1. Dr Y Thimma Reddy
Assistant Professor & Registrar
Department of Orthopedics
OSMANIA MEDICAL COLLEGE

2. Distal Radius Fractures
 Common injury
 Potential for functional
impairment and frequent
complications

3. HISTORY
 First surgeon to recognize these injuries was Pouteau 1783.
his work was not widely publicized.
 Later Abraham Colles 1814 gave the classic description of
fracture
 Dupuytren brought to the world attention that it is a fracture
rather than a dislocation as it was previously assumed.
 Goyrond 1832 differntiated between dorsal and volar
displacement.
 Barton 1838 described wrist subluxation consequent to
intraarticular fracture of radius which could be dorsal or volar.
 Smith described fracture of distal radius with „forward‟
displacement.
 Advent of X rays at the end of nineteenth century contributed
much to the understanding of different patterns of injury.

4. Incidence
 One sixth of all fractures treated in the
Emergency Room
 Bimodal distribution
○ less than 30 years (70% men)
○ over 50 years (85% women)

5. Introduction
 Occurs through the distal metaphysis of the radius
 May involve articular surface
 frequently involving the ulnar styloid
 FOOSH
 forced extension of the carpus,
 impact loading of the distal radius.
 Associated injuries may accompany distal radius
fractures.

6. Diagnosis: History and Physical
Findings
 History of a FOOSH
 Visible deformity of the wrist, with the hand
most commonly displaced in the dorsal
direction.
 Movement of the hand and wrist are painful.
 Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out.

7. Diagnosis: Diagnostic Tests and
Examination
 General physical exam of the patient,
including an evaluation of the injured
joint, and a joint above and below
 Radiographs of the injured wrist
 CT scan of the distal radius in selected
instances.

8. Osseous Anatomy
 Distal radius – 80% of axial load
 Scaphoid fossa
 Lunate fossa
 Sigmoid notch – DRUJ
 Distal ulna

9. 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

10. Anatomy
 Articular Surface
 Scaphoid facet
 Lunate facet
 Sigmoid notch

11. RADIOLOGY
 Ulnar inclination (22deg)
 Volar inclination (11deg)
 Radial length (11mm)
 Ulnar variance (+ / - 1mm)

12. Measurement of Radial Length and
Inclination
Inclination = 23
degrees

14. Scapholunate angle measured between lines 2 and 3
(normal 47 ± 15 degrees)
2: Line perpendicular to 1: Line connecting dorsal and
lunate volar tip of lunate
3: Line along axis of scaphoid

15. Computed Tomography
Indications:
 Intra-articular fxs with multiple
fragments
 centrally impacted fragments
 DRUJ incongruity
Cole et al: J Hand Surg, 1997

16. Classification of
Distal Radius Fractures
 Ideal system should describe:
 Type of injury
 Severity
 Evaluation
 Treatment
 Prognosis

17. Common Classifications
 Column theory
 Gartland/Werley
 Frykman
 Weber (AO/ASIF)
 Melone
 Fernandez (mechanism)

18. Frykman Classification
Extra-
articular
Radio-carpal joint
Same pattern as
Radio-ulnar joint
{ odd numbers,
except ulnar
styloid also
fractured
Both joints

19. AO/ OTA Classification
Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C:
Complete Intra-
articular

20. Column Theory
3 Columns: radial, intermediate,
medial
Rikli & Regazzoni,
1996

21. Three Column Theory
 Radial Column
Lateral side of radius
 Intermediate Column Radial column Ulnar column
Ulnar side of Intermediate column
radius
 Ulnar Column
distal ulna

22. Classification – Fernandez
(1997)
 I. Bending-
metaphysis fails
under tensile stress
(Colles, Smith)
 II. Shearing-fractures
of joint surface
(Barton, radial styloid)

23. Classification – Fernandez
(1997)
 III. Compression-
intraarticular fracture with
impaction of subchondral
and metaphyseal bone
(die-punch)
 IV. Avulsion-fractures of
ligament attachments
(ulna, radial styloid)
 V. Combined/complex -
high velocity injuries

24. Assessment of X-rays
 Assess involvement of dorsal or volar rim
 Is comminution mainly volar or dorsal?
 is one of four cortices intact?
 Look for “die-punch” lesions of the
scaphoid or lunate fossa.
 Assess amount of shortening
 Look for DRUJ involvement

25. Dorsal angulation and comminution

26. Volar subluxation of carpus with fracture
fragment

27. Options for Treatment
 Casting
 Long arm vs short arm
 Sugar-tong splint
 External Fixation
 Joint-spanning
 Non bridging
 Percutaneous pinning
 Internal Fixation
 Dorsal plating
 Volar plating
 Combined dorsal/volar plating
 focal (fracture specific) plating

28. Treatment Goals
 Preserve hand and wrist function
 Realign normal osseous anatomy
 promote bony healing
 Avoid complications
 Allow early finger and elbow ROM

29. Indications for Closed
Treatment
 Low-energy fracture
 Low-demand patient
 Medical co-morbidities
 Minimal displacement-
acceptable alignment

30. Closed Treatment of Distal
Radial Fractures
 Obtaining and then maintaining an
acceptable reduction.
 Immobilization:
 long arm
 short arm adequate for elderly patients
 Frequent follow-up necessary in order to
diagnose redisplacement.

31. Technique of Closed
Reduction
 Anesthesia
 Hematoma block
 Intravenous sedation
 Bier block
 Traction: finger traps and weights
 Reduction Maneuver (dorsally angulated fracture):
 hyperextension of the distal fragment,
 Maintain weighted traction and reduce the distal
to the proximal fragment with pressure applied to
the distal radius.
 Apply well-molded “sugar-tong” splint or cast, with
wrist in neutral to slight flexion.
 Avoid Extreme Positions!

32. Acceptable Reduction
Criteria
 No dorsal angulation

 > 15 degrees of inclination
 Articular step-off < 2mm
 < 5 mm shortening compared to opposite wrist.
 DRUJ congruent

34. After-treatment
 Watch for median nerve symptoms
 parasthesias 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.

35. Management of
Redisplacement
 Repeat reduction and casting – high rate of failure
 Repeat reduction and percutaneous pinning
 External Fixation
 ORIF

36. Indications for Immediate
Surgical Treatment
 High-energy injury
 Open injury
 Secondary loss of reduction
 Articular comminution, step-off, or gap
 Metaphyseal comminution or bone loss
 Loss of volar buttress with displacement
 DRUJ incongruity

37. Operative Management of Distal
Radius Fractures

38. External fixation:
The treatment of choice for
distal radius fractures in the
1980‟s

41. Literature Articles Discussing
External Fixation
50
45
40
35
30
25
20
15
10
5
0
No. of Articles
1974 1980 1986 1999

42. Types of External Fixation
 Spanning  Non-spanning
 Dynamic  Hoffman 2
○ Clyburne  Cobra
○ Agee  Zimmer
○ Pennig  AO
 Static
○ AO
○ Ace

43. Spanning ( Ligamentotaxis)
 A spanning fixator is
one which fixes
distal radius
fractures by
spanning the
carpus; I.e., fixation
into radius and
metacarpals

44. Non-spanning
 A non-spanning
fixator is one which
fixes distal radius
fracture by securing
pins in the radius
alone, proximal to
and distal to the
fracture site.

47. Courtesy of Hill
Hastings,MD

48. External Fixation
- Disadvantages -
 Bulky
 Poor screw hold in porosis and comminution
 Screws do not buttress
 More invasive

49. Ligamentotaxis
 Adverse effect of carpal over-
distraction well documented
 Kaempffe (1993): pain, function, grip
strength adversely affected
 Gupta (1999): 10# of distraction can induce
over 10mm of ligament elongation
 Davenport (1999): 10mm carpal distraction
produces >20% increase in ligament strain

52. Complications
 Complication rates high in almost all
reported series
 Mal-union
 Pin track infection
 RSD / arthrofibrosis
 Finger stiffness
 Loss of reduction; early vs late
 Tendon rupture

53. Percutaneous Pins

54. Percutaneous Pins

55. Percutaneous Pinning-Methods
 variety described
 most common radial styloid pinning +
dorsal-ulnar corner of radius pinning
 supplemental immobilization with cast,
splint
 in conjunction with external fixation
(Augmented external fixation)

56. Percutaneous Pinning
 2 radial styloid pins - Mah and Atkinson,
J Hand Surg 1992
 excellent anatomic 82%
 good-excellent functional results 100%
 radial styloid with dorsal - prospective
study, 30 pts (Clancey JBJS 1984)
 excellent anatomic results in 90%

57. Percutaneous Pinning-
Kapandji
 intrafocal pinning through
fracture site
 buttress against
displacement
 good results in literature

58. Internal Fixation of Distal Radius
Fractures
 Useful for elevation of depressed articular
fragments and bone grafting of
metaphyseal defects
 required if articular fragments can not be
adequately reduced with percutaneous
methods

59. Selection of Approach
 Based on location of comminution.
 Dorsal approach for dorsally angulated
fractures.
 Volar approach for volar rim fractures
 Radial styloid approach for buttressing of
styloid
 Combined approaches needed for high-
energy fractures with significant axial
impaction.

60. VOLAR
Classical Henry approach Extended carpal tunnel approach

61. Volar –Henry Approach

62. Radial to FCR

63. Elevate Pronator Quadratus

65. Distal Radius-volar barton
 64 yo M, MVA, contralateral tibial shaft Fx

66. Dorsal Fracture

67. CT Scan

68. DORSAL
APPROACH
3rd DC –EPL
1-2nd DC (extensile)
-

69. Dorsal Plating, PCP and Ex Fix

71. Volar Plating for Dorsal Fractures
-less tendon irritation than dorsal

72. Fixed angle locked screws
,,variable angle

73. Courtesy J. Orbay,
MD

75. Courtesy J. Orbay, MD

76. Fragment Specific System

77. Radial and Ulnar Columns
-Pin plates
-90-90 plating technique

78. Focal Plating
Radial Styloid Fragment
Dorsal ulnar fragment
70 – 90 degrees apart

79. Dorsal Fracture
Radial Styloid and dorsal-ulnar
corner

80. Dorsal Case: focal plating

81. Radial shortening,
comminution
Dorsal angulation
Indication for Volar and
Dorsal Plating

82. Volar approach,
application
buttress plate

83. Dorsal approach,
application of 2 “L” buttress
plates

84. EPL Tendon

85. Extensor retinaculum repaired
beneath EPL to prevent erosion
against plate- EPL left transposed

87. Advanced Techniques
Arthroscopic-Assisted
 reduce articular incongruities
 also diagnose associated soft tissue
lesions
 minimally invasive

89. Conclusions
 Need to be able to use all tools for
treatment of distal radius fractures
 Both external fixation and ORIF are useful.
 ORIF better in high-energy fractures associated
with depression of articular surface
 ORIF gives better anatomic restoration,
although not necessarily higher patient
satisfaction.

90. Conclusions
 External fixators still have a role in the
treatment of distal radius fractures
 Spanning ex fix does not completely
correct fracture deformity by itself
 Should usually combined with
percutaneous pins (augmented fixation)

91. Conclusions
 new plating techniques allow for accurate
and rigid fixation of fragments
 Plating allows early wrist ROM
 Volar, smaller and more anatomic plates are
better tolerated
 combination treatment is often needed

93. Relationship
of Anatomy to Function
Colles; “The wrist will regain perfect freedom
in all of its motions and be completely
exempt from pain” (1814)
 Generally true for low demand individuals
 Direct relation between residual deformity
and disability
 Quality of reduction more important than
method of immobilisation