CPC 1 – GENERAL PICTURE OF DISTAL END RADIUS FRACTURE

DR NOORNADIA YAHAYA

MENTOR: MR ABDUL RAZAK HUSSIN

GRAND MENTOR: DATO’ DR HAJI ZAMYN ZUKI

DEPARTMENT OF ORTHOPAEDIC

AND TRAUMATOLOGY

HOSPITAL SUNGAI BULOH

EPIDEMIOLOGY

Distal radius fractures (DRFs) are among the most common type of fracture, and many authors state that they are the most common type of fracture. DRFs have a bimodal distribution, with a peak in younger persons (aged 18-25 y) and a second peak in older persons (>65 y) 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 distal radius fracture (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 injuries 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

ANATOMY

The metaphysis of distal radius is composed primarily of cancellous bone. The articular surface has a biconcave surface for articulation with the proximal carpal row ( scaphoid and lunate fossae) as well as notch for articulation with distal ulna

80% of axial load is supported by distal radius and 20% by the ulna and the triangular fibrocartilage complex (TFCC)

Reversal of the normal palmr tilt result in load s transfer onto the ulnar and TFCC . The remaining load is then eccentrically by the distal radius and is concentrated on the dorsal aspect of the scaphoid fossa

Numerous ligamentous attachment exist to the distal radius. These often remain inatct durind distal radius fracture, facilitating reductin thorugh ligamentotaxis

The volar ligament are stronger and confer more stability to the radiocarpal articulation thsn the dorsal ligaments

RADIOLOGICAL EVALUATION

PA view should be taken with the wrist and elbow at shoulder height. 

Figure 1:On a correctly positioned PA view the extensor carpi ulnaris tendon groove (arrow) can be seen.The extensor carpi ulnaris tendon groove should be at the level of or radial to the base of the ulnar styloid.

Figure 2: True lateral, the Palmar cortex of Pisiform ( red arrow ) lies between the palmar cortex of scaphoid and capitate

A true lateral view is defined by the relationship between the pisiforme, capitate and scaphoid bones.

Apparent volar tilt of the surface of the distal radius, as measured on the lateral view, increases with supination and decreases with pronation of the wrist (5).A change of 10° rotation between two consecutive control lateral radiographs is not uncommon during clinical follow-up and results in 5° change in apparent tilt

CT scan may help to demonstrate the extent of intraarticular involvement

Measurements

Radial length or height Radial length is measured on the PA radiograph as the distance between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid. A second line intersects distal articular surface of ulnar head. This measurement averages 10-13 mm. 

Radial inclination or angleRadial inclination represents the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius.  The radial inclination ranges between 21° and 25°. Loss of radial inclination will increase the load across the lunate. 

Radial tiltRadial tilt is measured on a lateral radiograph. The radial tilt represents the angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin. The normal volar tilt averages 11° and has a range of 2°-20°.

FRACTURE DESCRIPTIONLocation

One of the most important characteristics is whether a fracture is extraarticular or intraarticular. Extraarticular fractures are usually less complicated, unless they are comminutive. Intraarticular fractures either involve the radiocarpal joint, distal radioulnar joint, or both

Configuration

Whether the fracture is transverse (good prognosis), oblique or comminuted (multifragmented).When a fracture is oblique or when it is comminuted.

Displacement

Fractures are either displaced or nondisplaced. A fracture with an offset of 2 mm or more in any plane or 2 mmm offset involving the articular surface is considered displaced. Displacement can be dorsal, volar, radial or proximal.Axial shortening, radial inclination and radio-ulnar displacement can be measured on the routine postlerior/anterior film.Dorsal tilt and dorsal or palmar displacement can be measured on the routine lateral X-ray. Fragment displacement and rotation may be further determined using CT.

Instability

The inability to maintain fracture allignment by closed reduction and casting define fracture instability. Many authors have proposed criteria to predict which fracture pattern inherently unstable and may benefit from surgical treatment .Lafontaine et al proposed five factors that indicates fracture instability

1) Initial dorsal angulation more than 20 degree

2) Dorsal comminution

3) Radiocarpal intrarticular involement

4) Associated ulnar fracture

5) Age greater than 60 years

In their experience patient who had 3 or more of these factors have high incidence of reduction loss with cast treatment

EPONYM

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 Pouteau 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 had not yet been invented. 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.

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

Colles Fracture.— Colles' fracture

A Colles' fracture is a fracture of the distal metaphysis of the radius with dorsal angulation and displacement leading to a 'silver fork deformity'. Colles fractures are seen more frequently with advancing age and in women with osteoporosis. In many cases a Colles' fracture is an extraarticular, uncomplicated and stable fracture, but it can be intraarticular. Signs of instability in all Colles' fractures, especially: Intraarticular radiocarpal or DRUJ extension of the fracture, radial shortening ,loss of radial inclination

Smith's fracture

Smith's fractures occur in younger patients and are the result of high energy trauma on the volar flexed wrist. Volar comminution and intraarticular extension are more common.

Barton's fracture

Volar-type Barton's is a fracture-dislocation of the volar rim of the radius.This type is the most common.

Dorsal-type Barton's is a fracture-dislocation of the dorsal rim of the radius.Dislocation of the radiocarpal joint is the hallmark of Barton's fractures. These are shear type fractures of the distal articular surface of the radius with translation of the distal radial fragment and the carpus. These fractures have a great tendency for redislocation and malunion.They usually require operative treatment.

Die-punch fracture

A die-punch fracture is a depression fracture of the lunate fossa of the distal radius. It is the result of a transverse load through the lunate

Classification widely used

Frykman classification based on pattern of intraarticular involvement

Fernandez classification, mechanism based injury classifictaion

TREATMENT

The goal is to return the patient to 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. This treatment paradigm is highlighted by a recently developed approach to surgically treat stable fractures that are in acceptable alignment.

Non surgical

Many distal radius fractures (DRFs) can be treated nonoperatively. Fractures that are undisplaced or minimally displaced (the definition of minimally displaced is controversial and varies with age and activity level 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

Fracture

Distal Ulna fracture

Absent Present

Extrarticular I II

Intra-articular involving radiocarpal joint

III IV

Intra-articular involving distal radioulnar joint (DRUJ)

V VI

Intra-articular involving radiocarpal and DRUJ

VII VIII

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.

Some fractures in elderly persons that are compressed dorsally can be minimally painful and can appear to be clinically stable. These fractures 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° dorsal tilt can be highly functional in a patient who drives and is active out of the home but does no sports. They have an unsightly wrist clinically (with a prominent ulnar head) that has limited supination and flexion, but they do not have symptoms with ADLs. Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.

A systematic review concluded that, in patients 60 years and older with distal radius fractures, cast immobilization provided functional outcomes similar to surgical treatments (volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation).

Cast immobilization had the worst radiographic outcome yet lowest complication rate. Additional studies are needed to evaluate the recovery rate, cost and outcomes of these treatment methods

Parameters of acceptable reduction are 1) restoration of radial length 2-3 mm of uninjured wrist 2)Radial inclinition is approximately 21 degree andradiocarpal congruence is within 1 mm 3)Not more than 5-10 degree of articular dorsal tilt preferably neutral or inclined towards the normal 10 degree palmar tilt

Surgical

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.

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 continues to be one of the most popular techniques internationally.

Many variations of external fixation have been developed. One variation of the fixator allowed early motion with the fixator 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 the location of the rotation—that is, 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.

One study compared the complication rates in patients treated with external fixation versus volar plating of distal radius fractures. The volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate.

While there were no significant differences between the groups in the scapholunate angle or palmar tilt measurements, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength. This author is a proponent of external fixators; however, note that at this time, most surgeons would place a volar plate rather than an external fixator when feasible. The rate of complications of volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, plate removal) has dramatically decreased.

Some studies have shown that open reduction and internal fixation resulted in better grip strength and range of motion than closed reduction and bridging external fixation in the treatment of nonreducible distal radial fractures. The results from one study noted that these benefits diminished with time; after a mean of 5 years, both groups had approached normal values

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 was originated by Fernandez, which he called the limited open approach, and was developed and popularized by Medoff, who coined the term fragment-specific. Fragment-specific fixation 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 the technique is difficult to learn 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 touted 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 gaining in popularity, but its complications, particularly the incidence of tendon rupture, are now becoming recognized

One study compared the complication rates in patients treated with external fixation versus volar plating of distal radius fractures. The volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate. While there were no significant differences between the groups in the scapholunate angle or palmar tilt measurements, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength. This author is a proponent of external fixators; however, note that at this time, most surgeons would place a volar plate rather than an external fixator when feasible. The rate of complications of volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, plate removal) has dramatically decreased.

The results from another study noted that extra-articular and simple intra-articular distal radial fractures realized similar outcomes in motion, grip strength, Gartland and Werley scores, and DASH scores at 2 years when treated with open reduction and internal fixation with a volar locking plate.

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.

Surgical techniques internationally

Despite the many techniques and the large number of studies on distal radius fractures (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 (eg, Japan, Germany), the plates are typically removed; however, in others (eg, the United States), they are rarely removed.

CASE ENCOUNTER

23 years old, malay gentleman had alleged motor vehicle accident, riding motorbike with high velocity, Motorbike skidded and fall on his right side with an outstretched hand. Work as an oil Palm boiler. Sustained Closed comminuted fractures distal end of right radius with ulnar styloid fractures. Able to minimally flex and extend all fingers with no neurological deficit. Peripheral pulse palpable.Hand was swollen and no apparent deformity noted.

Proceeded with Closed manipulative reduction, with full length backslab applied after that

x-ray reviewed was un acceptable , There are intraarticular involvement of radiocarpal and radioulna joint and articular gapping with loss of radial inclination. The fracture after reduction is unstable thus plan for Closed manipulative reduction , k- wiring and cross wrist external fixator of the right radius.

Apparently he defaulted treatment and requested for discharge at own risk and was given Appointment after 2 weeks. Was allowed dicharge at own risk with backslab of the right hand

CONCLUSION:

1.Distal radius fractures (DRFs) are among the most common type of fracture

2 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

3. Mode of treatment differs depending on patient related factor, fracture characterictic and stability

4. The goal is to return the patient to 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.

REFERENCES

1)Distal Radius Fracture: External fixation , Michael W. Grafe ,Paul D kim, Melvin P.Rossenwaser. Master technique in orthopaedic surgery, 2nd edition, edited by Donal A. Wiss, Lippincot william and wilkins copyright 2006

2)http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780584/

3)http://emedicine.medscape.com/article/1245884-treatment#a1128

4)Intrarticular fractures of distal end radius,David Ring ,MD Journal Of The American Society For surgery Of The Hand Vol 2, No. 2, MaY 2002

5)http://www.wheelessonline.com/ortho/distal_radial_frx_radial_length