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Introduction
  • Most common orthopaedic injury with a bimodal distribution
    • younger patients - high energy
    • older patients - low energy / falls
  • 50% intra-articular
  • Associated injuries
    • DRUJ injuries must be evaluated 
    • radial styloid fx - indication of higher energy
    • soft tissue injuries in 70%
      • TFCC injury 40%
      • scapholunate ligament injury 30%
      • lunotriquetral ligament injury 15%
  • Osteoporosis
    • high incidence of distal radius fractures in women >50
    • distal radius fractures are a predictor of subsequent fractures
      • DEXA scan is recommended in woman with a distal radius fracture
Classification
  • Fernandez: based on mechanism of injury
  • Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx
  • Melone: divides intra-articular fxs into 4 types based on displacement
  • AO:  comprehensive but cumbersome
  • Eponyms: see table for list of commonly used eponyms
Eponyms
Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius
Barton's fx Fx 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
x
Colles' fx Low energy, dorsally displaced, extra-articular fx
Smith's fx Low energy, volar displaced, extra-articular fx
 
Imaging
  • Radiographs
View
Measurement
Normal
Acceptable criteria 
AP Radial height 13 mm <5 mm shortening 
  Radial inclination 23 degrees change <5° 
  Articular stepoff congruous <2 mm stepoff 
LAT Volar tilt 11 degrees dorsal angulation <5° or within 20° of contralateral distal radius 
  • CT scans
    • important to evaluate intra-articular involvement and for surgical planning
  • MRI useful to evaluate for soft tissue injury
    • TFCC injuries
    • scapholunate ligament injuries (DISI)
    • lunotriquetral injuries (VISI)
Treatment
  • Successful outcomes correlate with
    • accuracy of articular reduction
    • restoration of anatomic relationships
    • early efforts to regain motion of wrist and fingers
  • Nonoperative 
    • closed reduction and cast immobilization
      • indications
        • extra-articular
        • <5mm radial shortening
        • dorsal angulation <5° or within 20° of contralateral distal radius
      • technique (see below)
  • Operative
    • surgical fixation (CRPP, External Fixation, ORIF)
      • indications: radiographic findings indicating instability (pre-reduction radiographs best predictor of stability) 
        • displaced intra-articular fx
        • volar or dorsal comminution
        • articular margins fxs
        • severe osteoporosis
        • dorsal angulation >5° or >20° of contralateral distal radius
        • >5mm radial shortening
        • comminuted and displaced extra-articular fxs (Smith's fx)
        • progressive loss of volar tilt and loss of radial length following closed reduction and casting
        • associated ulnar styloid fractures do not require fixation 
Closed reduction and cast immobilization
  • Indications
    •  most extra-articular fxs
  • Technique
    • 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% less than satisfactory results
  • Complications
    • acute carpal tunnel syndrome
      • (see complications below)
    • EPL rupture
      • (see complications below) 
Percutaneous Pinning
  • Indications
    • can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex
    • cannot maintain length/alignment when unstable or comminuted volar cortex
  • Techniques
    • Kapandji intrafocal technique
    • Rayhack technique with arthroscopically assisted reduction
  • Outcomes
    • 82-90% good results if used appropriately
External Fixation
  • Indications
    • alone cannot reliably restore 10 degree palmar tilt
      • therefore usually combined with percutaneous pinning technique or plate fixation
  • Technical considerations
    • relies on ligamentotaxis to maintain reduction 
    • place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
    • nonspanning ex-fix can be useful if large articular fragment
    • 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
  • Outcomes
    • important adjunct with 80-90% good/excellent results
  • Complications
    • malunion/nonunion
    • stiffness and decreased grip strength
    • pin complications (infections, fx through pin site, skin difficulties)
      • pin site care comprising daily showers and dry dressings recommended 
    • neurologic (iatrogenic injury to radial sensory nervemedian neuropathy, RSD)
ORIF
  • Indications
    • significant articular displacement (>2mm)
    • dorsal and volar Barton fxs
    • volar comminution
    • metaphyseal-diaphyseal extension
    • associated distal ulnar shaft fxs
    • die-punch fxs
  • Technique
    • volar plating
      • volar plating preferred over dorsal plating
      • volar 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
      • new volar locking plates offer improved support to subchondral bone
    • dorsal plating
      • dorsal plating historically associated with extensor tendon irritation and rupture
      • dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal comminution  
    • other technical considerations
      • can combine with external fixation and PCP
      • bone grafting if complex and comminuted
      • study showed improved results with arthroscopically assisted reduction
      • volar lunate facet fragments may require fragment specific fixation to prevent early post-operative failure 
Complications
  • Median nerve neuropathy (CTS)
    • most frequent neurologic complication
    • 1-12% in low energy fxs and 30% in high energy fxs
    • prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder Position)
    • treat with acute carpal tunnel release for:
      • progressive paresthesias, weakness in thumb opposition  
      • paresthesias do not respond to reduction and last > 24-48 hours
  • Ulnar nerve neuropathy 
    • seen with DRUJ injuries
  • EPL rupture   
    • nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon  
      • extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
    • treat with transfer of extensor indicis proprius to EPL
  • Radiocarpal arthrosis (2-30%)
    • 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm
    • may be nonsymptomatic
  • Malunion and Nonunion
    • Intra-articular malunion
      • treat with revision at > 6 weeks
    • Extra-articular angulation malunion
      • treat with opening wedge osteotomy with ORIF and bone grafting
    • Radial shortening malunion
      • radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs
      • treat with ulnar shortening
  • ECU or EDM entrapment
    • entrapment in DRUJ injury
  • Compartment syndrome
  • RSD/CRPS
    • AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively 
 

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Technique Guides (4)
Questions (32)
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(OBQ10.127) A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. She complains of wrist pain and deformity. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Radiographs are provided in Figure A. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Which of the following interventions should be taken? Review Topic

QID: 3224
FIGURES:
1

Evaluation of volar compartment pressures with a needle monitor

3%

(39/1284)

2

Icing and elevation of the arm with follow-up evaluation in 8 hours

3%

(34/1284)

3

Immediate EMG evaluation of the left upper extremity

1%

(8/1284)

4

Closed reduction, carpal tunnel release, and sugar tong splinting

3%

(33/1284)

5

Emergent open reduction internal fixation with carpal tunnel release

90%

(1162/1284)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ12.244) A 65-year-old female sustains a fall onto her outstretched right hand. The injury is closed and she is neurovascularly intact. There is no median nerve paresthesias. Radiographs are shown in Figures A and B. What is the next best step in management of this patient? Review Topic

QID: 4604
FIGURES:
1

Admit for acute carpal tunnel syndrome monitoring

1%

(9/1186)

2

Admit for acute open reduction/internal fixation

2%

(19/1186)

3

Place into removable soft splint and follow-up in clinic

5%

(64/1186)

4

Place into rigid splint and follow-up in clinic

90%

(1063/1186)

5

Place into rigid splint and schedule for outpatient open reduction/internal fixation

2%

(28/1186)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(OBQ07.226) A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Review Topic

QID: 887
FIGURES:
1

Triangular fibrocartilage complex tear

7%

(34/506)

2

Open injury

1%

(3/506)

3

Ipsilateral radial head fracture

5%

(25/506)

4

Time to reduction

2%

(10/506)

5

Severity of initial displacement

85%

(432/506)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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(OBQ13.78) A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Radiographs of the affected wrist are shown in Figure A. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? Review Topic

QID: 4713
FIGURES:
1

Radioulnar ligaments of the TFCC

88%

(5060/5732)

2

Ulnar collateral ligament

1%

(74/5732)

3

Fracture fixation

2%

(135/5732)

4

Ulnolunate ligament of the TFCC

3%

(184/5732)

5

Ulnotriquetral ligament of the TFCC

4%

(251/5732)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ09.254) A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function? Review Topic

QID: 3067
1

Posterior interosseous nerve entrapment

8%

(42/556)

2

Extensor pollicis longus rupture

78%

(436/556)

3

Extensor pollicis longus entrapment

8%

(44/556)

4

Distal radius malunion

1%

(8/556)

5

Intersection syndrome

4%

(21/556)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.102) Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Review Topic

QID: 288
1

Non-displaced distal radius fracture

80%

(307/386)

2

Non-displaced Rolando fracture

7%

(26/386)

3

Second metacarpal base fracture

6%

(24/386)

4

Boxer's fracture

1%

(5/386)

5

Non-displaced radial styloid fracture

6%

(22/386)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ12.105) A 17-year-old male falls from a retaining wall onto his left arm. He sustains the injury shown in Figure A. The patient undergoes open reduction and internal fixation of the fracture. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. This medication is given in an effort to decrease the incidence of which of the following? Review Topic

QID: 4465
FIGURES:
1

Upper extremity deep vein thrombosis (DVT)

1%

(44/4387)

2

Acute carpal tunnel syndrome (ACTS)

2%

(95/4387)

3

Complex regional pain syndrome (CRPS)

92%

(4036/4387)

4

Lower extremity deep vein thrombosis (DVT)

0%

(19/4387)

5

Surgical site infection (SSI)

4%

(172/4387)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ12.38) A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. He undergoes operative treatment of his fracture, and immediate post-op radiographs are shown in Figure C. Two weeks later he presents with significantly increased pain and deformity. He denies any new trauma, and has followed all post-operative activity restrictions. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient? Review Topic

QID: 4398
FIGURES:
1

Failure to support the lunate facet with fragment specific fixation

75%

(2167/2895)

2

Use of a non-locking plate

6%

(183/2895)

3

Lack of volar tilt restoration

4%

(127/2895)

4

Lack of radial styloid column plating

7%

(206/2895)

5

Use of only three bicortical screws in the intact radial shaft proximally

6%

(185/2895)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ06.60) A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Review Topic

QID: 171
1

Greater grip strength at 6 months

12%

(53/446)

2

Less wrist pain at 1 year

1%

(6/446)

3

Better hand dexterity at 1 year

2%

(9/446)

4

No difference in functional outcomes

71%

(317/446)

5

Quicker return to work

12%

(54/446)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ08.179) A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. What is the most appropriate treatment at this time? Review Topic

QID: 565
1

Occupational therapy for strengthening

5%

(82/1737)

2

Extensor carpi radialis longus transfer to extensor pollicus longus

4%

(65/1737)

3

Extensor pollicis brevis transfer to extensor pollicus longus

2%

(41/1737)

4

Extensor indicis proprius transfer to extensor pollicus longus

77%

(1337/1737)

5

Primary repair of extensor pollicus longus

12%

(206/1737)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ04.233) A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. What is the appropriate surgical treatment at this time? Review Topic

QID: 1338
FIGURES:
1

Distal radius corrective osteotomy

92%

(418/456)

2

Total wrist arthrodesis

1%

(4/456)

3

Proximal row carpectomy

4%

(19/456)

4

Scaphoid excision and four corner fusion

2%

(9/456)

5

Interposition arthroplasty

0%

(2/456)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ11.273) A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Review Topic

QID: 3696
FIGURES:
1

Worse outcomes on the Mayo wrist score are expected without fixation

2%

(43/2386)

2

Chronic distal radioulnar joint instability can be expected to occur without fixation

2%

(59/2386)

3

Wrist function depends on the level of ulnar styloid fracture and initial displacement

12%

(297/2386)

4

Grip strength and wrist range of motion are improved with fixation

3%

(60/2386)

5

There is no adverse effect on wrist function or stability without fixation

80%

(1912/2386)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ07.8) Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? Review Topic

QID: 669
FIGURES:
1

Abductor Pollicis Longus

6%

(48/825)

2

Extensor Pollicis Brevis

9%

(73/825)

3

Extensor Indicis Proprius

18%

(145/825)

4

Flexor Pollicis Brevis

2%

(13/825)

5

Flexor Pollicis Longus

66%

(541/825)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ06.136) A 25-year-old female falls from her horse and injures her left wrist. There are no open wounds and the hand is neurovascularly intact. Radiographs are provided in Figures A-C. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Review Topic

QID: 322
FIGURES:
1

Long arm cast above the elbow for 6 weeks

0%

(1/452)

2

Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks

0%

(1/452)

3

Closed reduction and external fixation

2%

(8/452)

4

Closed reduction and percutaneous pinning

2%

(7/452)

5

Open reduction and internal fixation

96%

(434/452)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ05.195) A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time? Review Topic

QID: 1081
1

Strict elevation

6%

(107/1860)

2

Removal of hardware

1%

(22/1860)

3

Immediate carpal tunnel release

90%

(1676/1860)

4

Carpal tunnel release if no resolution at 6-12 weeks

2%

(40/1860)

5

Trial of night splinting

1%

(12/1860)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.25) A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Adequate maintenance of reduction by non-operative treatment is unsuccesful. Which plating option provides the most appropriate treatment of this fracture? Review Topic

QID: 62
1

semitubular

1%

(3/470)

2

dynamic compression

4%

(20/470)

3

limited-contact dynamic compression

5%

(22/470)

4

peri-articular locked

89%

(420/470)

5

pelvic reconstruction

0%

(1/470)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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