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 lifetime risk is 15% for women and 2% for men 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) login to view 1 more bullet Anatomic location Approximately 65% extra-articular, 10% partial articular, and 25% complete Risk factors osteoporosis high incidence of distal radius fractures in women > 50 years old distal radius fractures are a predictor of subsequent fractures login to view 1 more bullet Etiology Pathophysiology mechanism of injury fall on outstretched hand (FOOSH) from standing height is most common in older population higher energy mechanism more common in younger patients, particularly motor vehicle collisions Associated conditions DRUJ injuries 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 login to view 6 more bullets comprised of 3 columns login to view 21 more bullets Lister's Tubercle login to view 3 more bullets Watershed region login to view 3 more bullets 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 Name Description Illustration X-ray Die-punch fx Depressed fracture of the lunate fossa of the articular surface of the distal radius Volar Barton Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar lip Dorsal Barton Fracture-dislocation of radiocarpal joint with intra-articular fx involving the dorsal lip Chauffer's fx Transverse or oblique radial styloid fx Colles' fx Dorsally angulated, extra-articular fx Smith's fx Volarly angulated, 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 login to view 3 more bullets Treatment Nonoperative closed reduction and immobilization indications login to view 3 more bullets technique login to view 1 more bullet Operative closed reduction percutaneous pinning (CRPP) indications login to view 1 more bullet outcomes login to view 1 more bullet open reduction internal fixation (ORIF) indications login to view 14 more bullets external fixation (Exfix) indications login to view 3 more bullets outcomes login to view 3 more bullets Techniques Closed reduction and immobilization technique reduction login to view 2 more bullets immobilization login to view 3 more bullets rehabilitation login to view 1 more bullet outcomes login to view 11 more bullets complications specific to this treatment login to view 2 more bullets CRPP technique Kapandji intrafocal technique login to view 1 more bullet 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 login to view 6 more bullets dorsal plating login to view 4 more bullets technique can combine with external fixation and percutaneous pinning perform bone grafting if complex and comminuted login to view 2 more bullets 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 login to view 2 more bullets tendon rupture outcomes Formal hand therapy has been shown to improve DASH scores and active range of motion at 6 weeks but not at long term follow-up when compared to self-directed home exercise programs External fixation technique guides distal radius fracture spanning external fixator distal radius fracture non-spanning external fixator types spanning ex-fix login to view 1 more bullet non-spanning ex-fix login to view 1 more bullet 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) login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 2 more bullets radial shortening malunion radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures treatment login to view 1 more bullet 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