms (i.e. FOOSH)
    • Anatomic location
      • 50% are intra-articular
    • Risk factors
      • osteoporosis
        • high incidence of distal radius fractures in women > 50 years old
        • distal radius fractures are a predictor of subsequent fractures
          • DEXA scan is recommended for women with distal radius fractures
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall on outstretched hand (FOOSH) is most common in older population
        • higher energy mechanism more common in younger patients
    • Associated conditions
      • radial styloid fractures
        • indicates higher energy mechanism
      • soft tissue injuries - seen in 70%
        • TFCC injury (40%)
        • scapholunate ligament injury (30%)
        • lunotriquetral ligament injury (15%)
  • Anatomy
    • Osteology
      • distal radius
        • responsible for 80% of axial load
        • articulates with
          • scaphoid
            • via scaphoid fossa
          • lunate
            • via lunate fossa
          • distal ulna
            • via ulnar/sigmoid notch
        • comprised of 3 columns
          • radial column
            • includes the radial styloid and scaphoid fossa
            • functions
              • attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament
              • serves as a buttress to resist radial carpal translation
              • functions as a load-bearing platform for activities performed with the wrist in ulnar deviation
              • holds the carpus out to length radially, allowing a more uniform distribution of load across the scaphoid and lunate facets
              • serves as an anchor for the radioscaphocapitate ligament that prevents ulnar translation of the carpus
          • intermediate column
            • lunate fossa
            • functions
              • transmits load from the carpus to the forearm
          • ulnar column
            • includes the TFCC and distal ulna
            • functions
              • stability of the DRUJ
              • forearm motion
    • Biomechanics
      • the distal radius is responsible for 80% of axial load at the wrist
  • Classification
    • Fernandez
      • based on mechanism of injury
    • Frykman
      • based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fracture
    • Melone
      • divides intra-articular fractures into 4 types based on displacement
    • AO
      • comprehensive but cumbersome
    • Eponyms
      • Eponyms
      • Die-punch fx
      • Depressed fracture of the lunate fossa of the articular surface of the distal radius
      • Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx)
      • Chauffer's fx
      • Radial styloid fx
      • Colles' fx
      • Low energy, dorsally displaced, extra-articular fx
      • Smith's fx
      • Low energy, volarly displaced, extra-articular fx
  • Presentation
    • History
      • usually a fall onto outstretched hand (FOOSH)
    • Symptoms
      • wrist pain 
      • wrist swelling
      • wrist deformity
    • Physical exam
      • inspection
        • ecchymosis & swelling
        • diffuse tenderness
        • visible deformity if displaced
      • motion
        • limited by pain
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • oblique
      • findings
      • Radiographic criteria
      • Measurement
      • Normal
      • Acceptable criteria
      • Radial height (AP)
      • 13mm
      • < 5mm shortening
      • Radial inclination (AP)
      • 23°
      • Change < 5°
      • Articular stepoff (AP)
      • Congruous
      • < 2 mm stepoff
      • Volar tilt (Lateral)
      • 11°
      • Dorsal angulation < 5° or within 20° of contralateral distal radius
    • CT
      • indications
        • evaluate intra-articular involvement
        • surgical planning
    • MRI
      • indications
        • evaluate for soft tissue injury
          • TFCC injuries
          • scapholunate ligament injuries (DISI)
          • lunotriquetral injuries (VISI)
  • Treatment
    • Nonoperative
      • closed reduction and immobilization
        • indications
          • extra-articular
          • < 5mm radial shortening
          • dorsal angulation < 5° or within 20° of contralateral distal radius
        • technique
          • immobilization can be in below arm cast or splint depending on fracture pattern
    • Operative
      • closed reduction percutaneous pinning (CRPP)
        • indications
          • extra-articular fracture with stable volar cortex
        • outcomes
          • 82-90% good results if used appropriately
      • open reduction internal fixation (ORIF)
        • indications
          • radiographic findings indicating instability (pre-reduction radiographs best predictor of stability)
          • dorsal angulation > 5° or > 20° of contralateral distal radius
          • volar or dorsal comminution
          • displaced intra-articular fractures > 2mm
          • radial shortening > 5mm
          • associated ulnar fracture
            • associated ulnar styloid fractures do not require fixation
          • severe osteoporosis
          • articular margin fractures (dorsal and volar Barton's fractures)
            • the volar ulnar corner (critical corner) supports the volar lunate facet with its strong radiolunate ligament attachments
            • failure to address this fragment can result in volar carpal subluxation
          • comminuted and displaced extra-articular fractures (Smith's fractures)
          • die-punch fractures
          • progressive loss of volar tilt and radial length following closed reduction and casting
      • external fixation (Exfix)
        • indications
          • open fractures
          • highly comminuted fractures
          • medically unstable patients unable to undergo a lengthy procedure
        • outcomes
          • important adjunct with 80-90% good/excellent results
          • alone cannot reliably restore 10° palmar tilt
            • therefore usually combined with percutaneous pinning technique or plate fixation
  • Techniques
    • Closed reduction and immobilization
      • technique
        • reduction
          • requires adequate anesthesia
          • apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment
        • immobilization
          • can be in below elbow cast or splint depending on fracture pattern and patient
          • avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position)
            • due to risk of carpal tunnel syndrome
        • rehabilitation
          • no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization
        • outcomes
          • repeat closed reductions have < 50% satisfactory results
          • LaFontaine predictors of instability
            • radial shortening is the most predictive of instability, followed by dorsal comminution
            • severe osteoporosis
            • associated ulnar fracture
            • dorsal comminution > 50%, palmar comminution, intraarticular comminution
            • dorsal angulation > 20°
            • initial displacement > 1cm
            • initial radial shortening > 5mm
          • higher loss of reduction with 3 or more of LaFontaine criteria
          • Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old)
        • complications specific to this treatment
          • acute carpal tunnel syndrome
          • EPL rupture
    • CRPP
      • technique
        • Kapandji intrafocal technique
          • K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius
        • Rayhack technique with arthroscopically assisted reduction
      • complications specific to this treatment
        • radial sensory nerve injury
        • pin tract infections
    • ORIF
      • technique guides
        • distal radius extra-articular fracture ORIF with volar approach
        • distal radius intra-articular fracture ORIF with dorsal approach
      • types
        • volar plating
          • preferred over dorsal plating
          • associated with irritation of both flexor and extensor tendons
            • rupture of FPL is most common with volar plates
              • associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons
          • can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius
          • new volar locking plates offer improved support to subchondral bone
        • dorsal plating
          • indicated for displaced intra-articular distal radius fractures with dorsal comminution, polytrauma patients, or elderly patients
          • can allow immediate post operative weight bearing (front wheel walker assistance)
          • avoids complications associated with wrist-spanning external fixators but similarly must be removed via second surgery
          • historically associated with extensor tendon irritation and rupture
      • technique
        • can combine with external fixation and percutaneous pinning
        • perform bone grafting if complex and comminuted
          • the utilization of calcium phosphate demonstrates radiographic evidence of successful incorporation into the host bone at 1 year postoperatively
          • calcium phosphate possesses osteoconductive and osteointegration capabilities allowing for incorporation into host bone 
        • study showed improved results with arthroscopically-assisted reduction
        • volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure
      • complications specific to this treatment
        • screw penetration into the radiocarpal joint or DRUJ
          • assess intra-articular screws with a 23 degree elevated lateral view
          • assess dorsal cortex penetration with a skyline view
        • tendon rupture
      • outcomes
        • no benefit of therapist-directed physical therapy compared to home exercise program 
    • External fixation
      • technique guides
        • distal radius fracture spanning external fixator
        • distal radius fracture non-spanning external fixator
      • types
        • spanning ex-fix
          • useful for fractures with small articular fragment
        • non-spanning ex-fix
          • useful for fractures with large articular fragment
      • technique
        • relies on ligamentotaxis to maintain reduction
        • place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
        • avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation
        • limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
      • complications specific to this treatment
        • malunion
        • nonunion
        • stiffness and decreased grip strength
        • pin complications (infections, fractures through pin site, skin difficulties)
          • pin site care comprising daily showers and dry dressings recommended
        • neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
  • Complications
    • Median nerve neuropathy (CTS)
      • incidence
        • most frequent neurologic complication
        • seen in 1-12% of low energy fxs and 30% of high energy fxs
      • risk factors
        • prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position)
      • treatment
        • acute carpal tunnel release
          • indications
            • progressive paresthesias, weakness in thumb opposition
            • paresthesias that do not respond to reduction and last > 24-48 hours
    • Ulnar nerve neuropathy
      • risk factors
        • DRUJ injury
    • EPL rupture
      • risk factors
        • nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon
          • extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon
        • volar plating with screw fixation that penetrates the dorsal cortex and is proud dorsally
      • treatment
        • EIP to EPL transfer
    • FPL rupture
      • risk factors
        • very distal volar plate placement on the radius (distal to watershed line) is associated with FPL rupture
          • due to physical contact of tendon on plate and subsequent tendinopathy
    • Radiocarpal arthrosis (2-30%)
      • incidence
        • 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2mm
      • may also be nonsymptomatic
    • Malunion/nonunion
      • intra-articular malunion
        • treatment
          • revision at > 6 weeks
      • extra-articular angulation malunion
        •  dorsal angulation > 10° from neutral results in increased stiffness of the interosseous membrane and limitation of simulated forearm pronation and supination 
        • treatment
          • opening wedge osteotomy with ORIF and bone grafting
          • delayed procedure associated with higher need for bone grafting and a more difficult procedure 
      • radial shortening malunion
        • radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures
        • treatment
          • ulnar shortening
    • ECU or EDM entrapment
      • risk factors
        • DRUJ injury
    • Compartment syndrome
    • RSD/CRPS
      • prevention
        • AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively
        • subsequent analyses show no benefit to vitamin C
        • strong evidence to suggest the efficacy of prompt physiotherapy, lidocaine, ketamine, bisphosphonates, sympathectomy and brachial plexus blocks
  • Prognosis
    • Poor functional outcomes associated with
      • worker's compensation
      • low socioeconomic status
      • low education levels
      • low bone density
    • Successful outcomes correlate with
      • accuracy of articular reduction
      • restoration of anatomic relationships
      • early efforts to regain motion of wrist and fingers
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