DISTAL RADIUS FRACTURE

CASE DISCUSSION

CASE : FEMALE 52 YR, FALL ON OUTSTRETCHED HAND• History : 1 hrPTA falls on her outstretching hand. She has pain and swelling

in her wrist. Her wrist has fork-shape deformities.• Past History : no underlying disease, no drug allergy• Physical Examination• V/S – Stable• Rt wrist - Fork-shape deformity

- Swelling and tender around wrist- Stepping was palpable at distal radius- Limit ROM due to pain- Motor and sensory are intact

ANATOMY scaphoid and lunate fossa

• Ridge normally exists between these two

sigmoid notch: second important articular surface

triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid

DIAGNOSIS: HISTORY AND PHYSICAL FINDINGS• History of mechanism of injury • A visible deformity of the wrist is usually noted, with the hand most commonly

displaced in the dorsal direction. (90% cases)• The acute shortening of the radius relative to the ulna may manifest as an open

wound palmarly and ulnarly where the intact ulna buttonholes through the skin.• Movement of the hand and wrist are painful. • Adequate and accurate assessment of the neurovascular status of the hand is

imperative. (Median nerve involvement – Carpal tunnel syndrome)

DIAGNOSIS: DIAGNOSTIC TESTS AND EXAMINATION

• Evaluation of the injured joint, and a joint above and below (ipsilateral elbow & shoulder joint)

• Radiographs of the injured wrist (PA & Lateral)• Radiographs of other areas, if symptoms warrant.• CT scan of the distal radius in selected instances.

IMAGING

• 1- Posteroanterior (PA)• 2- lateral• 3- oblique radiographs: (reveal intra-

articular involvement)• A- The semisupinated, demonstrates

the dorsal facet of the lunate fossa.• B- The partially pronated, allows

visualization of the radial styloid.

ASSESSMENT OF RADIOLOGICAL PARAMETERS• 1- Radial height (PA view)Two

Tangential Lines to the Styloid tip and distal ulnar surface normal is 11-13mm

• 2- Ulnar variance (UV) measured on PA radiograph w/ wrist in neutralThis image demonstrates ulnar plus variance.

• 3-Radial inclination is measured onthe PA viewThe normal angle is 15-25º.

• 4-The volar tilt, or palmar inclination, is measured on the lateral view. Slope of the dorsal-to-palmar surface of the radius. The normal angle is 10-25º.

TRUE LATERAL

PATHOMECHANICS

• Injury depends on the position of the wrist, the magnitude and direction of force, and the physical properties of the bone.

CLASSIFICATION

Ideal system should describe:• Type of injury• Severity• Evaluation• Treatment• Prognosis

COMMON CLASSIFICATIONS

1. Gartland & Werley2. Frykman (radiocarpal & radioulnar)3. AO4. Melone (impaction of lunate)5. Fernandez (mechanism)

CLASSIFICATION – FERNANDEZ (1997)I. Bending-metaphysis fails under

tensile stress (Colles, Smith)• extraarticular

II. Shearing-fractures of joint surface • Intra articular

(Barton, radial styloid)

importance of mechanism and energy level of injury

CLASSIFICATION – FERNANDEZ (1997)III. Compression - intraarticular fracture with

impaction of subchondral and metaphyseal bone (die-punch)

• Complex articular fracture & radial pilon fracture

IV. Avulsion- fractures of ligament attachments (ulna, radial styloid)

V. Combined complex - high velocity injuries

FRACTURE DESCRIPTION

• Location : Extra or Intra articular• Configuration : Simple : transverse or oblique/ Comminuted.• Displacement : Radial inclination Radial length Volar tilt intra-

articular incongruity• Ulna & DRUJ

COMPLICATIONS OF DISTAL RADIAL FRACTURES• Disruption of the triangular fibrocartilage (TFC) complex.• Scapholunate and lunotriquetral interosseous ligament injuries.• Ulnar nerve injury• Carpal tunnel syndrome• Posttraumatic radiocarpal osteoarthritis6-Heterotopic ossification• Reflex sympathetic dystrophy (RSD)• Tendon rupture (extensor pollicis longus)

TREATMENT GOALS• Preserve hand and wrist function

• Realign normal osseous anatomy • Articular surface

• Promote bony healing

• Allow early finger and elbow ROM

OPTIONS FOR TREATMENTCasting• Long arm vs. short arm

External Fixation• Joint-spanning• Non bridging

Percutaneous pinningInternal Fixation• Dorsal plating• Volar plating• Combined dorsal/volar plating• focal (fracture specific) plating

INDICATION OF INSTABILITY1. >10 degrees loss of volar angulation2. >5 mm of radial shortening3. >2mm of articular incongruity4. comminution of cortex across the midaxial line on lateral x-ray5. comminution of dorsal and palmar cotices6. Irreducible fracture7. Loss of reduction at follow up.

TECHNIQUE OF CLOSED REDUCTIONAnesthesia (pain relief & decrease muscle spasm)• Hematoma block• Intravenous sedation• Bier block

Traction: finger traps and weightsReduction Maneuver (dorsally angulated fracture): • hyperextension of the distal fragment, • Correct radial tilt• Maintain weighted traction and reduce the distal to the proximal

fragment with pressure applied to the distal radius.Apply well-molded splint or cast, with wrist in neutral to slight flexion.Do check X-ray to confirm the acceptable reduction.

NON-ACCEPTABLE REDUCTION• Radial shortening > 5 mm• Radial inclination < 10°• Tilt on lateral projection > 10°dorsal tilt

and > 20° volar tilt• Intra-articular step-off 2 mm or more• Articular incongruity 2 mm or more of the

sigmoid notch ( articular surface of distal radius in DRUJ).

AFTER-TREATMENT

Watch for median nerve symptoms • parasthesia common but should diminish over few hours• If persist release pressure on cast, take wrist out of flexion• Acute carpal tunnel: symptoms progress; CTR required

Follow-up x-rays needed in 1-2 weeks to evaluate reduction.Change to short-arm cast after 2-3 weeks, continue until fracture

healing.

INDICATIONS FOR SURGICAL TREATMENT1. High-energy injury with instability2. Comminuted displaced intraarticular fracture3. Open injury4. Radial inclination < 15°5. Articular step-off, or gap > 2mm6. Dorsal tilt > 10 °7. DRUJ incongruity

INDICATION FOR SURGERY 1. Unstable • 1) Fernandez type II, IV, V and some case in I, III • 2) Lafontaine criteria > 3 of 5 instability parameters • 3) Secondary displacement after casting

Lafontaine criteria (1989)

Dorsal angulation > 20°

Ulnar fracture Dorsal comminution

Intraarticular Fx

Age >60

2. Irreducible fracture

1) Double die punch

2) Displaced comminuted PM fragment

3) Articular step off > 2 mm

4) Severe comminution

5) Shortening > 5mm

• 3. Unacceptable alignment 1) Radial inclination < 15°2) Shortening > 5 mm 3) Dorsal tilt > 10° 4) Volar tilt > 20° 5) Articular step off or gap > 2 mm

• 4. Open fracture • 5. Associated injury

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.

CLOSED REDUCTION :Technique

Traction on fingers and counter traction near elbow by assistant.

Fracture is disimpacted.

Length is established.

Fracture is locked by over flexing and ulnar deviation of the wrist.

Below elbow cast is applied.

CLOSED REDUCTION

Closed reduction and below elbow cast application under Hematoma block: Local anesthetic (2% Xylocaine is infiltrated into the fracture hematoma

Closed reduction and below elbow cast application under anaesthesia