Fractures of the Distal Radius

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Fractures of the Distal Radius

• Eponyms, anatomy, mechanism of injury,
  classifications, treatment, and complications of
  fractures of the distal radius.

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Eponyms-historically described

• Colles-1814
• Barton-1838
• Smith-1854
• Dupuytren-1847

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Anatomy

• The distal radius joint and the DRUJ support the
  carpus with three separate articulations that are
  of concern in treatment of fractures of the
  distal radius.
• The scaphoid and lunate fossa are two concave
  articular surfaces separated by a dorsal-volar
  ridge.
• The sigmoid notch is present for the head of the
  ulna.

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• The distal articular suface of the radius had 14
  degrees of volar tilt and 22 degrees of ulnar
  inclination.
• The ulnar side of the wrist is supported in
  addition by the triangular fibrocartilage complex
  (TFCC).
• The length of the ulna varies with pronation and
  supination

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Mechanisms of Injury

• Fractures occur most often from falls on the
  outstretched hand
• The amount of force varies in the dorsiflexed
  wrist from 105-440kg
• The exact mechanism is not known

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• Distal radius fractures that have a shear or
  compression component produce intra-articular
  fractures that are considerably more unstable
  than the bending metaphyseal extra-articular
  fractures

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Classification

• The presentation of a classification of fractures
  of the distal radius must begin with an initial
  recognition of the different common types of
  fracture.

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• Colles-it involves the distal metaphysis , which
  is dorsally displaced and angulated. It occurs
  within 2 cm of the articular surface and may
  extend into the radiocarpal joint or DRUJ.
  Dorsal displacement (silver fork deformity),
  dorsal angulation, radial angulation, and radial
  shortening are present. Accompanying fractures
  of the ulnar styloid my signify TFCC damage.

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• Smiths fracture-is a volar angulated fracture of
  the distal radius with a garden spade
  deformity. The hand and wrist are displaced
  forward or volarly with respect to the forearm.
  This too can be extra-articular, intra-articular,
  or part of a fracture-dislocation of the wrist.

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• Bartons fracture-is an actual fracture-dislocatio
  n or subluxation in which the rim of the distal
  radius, dorsally or volarly, is displaced with
  the hand and carpus

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• A Classification should serve the purpose of
  description of the fracture as well as treatment
  basis.

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• Frykman Classification-Based on the pattern of
  intraarticular involvement
• Types I,II Extraarticular
• Types III,IV Involves radiocarpal joint
• Types V,VI,VII Involves distal radioulnar joint
• Types VII,VIII Involves both radiocarparl and
  distal radioulnar joints
• Types I,III,V,VII Have an intact ulnar styloid
• Types II,IV,VI,VIII Have a fractured ulnar
  styloid

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• Universal Classification-emphasizes that
  different treatment modalities are indicated for
  the variations that exist in distal radius
  fractures
• Type I Non-articular, undisplaced
• Type II Non-articular, displaced
• Type III Intra-articular, undisplaced
• Type IV Intra-articular, displaced
• A. Reducible (stable)
• B. Reducible (unstable)
• C. Irreducible (unstable)

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• Mayo Clinic Classification-all of the
  articulations are treated separately
• Type I Radiocarpal joint undisplaced
• Type II Radioscaphoid joint (intra-articular)
• Type III Radiolunate joint (die punch fracture,
  intra-articular)
• Type IV Radioscapholunate joint
  (intra-articular)

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Treatment

• Factors
• Fracture pattern
• Local factors bone quality, soft tissue injury,
  associated comminution, extent of displacement
  and energy of injury.
• Patient factors Physiological age, life style,
  occupation, dominance, associated medical
  conditions, associated injuries, compliance.

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• Stable fractures
• Closed reduction/plaster immobilization is still
  the treatment of choice for 75-80 of distal
  radius fractures.
• Place wrist in 20 degrees volar flexion and ulnar
  deviation.
• A well-molded cast is a must

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• Forearm position, duration of immobilization, and
  need for long arm cast--still unclear no
  prospective study has demonstrated superiority of
  one method vs. another.
• Avoid extreme flexion--it increases carpal canal
  pressure and thus median nerve compression, and
  increases digital stiffness.

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• Unstable fractures
• Percutaneous pinning
• Primarily used for extra-articular fractures or
  two-part intra-articular fractures.
• Two or three K-wires placed across the fracture
  site generally from the radial styloid,
  proximally and from the dorsoulnar side of the
  distal radial fragment proximally.
• Others advocate transulnar pinning with multiple
  pins.

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• External fixation
• Has grown in popularity based on studies
  yielding relatively low complication rates.
• Ligamentotaxis can restore radial length and
  radial inclination, but rarely restores volar
  tilt.
• Most still recommend 8 weeks of external
  fixation.
• Complication pin tract infections, RSD, wrist
  stiffness, fracture through the pin sites.

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• Open reduction /Internal fixation
• The primary indication is articular fragment
  displacement, which if left unreduced leads to
  radiocarpal and radioulnar arthritis.
• Options include a longitudinal dorsal approach,
  volar approach, a limited tranverse dorsal
  approach, or reduction under arthroscopic control.

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• The choice of fixation depends on the fracture
  configuration
• A dorsally comminuted, dorsally displaced
  fracture can use a dorsal distraction plate.
• Volar displaced fractures are best approached
  with a palmar incision buttress plate.

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Complications

• Reported complication rates are approximately
  30, but vary from series to series.
• Median nerve dysfunction Although management is
  controversial, some generalities can be made
• Complete lesion with no improvement following
  reduction requires surgical exploration.

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• A nerve lesion developing postreduction release
  the splint and position the wrist in neutral
  position if there is no improvement, consider
  exploration and release.
• With incomplete lesions in fractures requiring
  operative intervention, most advocate release.

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• Malunion
• Posttraumatic arthrosis, radiocarpal as well as
  radioulnar
• Reflex sympathetic dystrophy
• Digital, wrist, and forearm stiffness

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• Tendon rupture (most commonly EPL)
• Midcarpal instability (i.e., DISI, VISI)
• Infection (pin tract, deep, etc)
• Volkmanns ischemic contracture