Distal Radius Fractures, for Surgeons

Note: this is an essay I wrote for eMedicine, according to their format. This version is longer, has more illustrations, has more hyperlinks, and is more complete than the edited on their site. This essay I continually update, and then use to update their version, when allowed to by eMedicine. They have updates on a periodic basis.

David L Nelson is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, California Orthopedic Association, Orthopaedic Research Society, and Western Orthopaedic Association.

Editors: A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas R Hunt III, MD, John D Sherrill Professor of Surgery, Director, Division of Orthopedic Surgery, Surgeon in Chief, UAB Upper Extremity Fellowship, UAB Highlands Hospital, University of Alabama at Birmingham School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine. (Note: these editors have not reviewed the revisions of this article made after August 28, 2007. Dr. Nelson is alone responsible for the content.)

Synonyms

Colles' fracture, Pouteau's fracture, Smith fracture, volar Barton's fracture, chauffeur's fracture, broken wrist.

Distal radius fractures (DRFs) in the time of Hippocrates and Galen were thought to be wrist dislocations. Pouteau first varied from this tradition when he described a variety of forearm fractures in the French literature, including a DRF. As a result, DRFs are termed Pouteau fractures in the French-speaking world. However, politics and communications being what they were, the English-speaking world did not recognize the description.

The Irish surgeon Abraham Colles (pronounced "Collis") described DRFs in the 1814 volume of the Edinburgh Medical Surgical Journal. Colles based his descriptions on clinical examinations alone, because radiography was invented by Roentgen in 1899 (his first image, by the way, was of a hand). Despite this limitation, his description of the fracture itself is quite accurate and his name is most often associated with this fracture in the English-speaking world. Colles stated "One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain..." This claim that all DRFs, despite displacement, fare well has been a source of criticism.

Over time, other eponyms have been added to the various subclassifications of DRFs, such as the Smith fracture, Barton fracture, and volar Barton fractures. The fractures are also referred to as various stages of classification systems, such as a Melone IV or an AO (ie, Arbeitsgemeinschaft für Osteosynthese, or Association for the Study of Osteosynthesis) C3 fracture, or are referred to the region of the fracture, such as a chauffeur's fracture.

In current practice, as a result of greater knowledge of the varieties of fracture configurations. Eponyms are best avoided and a direct description of the fracture is preferred. The term designation DRF properly covers all fractures of the distal articular and metaphyseal areas. Although all classification systems have serious problems, general agreement exists regarding what some of the classification terms mean, such as the Melone IV or AO C3 fracture, and they do add some degree of specificity and understanding to the generic designation DRF.

Problem

The ultimate goal of treatment is to restore the patient to his or her prior level of functioning. The goal, therefore, is not the same in all patients. For example, a 21-year-old athlete wants to resume competition, but an 82-year-old person usually only wants to return to activities of daily living (ADLs). Because the goals are different, the treatment options are different. As the population stays active longer, the definition of "prior level of functioning" is changing. For example, a 92-year-old patient who was being treated in the emergency department had only one concern when conversing with his physician: how soon could he return to playing golf (he had a tournament the next week). Treatment goals, therefore, must be tailored to each patient. Specifically, age should not determine the treatment; the activity level should determine the treatment.

Frequency

DRFs are among the most common type of fracture, and many authors state they are the most common type of fracture. DRFs have a bimodal distribution, with a peak in younger (aged 18-25 years) persons and a second peak in older (>65 years) persons. The mechanism of injury is unique to each group, with high-energy injuries being more common in the younger group and low-energy injuries being more common in the older group.

Etiology

Younger patients have stronger bone and require more energy to create a fracture. Motorcycle accidents, falls from a height, and similar situations are common causes for a DRF. Trauma is the leading cause of death in the 15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas.

Older patients have much weaker bones and can sustain a DRF from simply falling on an outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to these being termed fragility fractures, with the implication that a workup for osteoporosis should be a standard part of treatment. As the population lives longer, the frequency of this type of fracture will increase.

Pathophysiology

The pathophysiology of a fracture is rather obvious: more load is imparted than the bone can sustain. However, the patient should be questioned regarding the circumstances of the injury, especially older patients. Heart attacks or transient ischemic attacks can cause a DRF and should not be overlooked. In addition, more problems may be involved with the injury than just the fracture. A useful perspective is that a DRF is a soft tissue injury surrounding a broken bone, and the immediacy of the radiographic diagnosis should not distract the surgeon from carefully assessing systemic issues or forearm soft tissue issues.

Clinical

The history should be directed toward ascertaining the probable amount of energy involved. A fall from 20 feet can be associated with quite a different constellation of injuries (ie, more than just the fracture seen on the radiograph) compared with a fall from a standing position. A history of prior fractures should be sought. A history of fragility fractures helps predict the stability of any reduction. A history of multiple high-energy fractures in a younger patient helps predict the ability of the patient to comply with directions.

The median nerve is always compressed after a fall on the palmar aspect of the hand that results in a DRF, and the chart note should specifically document the quality (not just the presence or absence) of the median nerve function. Most treatments have median nerve implications. A cast or splint without a reduction may result in median nerve compromise due to pressure. A reduction, whether closed or open, involves some level of anesthesia, temporarily compromising the ability to assess the median nerve. Careful documentation of median nerve function at the first assessment is critical to planning and assessing treatment, not to mention protecting the surgeon from subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

Indications

Introduction

No consensus has been reached on classification systems, indications for surgery, or a particular choice of surgery since the orthopedic community first rejected Colles' contention that all DRFs heal well. Gartland and Werley are generally credited with starting the revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the discussion into the modern era with his 1986 paper that emphasized the importance of reduction.

Despite the number of papers published each year on DRFs (PubMed lists 1988 papers since 1959 and 40 papers in the English literature alone in the first 5 months of 2006.), no consensus has been reached on treatment and no indications are evident that a consensus might be developing. Indeed, with one approach advocating immediate motion using a fixed-angle volar plate and another advocating motion at 3 months using an internal joint-spanning plate, the treatment options seem to be diverging rather than converging.

One area of agreement is that fractures in active adults should be reduced anatomically; however, unfortunately, the term “anatomically” also has not had any consensus definition.

Even with classification, no consensus has been reached. The International Federation of Societies for Surgery of the Hand formed a working group of the most distinguished minds in DRF management to investigate for the existence of a consensus on the best classification system or, if one did not exist, to develop one. The group concluded no available system was universally useful or accepted and none could be developed by the working group. Please see the report How to Classify Distal Radial Fractures.
The consensus has been reached that the goal of treatment is to restore the patient to the prior level of functioning, and this is the starting point for all discussion.

Classification

The goals of any classification system are to stratify the injuries, guide treatment, facilitate discussion, and predict outcome. Each classification system has its merits and weaknesses with respect to each goal, and oftentimes more than one classification system is needed. Please see the report How to Classify Distal Radial Fractures.

The classification systems used most frequently are the Frykman, Melone, AO, and Fernandez systems. The Frykman classification highlights the injury to the distal radial ulnar radioulnar joint. The Melone classification, based on the paper by Scheck, highlights the fragmentation of the articular surface, especially the dorsoulnar corner of the distal radius. The AO classification emphasizes the location as extra-articular, partial articular, and completely articular. The Fernandez classification is based on the mechanism of injury, deduced from the displacement of the bone and the location of the fracture lines.

Another classification system that approaches the topic from another angle categories categorizes fracture patterns according to the 3-column concept of the wrist and proposes treatment accordingly. This approach was independently developed by Rob Medoff, MD, in 1994 (personal communication) and by Rikli and Rigazzoni (1996). The three columns are the lateral column (the radial half of the radius, including the radial styloid and the scaphoid facet; although Medoff differentiates these two), the central column (the ulnar half of the radius, including the lunate facet), the medial column (the ulna, TFC, and the DRUJ). (See Image 15) Each column is considered separately as to its need for reduction and stabilization. It should be noted that this conceptual approach does not exclude any other approach, but is complementary to them.

Indications for reduction and/or operative treatment

For more information, please see Indications for Reduction in Distal Radial Fractures.

The goal of treatment is to return the patient to his or her prior level of functioning. Most authors advocate an anatomic reduction. This admonition has 2 problems. First, not all patients need an anatomic reduction to be able to resume their normal activities. Second, the concept of anatomic reduction is not defined. No authorities advocate operative reduction if the stepoff is 0.5 mm; however, a stepoff of 0.5 mm is obviously not anatomic. On the other hand, a 20 degrees dorsal tilt is not anatomic, yet inactive elderly adults can easily return to their previous level of functioning with this alignment.

The indications for reduction or operative treatment need to be tailored to the individual patient. Also avoid erring in the opposite direction, that is, considering that any patient who is old does not require an anatomic reduction. Balanced judgment is required.

Most authors would recommend anatomic reduction in a patient who is active in recreation. Remember that golf and tennis are common activities for persons older than 70 y.) or engages in forceful activities at work. Conversely, if the patient is sedentary, a lesser reduction may allow full activities. Usually, 3 parameters are relevant: intra-articular stepoff, dorsal tilt, and radial length. Radial tilt is generally considered a lesser parameter.

Intra-articular stepoff

Defining anatomic reduction in terms of intra-articular stepoff is challenging. Most authors would accept less than 1 mm of intra-articular stepoff but not 2 mm, neutral dorsal tilt but not more than 10 degrees (the range is quite large in the literature, with some authors not accepting more than neutral), and 2 mm of radial shortening but not more than 5 mm. The challenge can be in making a reliable determination of these parameters, that is, how to distinguish between less than 1 mm and greater than 1 mm. Please see Indications for Reduction in Distal Radial Fractures for more information. The challenge is that these opinions are based on routine plain xrays, which cannot accurately measure stepoff at the 1 mm level.

The threshold of 1 mm for intra-articular displacement is commonly cited in the literature, referencing a 1986 landmark paper by Knirk and Jupiter. However, Jupiter has stated repeatedly that this threshold is not the benchmark that subsequent authors have tried to make it, that the 1986 study had methodological flaws, and that ligamentous injuries may better account for the functional limitations of the patients than the intra-articular stepoff. Surgeons need to review the literature with this in mind because it changes the reliability of the conclusions reached by many authors after 1986.

Dorsal tilt

Fewer comparative studies have been published on dorsal tilt, both basic science and clinical, but this has not limited authors from making pronouncements. The range of anatomical alignment for dorsal tilt has reportedly been from 0-10 degrees, with no proviso for less active patients. A neutral (0 degrees) alignment represents an 11degrees loss of volar angulation, so even the most conservative figure is not truly anatomic. Commonly, some older, inactive patients have full resumption of their activities with dorsal tilts of 45degrees or more. Although orthopedic surgeons may find the radiographs from these patients disturbing, and the clinical deformity not much better, some patients are quite satisfied and able to function in all of their ADLs, which calls into question any rigid threshold of dorsal tilt, whether it be 0 degrees or 10 degrees. Most authors recommend no more than neutral to 10 degrees of dorsal tilt in healthy, active individuals.

Radial length

The basic science of radial length is clear. Shortening of 2 mm of radial length doubles the load through the triangular fibrocartilage and the ulna. The clinical relevance of this fact in the context of DRFs is unclear. Additionally, altering the radius length relative to the ulna effects the function and forces associated with the distal radioulnar joint. Based on less well-defined clinical grounds, most authors would not accept more than 2-5 mm of shortening.

Stability of reduction

Another topic that has not been resolved is the stability of the reduction if performed in a closed procedure and without operative support to the fracture fragments. Some authors believe that a 30 degreesdorsal tilt or any radial shortening will not be stable and will subside. If function requires that reduction is achieved, surgery is needed to keep it.

Agreement has been reached that weekly radiographic assessment is required for approximately 3 weeks. Fractures do not commonly subside after 3 weeks, but this is not a certainty. Care must be observed to compare the current radiograph with the postreduction radiograph because subsidence is gradual and can be difficult to detect.

Images 3-7 show the volar, dorsal, radial, ulnar, and distal surfaces of the radius.


Fig 3: Volar View		Fig 4: Dorsal View
The large lunate facet is seen on the left, projecting out from the surface. The volar radial tuberosity is at the right margin of the bone. The surface is covered with the pronator quadratus (PQ). The cortical bone is quite thick and is strong, even in osteoporotic patients.		Lister's tubercle is seen in the center. This bone is a thin cortical shell, with little structural strength.

5 Ulnar View		6 Radial View
Note the sigmoid notch for articulating with the ulna.

7 Distal View
The scaphoid facet is to the right, and the lunate facet is to the left. This bone is the strongest of all the surfaces, and, even if it is osteoporotic, it is quite strong.


Fig 8: a normal posteroanterior radiograph. The ulna is generally within (plus or minus) 2 mm of the radius.	Fig 9: shows a normal lateral radiograph. Note that the center of the lunate facet overlies the volar surface of the bone.

Image 10 shows anatomic landmarks important for the volar approach to the radius.
Click on image for a larger view and a discussion of the terms.

Workup

Imaging Studies

Plain radiographs are all that is needed for most fractures.
CT scans are useful for evaluating the articular fracture lines and degree of comminution, and they are sometimes useful for planning the approach. Remember that plain films underestimate the number of fracture lines and CT scans overestimate the number of fracture lines. CT scans are necessary when planning intra-articular osteotomies for nascent malunions and mature malunions. Three-dimensional reconstructions may look impressive in presentations, but, to date, the resolution has not been very helpful in preoperative planning or postoperative assessment.

Diagnostic Procedures

Plain radiographs are the foundation of treatment. If the fracture is placed in traction as an early part of treatment, traction radiographs are very helpful. Often the fragments cannot be adequately identified or assessed on the injury films, and the traction views are the first radiographs that define the fragments. Final reduction films need to be evaluated for adequacy of reduction and for an assessment of stability, even though this is an area with no clear guidelines.
CT scans can be useful to assess the articular comminution. Importantly, however, note that plain films underestimate the number of fragments, while the CT scan overestimates them. Three-dimensional reconstructions are usually not useful.
The threshold for treatment, while not clearly defined, often involves assessing the displacement in terms of millimeters. Both plain films and CT scans have been evaluated for their accuracy at the 1-mm level. Neither modality can reliably be read at the 1-(NOTE DELETION OF THE HYPHEN)mm level, adding to the challenge of treating DRFs.

Treatment

Nonsurgical treatment

The goal is to return the patient to his or her prior level of functioning. The physician's role is to discuss the options with the patient, and the patient's role is to choose the option that best serves his or her needs and wishes. A recently developed approach to surgically treat stable fractures that are in acceptable alignment highlights this treatment paradigm. For a case discussion of this approach, see Radius Fracture with Immediate Return to Work.

Many DRFs can be treated nonoperatively. Fractures that are undisplaced or minimally displaced can be treated in a cast for 6 weeks. In most instances, unless the distal ulna is fractured and unstable (Type I and II ulna fractures are not usually unstable.), it can be treated in a short arm cast. Long arm casts are not required if the ulna is stable; additionally, these casts significantly disable the patient during the treatment of the fracture.

The definition of minimally displaced in the paragraph above is controversial and varies with age and activity level (see Indications).

The timing of followup xrays depends on the circumstances. In general, a follow-up xray needs to be done immediately after a reduction, to evaluate the reduction that was obtained, and to determine if further reductions should be done, if the alignment is acceptable or to determine if surgery is indicated. If the reduction is considered acceptable, further followup xrays are done at one week, two weeks, and three weeks, to carefully evaluate the reduction for subsidence. If there is subsidence, generally the fracture will continue to subside, often back to the original alignment, and a discussion regarding the indications for surgery in light of the present circumstances should be had with the patient. Further observation of a subsiding fracture will almost always result in further subsidence in the first three to four weeks, and this should be considered when evaluating the indications for surgery. It is important to compare the current xray with the immediate post-reduction xray, as the change from one week to the next can be subtle, and may be easier to detect if the comparison is made to the immediate post-reduction xray. If there is no subsidence at all by three weeks, further subsidence is unlikely (not impossible), and follow-up at six weeks post fracture is indicated.

If no reduction is performed and the original alignment is accepted, the follow-up xrays may be done at three weeks. While subsidence is unlikely, it is not impossible. A follow-up at three weeks will detect subsidence and a reduction can still be performed, although the fracture may likely be a nascent malunion and a slightly different surgical technique will be needed as compared to a fresh fracture. However, a frank osteotomy will not be needed.

Some fractures in elderly persons that are compressed dorsally can be minimally painful and can appear to be clinically stable. These may be treated with a splint only. This variant is somewhat rare.
Elderly, low-activity patients can have very high function and return to prior activities even with a significantly displaced fracture. A 45 degree dorsal tilt may be highly functional in a patient who drives, is active out of the home, but does no sports. They will have an unsightly wrist clinically (with a prominent ulnar head) that has limited supination and flexion, but in general they do not have symptoms with ADLs. Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.

Surgical therapy

Surgical treatment has been traditionally reserved for displaced, irreducible fractures or reducible but unstable fractures. One approach that is becoming more popular is to surgically treat patients who cannot or do not want to accept the constraints of cast treatment because of ADL, work, or recreational concerns.
No consensus has been reached as to which surgical treatment is best. Several options are available, each with its own variations.

Closed reduction and percutaneous pinning

Closed reduction and percutaneous pinning has been popular for many years and continues to be one of the most popular techniques internationally. The pinning can be of several varieties, including Clancey pinning (ie, 0.062-inch wires into the radial styloid and the dorsal ulnar corner of the radius, and crossing the fracture site; see Images 11-12) and Kapandji pinning (ie, wires or arum pins placed into the fracture site dorsally and used as levers to reduce the fracture and then to stabilize it).

External fixation

External fixation became the most popular treatment throughout much of the world in the decades after the development of a radius-specific fixator by Anderson in 1944. The proper technique of application of external fixators, however, was not defined until 1990 by Seitz. More than 25 brands of external fixators are now on the market, which is a testimony to the popularity of the technique. Small open incisions are used to avoid injuring the sensory branches of the radial nerve and to ensure central placement in the second metacarpal and the radial shaft. This technique currently continues to be one of the most popular techniques internationally.
Many variations of external fixation have been developed. One variation of fixator allowed early motion while the fixator is still in place. The concept was originated by Clyburn and popularized internationally by Pennig. The axis of motion of the fixator was placed over the center of motion of the wrist, thought to reside in the center of the head of the capitate. This approach has largely been abandoned because of theoretical criticisms and clinical experience. Theoretical criticisms are related to where the center of rotation is located, whether it is an instant center or a constant center, and whether or not it is possible to place the center of motion of the fixator reliably over the center of motion of the wrist. An additional practical consideration is the impossibility of having a center of motion of the fixator not coaxial with the center of the wrist.
Clinical studies also noted a decrease in final range of motion and an increase in complications related to the device; thus, early motion in external fixation has largely been abandoned. Some researchers are still investigating this technique, and it is still used clinically in some regions of the world.

Dorsal plating

Dorsal plating had its greatest popularity in the 1990s, with the development of plates specifically for the distal radius. The technique has lost most of its appeal for most fractures because of tendon irritation problems.

Fragment-specific fixation

Fragment-specific fixation, originated by Fernandez (called the “limited open approach” by Fernandez) and developed and popularized by Medoff, uses very small, low-profile plates that are specifically designed for the radial column, the central column, or the ulnar column of the radius. They lend themselves to many types of fractures, but learning the technique is difficult and many times the plates must be removed.

Nonspanning external fixation

Nonspanning external fixation was popularized by McQueen and capitalized on the strength of the subchondral bone and the volar cortex. While the proponents tout the possibility of early motion, others found that the range of motion was poor.

Volar plating

Volar plating, especially for dorsally unstable fractures, was independently developed by Orbay, Jennings, and Drobetz, but Orbay successfully developed a practical device, promoted it internationally, and was the first to publish information on it. Orbay is properly considered the grandfather of the technique. It is fairly new (1990), but is gaining in popularity; consequently, however, its complications are just now being becomming recognized.

Spanning internal fixation plates

Spanning internal fixation plates were originated by Becton and popularized by Ruch, and several companies make such plates. The screws are placed into the metacarpals and the midradial shaft, and the plates are removed at 3 months. This technique is very new and only a few series have been published.

Despite the many techniques and the large number of studies on DRFs, no consensus has been reached on the best surgical approach. Strong regional tendencies exist, such as volar plating in the United States, Kapandji pinning in France, and traditional external fixation in the United Kingdom and in Italy. In some regions (Japan, Germany), the plates are typically removed; however, in others (United States), they are rarely removed.

Intraoperative details

Percutaneous pinning (Clancey technique)

After adequate anesthesia is established, prepare the skin. Many surgeons find that placing the fingers in finger-trap traction assists with reduction. Reduce the fracture, and place a 0.062-inch Kirschner wire into the radial styloid. Using image intensification, drive the Kirschner wire across the fracture site and into (but not through) the opposite cortex. Pin migration can be limited by not going through the opposite cortex, but the pin must be securely in the cortex to maintain the reduction. The second pin is placed into the dorsal ulnar corner of the radius. Under image intensification, drive the pin across the fracture site and into the opposite cortex. Additional pins can be placed if needed for stability.

Percutaneous pinning (Kapandji technique)

Prepare as above, but place the pins into the fracture site dorsally, lever the distal fragment into place with the pin, observing the reduction with image intensification, and then drive it into the volar cortex. Usually, more than one pin is used. Kapandji has developed special pins called arum pins for this purpose.

Volar plating

The skin incision is directly over the flexor carpi radialis (FCR) tendon. The incision should be approximately 10 cm long and does not need to cross the wrist crease. Mobilize the FCR tendon radially and incise the floor of the FCR tendon sheath. Distally, be aware that the course of the branch from the radial artery to the superficial palmar arch is variable and can cross the FCR tendon. Divide the septum between the FCR tendon and the flexor pollicis longus tendon distal to the wrist crease. This avoids making a skin incision distal to the wrist crease. If, subsequently, the distal portion of the surgical field cannot be visualized adequately, release this septum further. Release the muscular fibers of the flexor pollicis longus originating from the shaft of the ulna or the septum between the radius and the first dorsal compartment. The PQ is seen, often with a tear in its fascia where the shaft has displaced and torn it at the moment of fracture.
Release the PQ just 1-2 mm distal to the line marked by the distal end of the muscular fibers and the proximal end of the fibrous tissue that continues distally to become the wrist joint capsule. This line is called the PQ line. Release the PQ radially 1-2 mm beyond the radial margin of the muscular fibers of the PQ by including a small margin of fibrous tissue from the septum of the first dorsal compartment. The fibrous rim, distally and radially, allows a secure repair of the PQ and protects the tendons from the plate. Reflect the PQ and release the brachioradialis (BR). Clear the fat from the volar wrist capsule.
The 2 different approaches at this point are to either (1) reduce the fracture and place the plate or (2) partially reduce the fracture, place the distal row(s) of screws, and then use the plate to obtain the final few degrees of volar tilt.
If unreduced intra-articular comminution is noted, a different approach is required. Release the BR, if not released previously. Release the first dorsal compartment from the radius, and pronate the radius shaft away from the articular fragments. Using the carpus as a template, reduce the intra-articular fragments, pin and/or bone graft as necessary, and then supinate the radial shaft and continue as above.

Document the reduction using the facet lateral and facet PA views with the mini C-arm and with fluoroscopic views in the facet manner, aligning the view with the joint surface, not the clinical position of the forearm.
Be careful to assess the position of the tip of each distal screw. The radial styloid screw may be either in the joint or outside the radial cortex radially. The distal screws should not extend beyond the dorsal cortex and, indeed, probably should be 2 mm short of the dorsal cortex. The dorsal cortex is very thin and usually comminuted; therefore, it provides no increase in fixation security. Past-pointing of even 1 mm can shred a dorsal tendon if it is precisely in the wrong place. Carefully check for past-pointing.
Close the PQ securely with interrupted sutures. No intermediate closure is needed. Close the skin.

External fixation

The key to external fixation is placing the pins through small, open incisions. Blind percutaneous placement or placement through small stab incisions increases the rate of nerve and tendon injury and makes it easier to create open section defects and off-center placements into the bones. Proximally, the plane of dissection should be dorsolateral, not straight lateral, through the extensor carpi radialis longus and brevis or through the extensor carpi radialis brevis and the extensor digitorum communis. This avoids placing the pins near the radial sensory nerve and injuring it upon pin insertion or removal or subjecting it to the minor cellulitis of the pin tract.

Postoperative details

Postoperative management varies.
Most casts are kept on for 6 weeks, but some compressed fractures require only a splint. Most external fixators are kept in place for 6 weeks, but 8 weeks is also common and some fractures that are not bone grafted still collapse at 3 months. Volar fixed-angle plates are moved anywhere from 3 days to 3 weeks. Spanning internal fixation plates are usually removed at 3 months, and therapy is initiated at that time. It is difficult to make useful generalizations.

Discussing the postoperative hand therapy with the patient and arranging the appropriate appointments prior to surgery is advantageous, including obtaining required authorization. Otherwise, the full benefits of the procedure may be lost because of paperwork issues.

Follow-up

Fractures treated with a cast require close follow-up to observe for subsidence. Although fractures that have been reduced are the most at risk, even fractures that were accepted and not reduced can still subside further and require reassessment. The general rule for fractures that were reduced is to obtain a radiograph at weekly intervals for the first 3 weeks, being careful to compare the current film with the original reduction film. Minor degrees of subsidence may not be evident if compared with the most recent film. Instability and the likelihood of further subsidence is demonstrated by any loss of the original reduction. A common error is to accept the minor increase in loss of reduction at each week, expecting that the subsidence will cease, and then discovering at 3 or more weeks that the current alignment is unacceptable after the fracture has healed and is not reducible by closed means.

Fractures stabilized operatively should be followed at 7-10 days, as the surgeon prefers. Subsidence should not be an issue.

Complications

DRFs heal quickly. Nonunion is usually not an issue; malunion before or after treatment is initiated is the most common problem. Careful attention to follow-up radiographs helps avoid this problem.

Each operative treatment has its own complications.

Percutaneous pinning has 2 principle areas of complications, which include insertion problems (injury to the radial sensory nerve) and late problems (infected pin sites). The former can be mitigated by limiting the number of times a pin is placed, the later by appropriate pin care. While no consensus has been reached on appropriate pin care, most agree that the pin site should be kept clean and that showering helps in this endeavor. Early oral antibiotic therapy is usually successful for controlling pin site problems, and, if not, prompt pin removal usually cures the problem. Osteomyelitis is rare ( <1%).

External fixation has 2 largely similar areas of complications, which include insertion problems (injury to the radial sensory nerve, tendon injuries, open section defects in the bone) and late problems (infected pin sites). Insertion problems were addressed in a landmark paper by Seitz in 1990, in which he advocated open pin placement. Insertion problems with this technique should be rare. Pin problems are avoided and treated as above.

Dorsal plate complications are primarily related to the close apposition of the extensor tendons to the bone. While many plates claim to be low profile to avoid this problem, 2-mm plates in a 1-mm space are still too large and may cause tendon irritation. Tendon rupture is also a potential problem likely related to specific plate design or application and perhaps influenced by the composition of the fixation device. Many authors routinely remove their plates (in countries that do not routinely remove plates; see below). At present, the dorsal approach has largely been relegated to fractures that can only be addressed by a dorsal approach.

Volar plate complications are only now becoming identified (see this essay), and they can be classified as dorsal or volar problems. Dorsal problems are related to past-pointing (screw tips extending beyond the bone) of the distal screws. Most orthopedic screws are designed with cutting flutes at the tip, and optimum bicortical purchase requires approximately a screw diameter of past-pointing. However, due to the design of most volar fixation systems in which the screws lock to the plate, the dorsal cortex does not offer additional fixation. Additionally the dorsal cortex is thin and often comminuted. Secure fixation comes from the plate and the subchondral bone. Any past-pointing of the distal screws endangers the extensor tendons, which are in close apposition to the bone. For a case example, see this case on eRadius.

Volar problems with volar plates come from contact of the tendons with the plates, particularly with titanium plates. This can be due to poor plate design (extension distal to the PQ, out over the volar capsule; or excessive thickness at the distal margin of the plate such that it extends volar to the PQ) or loss of reduction, such that the flexor tendons are forced to use the plate as a fulcrum.

Spanning plates require a second surgical procedure for plate removal. While not a complication per se, because it is planned, it is a downside to the procedure that is not common to the other techniques.

Outcome And Prognosis

In spite of the number of unresolved controversies, most patients are able to resume their previous level of activity, including competitive sports. While many cases are described in which the return to function was not limited by malunion or complications, patients are, in general, living longer and continuing to be active longer than in previous generations. This places demands on the distal radius that have not been seen previously, and, despite apparently good quality care, some patients are not able to resume their previous level of functioning.

All treatment approaches have a percentage of poor results, with decreased supination, prominent ulnar heads, ligamentous problems, distal radioulnar problems (usually instability), or degenerative joint disease being common problems. These are the cases that prompt researchers to continue to refine the techniques and devices.

Patients, however, want more concrete prognostic statements. Most patients treated with a volar fixed-angle plate can resume nonforceful ADLs within 3 days to 2 weeks. Patients treated with a cast have the cast removed at 6 weeks and can then start ADLs. Grip strengthening can often be started at 2 months after any type of treatment, but forceful use of the hand should be delayed for 3 months. Contact sports or activities in which the likelihood of falling on an outstretched hand is high should be delayed for approximately 4 months. These are just general guidelines, and great variation exists among specific cases and specific physicians.

The long-term prognosis for a properly treated DRF is good, even with an intra-articular fracture. Osteoarthritis is rare if the articular surface is not comminuted and is able to be reconstructed. Wrist range of motion will continue to increase and wrist tenderness with forceful use will continue to decrease even beyond 2 years.

Future And Controversies

The field of DRFs has always been an area of intense research and innovation. It has changed more rapidly in the last 5 years than in any previous 2 decades. While percutaneous pinning and external fixation remain the mainstays of treatment throughout much of the world, with strong and somewhat idiosyncratic national trends due to the prominence of individual surgeons in those countries, volar fixed-angle plating has become popular and dramatically shifted the landscape in several ways.
For many surgeons, the volar approach for dorsally unstable DRFs, using fixed-angle devices, is the main treatment option. Orbay has popularized this treatment and broadened its applicability to highly comminuted intra-articular fractures with the extended FCR approach, pronating the radial shaft out of the way and looking directly at the undersurface of the articular bone. The low rate of complications and postoperative pain, the quality of the results, and the rapid return to activities has, for some surgeons, shifted the balance of risks to benefits such that they are offering patients the option of surgery versus a cast for stable undisplaced or stable reducible fractures. See Radius Fracture with Immediate Return to Work.

Volar fixed-angle plates have been used widely for approximately 6 years, and the rate of complications for this technique is not yet defined. The author has found 43 cases of tendon injury or rupture, but most cases seem to be due to failure to follow proper technique. One aspect of technique is to avoid any past-pointing of distal screws and, preferably, placing their tips 2-4 mm short of the dorsal cortex. A second important technique is to use a plate that does not extend distally as far as the volar wrist capsule and to completely and securely cover it with the PQ.

Arthroscopy continues to be a controversial adjunct to the management of intra-articular fractures. While rate of unrecognized scapholunate, lunotriquetral, and triangular fibrocartilage tears in DRF has been shown to be greater than 60%, the role of arthroscopy continues to be controversial because of a lack of any outcome studies that have demonstrated improved results.

Question 1:

What is the most important aspect of treating distal radius fractures?
A. Proper classification of the fracture
B. Treatment decision making
C. Whether to approach the fracture dorsally or volarly
D. Choosing the optimal device for the fracture
E. Close follow-up

The correct answer is B: Treatment decision making is key to excellent outcomes. A bad treatment decision can sometimes be remedied by close follow-up (eg, if the fracture subsides when the treating physician thought it would not, when hardware that initially seems well-placed is in the joint or loose), but it can never be remedied by implanting the latest and greatest hardware. Classification systems help to understand the personality of the fracture, but the decision-making process is still key because classification probably will not define the proper treatment or determine if the fracture is stable. A great surgeon could probably treat any fracture in more than 5 ways (eg, pins, external fixation, dorsal plate, volar plate, fragment specific) and have a good result, but a poor decision initially can be hard to amend. Despite all the emphasis on brands of devices, this is the least important.

Question 2:

A 45-year-old woman falls on an outstretched hand and sustains a distal radial fracture (DRF). Upon assessment, the alignment is 10° dorsally tilted. Minimal dorsal comminution is present and no intra-articular involvement is noted. She is an active person, but does not play competitive sports such as tennis or golf. Which of the following is false regarding treatment for this fracture?
A. This is an unacceptable degree of dorsal tilt and needs reduction.
B. This fracture is unstable, will subside, and requires fixation. The choice of fixation (eg, pins, external fixation, plate) should be left up to the surgeon.
C. Cast treatment generally produces excellent results, and operative treatment should not be discussed.
D. Closed reduction with cast treatment and weekly follow-up for 3 weeks is the least invasive, the least risky, and works the best; the possibility of operative complications exclude other, more invasive treatments.
E. None of the above is fully correct.

The correct answer is E: All of the options, while true to some extent, are too dogmatic. DRFs do not invite absolute standards of care. A 10° dorsal tilt, while at many surgeons' upper limit of acceptability, generally is functional in a 45-year-old person who does not play competitive sports. However, successful athletic performance has been witnessed in persons with 20° of dorsal tilt, and 10° of tilt would only rarely affect performance. Many 10° dorsally tilted fractures in someone as young as 45 years and without comminution are quite stable. However, not all are, and often some degree of comminution is missed in the emergency department radiographs.

If surgery is chosen, the patient should hear more than one option because no single choice of technique is absolutely correct. Cast treatment of this type of DRF generally produces excellent results, but the choice should be up to the patient, not the physician.

This patient may not be able to function in a cast for 6 weeks (eg, because of a demanding job or the need to care for a sick spouse) and the surgical options, including risks and benefits, need to be discussed. The clinical interaction should be about what serves the patient`s best interest, not about what the surgeon would do if it were his or her arm. A plan for weekly follow-up visits for 3 weeks is wise, and indeed needed if a reduction is performed. However, operative complications are rare enough that surgery should not be excluded.

The patient needs to hear the options, risks, benefits, and possible outcomes and then make the choice. The options for the treatment of distal radius fractures are so varied, each supported by good clinical series, and the controversies among surgeons so plentiful, being dogmatic about treatment options is a mistake. The surgeon needs to be skilled in more than one technique, and patient choice is never more important when several options exist for treatment.

Question 1 (T/F):
Percutaneous pins should all be buried under the skin to avoid the complication of infection.

The correct answer is False: No clear consensus (ie, pins buried vs pins left long) has been reached, only recognized advantages and disadvantages, which need to be discussed with the patient and which the surgeon must clearly recognize. Pin infections with current treatment regimens are rare, pins can often be removed without subsidence, and the buried pins are often painful and more difficult to remove. Pins left long have a higher incidence of infection or irritation, are a psychological burden for many patients, and prompt many calls to the doctor regarding site status or accidental pin removal. Do not be dogmatic and do not make the decision because of a recently experienced complication in another patient.

Question 2 (T/F):

If a fracture is not reduced, it is stable and requires less follow-up than a fracture that is reduced.

The correct answer is False: While it is true that a fracture that is not reduced is more stable than one that has been manipulated, they both still need weekly follow-up for 3 weeks. Many fractures that do not have appreciable comminution are not reduced, yet they may subside over the ensuing 3 weeks. Close follow-up is needed for both the more frequent former situation and the less frequent latter situation.

Question 3 (T/F):

Distal radial fractures are healed at 6 weeks and full recovery is by 6 months.

The correct answer is False: While most fractures are healed by 6 weeks, some are not. Fractures that are reduced and have a void require more time to heal, and all dorsally plated fractures have had the healing cascade interrupted and heal more slowly. In addition, patients continue to improve in range of motion and wrist discomfort for at least 2 years, and many patients continue to improve for several years thereafter. For this reason, most medical journals will not accept a study for publication with less than 2 years follow-up after a distal radius fracture.

Question 4 (T/F):

The most humbling and most instructive exercise a surgeon can do is to retrospectively review his or her own series.

The correct answer is True: Most surgeons believe they are highly proficient at their task, and probably most are proficient; however, it is human nature to remember personal victories and forget the failures. No exercise is more humbling than to review personal cases after a few years, and none is more instructive nor more helpful to the next patient who walks through the office door.

MULTIMEDIA (This section is part of eMedicine and is retained to make up-dating their webpage easier; it is not relevant to my page or to you if you are reading this on any of my websites- Dr. Nelson.)
Media file 1: Posteroanterior radiograph demonstrating the typical features of a common distal radius fracture: loss of radial length, loss of radial tilt, and comminution at the fracture line.

Media file 2: Lateral radiograph demonstrating the other common features (also see Image 1) of a distal radial fracture: loss of the normal volar tilt and documentation that the comminution is primarily in the dorsal metaphysis.

Media file 10: Volar anatomic landmarks important for the volar approach. The region marked pronator fossa is covered by the pronator quadratus (PQ) muscle. It extends distally to the PQ line, marked in blue. The watershed line marks the highest crest (most volarly projecting) surface of the radius. The red X marks the volar radial tuberosity, which lies just off the pronator quadratus. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR marks the volar radial ridge.
Media type: Photo

Media file 11: Percutaneous pinning with the Clancey technique, posteroanterior view.

Media file 12: Percutaneous pinning with the Clancey technique, lateral view.
Media type: X-RAY

Media file 13: Dorsal plate fixation using the Synthes Pi plate, posteroanterior view.

Media file 14: Dorsal plate fixation using the Synthes Pi plate, lateral view.
Media type: X-RAY

Media file 16: Standard (bridging) external fixation using an Orthofix RadioLucent external fixator.
Media type: Photo

Media file 17: Nonbridging external fixation using the Howmedica Mini-Hoffman external fixator.

Media file 18: Volar fixed-angle plate using the Orthofix Contours VPS plate, posteroanterior view. This is a facet posteroanterior view, which is tilted at the same angle as the tilt of the distal articular surface, which allows assessment of the intra-articular versus extra-articular placement of the screws. Note that the distal screws engage both the radial styloid fragment and the dorsal ulnar fragment.
Media type: X-RAY

Media file 19: Volar fixed-angle plate using the Orthofix Contours VPS, lateral view. This is not a facet lateral view, and the distal articular surface is not seen tangentially, which makes some of the screws appear to be intra-articular. However, the posteroanterior view demonstrates that they are not. Note also that the distal screws do not past-point the dorsal cortex, but instead stop a few millimeters short of the dorsal cortex. Due to the difficulty of evaluating screw length, even with fluoroscopy, the screws should stop 2 to 4 mm short of the dorsal cortex.

Media file 20: PA view of fragment specific fixation (courtesy of Rob Medoff, MD). The hardware to the radial side is a radial pin plate. The pins hold the fragment in place and the pin plate gives greater stabilization to the pins. The hardware to the ulnar side is a dorsal pin plate (see next image), which holds the dorsal ulnar corner in place.
Media type: X-RAY

Media file 21: Lateral view of a fragment specific fixation (courtesy of Rob Medoff, MD). The hardware on the volar side is called a wireform and is supporting the subchondral bone. The hardware in the center of the image is a pin plate along the radial border of the radial styloid and serves to hold the large radial styloid fragment in place. There is a small pin plate along the dorsal surface.

REFERENCES
1. Atroshi I, Brogren E, Larsson GU, et al. Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. Acta Orthop. Jun 2006;77(3):445-53. [Medline].
2. Benson EC, Decarvalho A, Mikola EA, et al. Two Potential Causes of EPL Rupture after Distal Radius Volar Plate Fixation. Clin Orthop Relat Res. Jun 8 2006;[Medline].
3. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. Jun 1986;68(5):647-59. [Medline].
4. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am]. Mar 2002;27(2):205-15. [Medline].
5. Orbay JL, Badia A, Indriago IR, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. Dec 2001;5(4):204-11. [Medline].
6. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br. Jul 1996;78(4):588-92. [Medline].
7. Ruch DS, Ginn TA, Yang CC, et al. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. May 2005;87(5):945-54. [Medline].

Remember the admonition from the Patient Education Links Page: the Internet has a lot of information, much of it incorrect. I have reviewed the sites that I have linked to, and have only linked to sites when I personally know the surgeon who posted it, or am a member of the organization that posted it. However, I may not agree with all that is on that site, and it may have changed since I reviewed it. If any of the information is not consistent with what I have told you, please download the material and bring it in.

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Distal Radius Fractures for Surgeons

First posted August 29, 2007 Last updated July 15, 2009