A distal radius fracture is a common bone fracture of the radius in the forearm. Because
of its proximity to the wrist joint, this injury is often called a wrist fracture. Treatment
is usually with immobilization, although surgery is sometimes needed for complex fractures.
Specific types of distal radius fractures are Colles' fracture; Smith's fracture; Barton's
fracture; Chauffeur's fracture. Most of these names are applied to specific patterns of
distal radius fracture but confusion exists because "Colles' fracture" is used as a generic
term for distal radius fracture.
Signs and symptoms History
The most common cause of this type of fracture is a fall on an outstretched hand. In young
adults this fracture is the result of moderate to severe force such as a fall from a significant
height or a motor vehicle accident. The risk of injury is increased in patients with osteoporosis
and other metabolic bone diseases. Patients usually present with a history of
an injury and localized pain. There is often a deformity in the wrist with associated swelling.
Numbness of the hand can occur because of compression on the median nerve across the
wrist. There is often limited digital motion secondary to the wrist deformity.
Examination Swelling, deformity, tenderness and loss of
wrist motion are normal features on examination of a patient with a distal radius fracture.
Examination should rule out a skin wound which might suggest an open fracture. It is imperative
to check for loss of sensation, loss of circulation to the hand, and more proximal injuries to
the forearm, elbow and shoulder. The most common associated neurological finding is
decreased sensation over the thenar eminence due to associated median nerve injury.
Injuries associated The most commonly associated injury is to
the ulnar styloid. Styloid fractures can occur either to the very tip of the styloid or at
the base. Because the triangular fibrocartilage attaches to the base of the ulna styloid,
displaced fractures can result in instability of the distal radio-ulnar joint. Carpal bone
fractures such as those to the scaphoid have been described, whereas instability or dislocations
of the wrist are seen with certain types of distal radius and ulna fractures. Injuries
to the elbow, humerus and shoulder are also common after a FOOSH. Swelling and displacement
can cause compression on the median nerve across the wrist, an acute carpal tunnel syndrome.
Very rarely is pressure on the muscle components of the hand or forearm sufficient to create
a compartment syndrome. Diagnosis
Diagnosis may be evident clinically when the distal radius is deformed but should be confirmed
by X-ray. The differential diagnosis includes scaphoid fractures and wrist dislocations,
which can also co-exist with a distal radius fracture. Occasionally, fractures may not
be seen on X-rays immediately after the injury. Delayed X-rays, X-ray computed tomography,
or Magnetic resonance imaging will confirm the diagnosis.
Medical imaging X-ray of the affected wrist is required if
a fracture is suspected. CT scan is often performed to investigate the articular anatomy
of the fracture, especially if surgery is considered. Investigation of a potential distal
radial fracture includes assessment of the angle of the joint surface on lateral X-ray,
the loss of length of the radius from the collapse of the fracture, and congruency of
the distal radioulnar joint. Displacement of the articular surface is the most important
factor affecting prognosis and treatment. Articular surface
The articular joints rough surface must be smooth for it to function properly. Irregularity
may result in radiocarpal arthritis, pain, and stiffness. More than 1 mm of incongruity
places the patient at a high risk for posttraumatic arthritis. Significant articular incongruity
typically occurs in young patients after high energy injuries. If the surface is very irregular
and cannot be reconstructed, then the only option may be a fusion.
Lateral articular angle The lateral articular angle is the angle on
an x-ray film between the axis of the radius and the articular cup. Normally, the angle
is tilted toward the thumb by 11°. The most common fracture pattern usually demonstrates
malalignment of this angle and collapse in a dorsal direction. Alignment up to 0° is
still considered to be functional, and does not require any intervention. However, tilt
away from the thumb beyond this point begins to create biomechanical changes that can lead
to arthritis, pain, and stiffness. When dorsal tilt beyond the acceptable threshold occurs,
distal radio-ulnar joint motion is altered, and forearm rotation becomes restricted. The
upper limit of an acceptable deformity after reduction of the fracture is 20° of dorsal
tilt. Radial length
Radial length is an important consideration in distal radius fractures. Distal radius
fractures typically result in loss of length as the radius collapses from the loading force
of the injury. With increasing relative lengthening of the uninjured ulna, ulnar positive variance,
ulnar impaction syndrome may occur. Ulnar impaction syndrome is a painful condition
of excessive contact and wear between the ulna and the carpus with an associated is
a degenerative tear of the TFCC.
Classification In medicine, classifications systems are devised
to describe patterns of injury which will behave in predictable ways, to distinguish
between conditions which have different outcomes or which need different treatments. Most wrist
fracture systems have failed to accomplish any of these goals and there is no consensus
about the most useful one. At one extreme, a stable undisplaced extra-articular
fracture has an excellent prognosis. On the other hand, an unstable, displaced intra-articular
fracture is difficult to treat and has a poor prognosis without operative intervention.
Eponyms such as Colles', Smith's, and Barton's fractures are discouraged. Though the Frykman
classification system has traditionally been used, there is little value in its use because
it does not help direct treatment. The Universal classification system is descriptive but also
does not direct treatment. Universal codes include:
Type I: extra articular, undisplaced Type II: extra articular, displaced
Type III intra articular, undisplaced Type IV: intra articular, displaced
The system that comes closest to directing treatment has been devised by Melone:
I Stable fracture II Unstable "die-punch"
III "Spike" fracture IV Split fracture
V Explosion injuries
However, an anatomic description of the fracture is the easiest way to describe the fracture,
decide on treatment, and make an assessment of stability.
Articular incongruity Radial shortening
Radial angulation Comminution of the fracture
Open or closed injury Associated ulnar styloid fracture
Associated soft tissue injuries
Natural history Nonunion is rare; almost all of these fractures
heal. However, if the fracture is unstable the deformity at the fracture site will increase
and cause limitation of wrist motion and forearm rotation, pronation and supination. If the
joint surface is damaged and heals with more than 1–2 mm of unevenness, the wrist joint
will be prone to post-traumatic osteoarthritis. Displaced fractures of the ulnar styloid base
associated with a distal radius fracture result in instability of the distal radioulnar joint
and resulting loss of forearm rotation. Treatment
The type of treatment required depends on many factors, including displacement and stability
of the fracture fragments. Non-operative
For torus fractures a splint may be sufficient and casting may be avoided.
Where the fracture is undisplaced and stable, non operative treatment involves immobilization.
Initially the wrist is splinted to allow swelling and subsequently a cast is applied. Depending
on the nature of the fracture, the cast may be placed above the elbow to control forearm
rotation. In displaced fractures, the fracture may be
manipulated under anaesthesia and splinted in a position to minimize the risk of re-displacement.
Typically, this involves injecting local anesthesia into the fracture possibly combined with intravenous
medication. A manual reduction is performed to reposition the displaced distal radius
into its preinjury position and maintain this position in a well formed splint or cast.
During the period of follow-up, it is common practice to repeat x-rays at about 1 week
to make sure the position is still acceptable. Further followup is needed to determine when
the fracture has healed and when rehabilitation is complete. The critical time during the
period of attempted treatment with casting is the first 3 weeks. The swelling will reduce
during this time and the fracture can displace. If the displacement becomes unacceptable,
closed treatment may need to be abandoned and surgery pursued. More than 3 weeks after
injury, the fracture will start to heal and further displacement becomes less likely.
The length of time in the cast varies with different ages. Children heal more rapidly,
but may ignore activity restrictions. Three weeks in a cast and 6 weeks off sports may
be appropriate for certain fractures. In adults, the risk of stiffness of the joint increases
the longer it is immobilized. If callus is seen on x-ray at 4 weeks, the cast may be
replaced by a removable splint. However, many hand surgeons leave the patients in the cast
for up to 6 weeks. In general, the x-rays will not show any callus until about a month
after the fracture is healed; therefore the cast is removed before the x-rays confirm
that it is healed. Displaced fractures in the elderly or those
physiologically unable to undergo surgery are treated differently. When the fracture
is displaced and there are no plans for a surgery, a short arm cast is placed for only
4 weeks or until the tenderness resolves. A larger cast placed for an extended period
of time only slows down recovery in this group of patients.
Following healing and cast removal a period of rehabilitation for recovery of strength
and range of motion is necessary. Patients will continue to improve after the fracture
for 4 to 12 months. Reduction
Closed management of a distal radius fracture involves first anesthetizing the affected
area with a hematoma block, regional anesthesia, sedation or a general anesthetic.
Manipulation generally includes first placing the arm under traction and unlocking the fragments.
The deformity is then reduced with appropriate closed manipulations reduction, after which
a splint or cast is placed and an X-ray is taken to ensure that the reduction was successful.
The cast is usually maintained for about 6 weeks.
Closed treatment is frequently unsuccessful in maintaining a good position in adults,
because there is frequently comminution of the fracture. Re-displacement and deformity
can reoccur with an unacceptable ultimate result.
Risks of non-operative treatment Failure of non-operative treatment is common
and is the largest risk of an adverse outcome. Studies have shown that the fracture often
re-displaces to its original position even in a cast. Only 27% - 32% of fractures are
in acceptable alignment 5 weeks after closed reduction. In the long term this increases
the risk of stiffness and post traumatic osteoarthritis leading to wrist pain and loss of function.
It is because of these findings that many surgeons recommend operative intervention
if the fracture is displaced enough to consider a reduction. Ultimately, the fractures that
have a closed reduction may return to the position before the reduction is attempted.
Stiffness of the wrist is universal following a fracture of the distal radius. The degree
of stiffness in the wrist is dependent on the type of fracture and the period of immobilization.
It is for this reason that an open reduction is advantageous. It is also quite common for
patients to develop digital stiffness after a fracture of the distal radius. Aggressive
movement of the digits while immobilized or following operative treatment is stressed
to minimize digital stiffness. Other risks specific to cast treatment relate
to the potential for compression of the swollen arm causing carpal tunnel syndrome or compartment
syndrome. Carpal tunnel syndrome may be related to the position of the wrist or excess distraction
if the wrist is placed in an external fixator. Compartment syndrome is swelling in the muscle
compartments, usually in the forearm, leading to severe pain, loss of nerve function and
a contracture. Finally, complex regional pain syndrome is a serious complication following
injury and is thought to be more common after cast immobilization than after surgery. The
provoking factors for regional pain syndromes, however, are very complex but the condition
often leads to chronic pain and stiffness. Prognosis following non-operative treatment
In children the outcome of distal radius fracture treatment in casts is usually very successful
with healing and return to normal function expected. Some residual deformity is common
but this often remodels as the child grows. In the elderly, distal radius fractures heal
and may result in adequate function following non-operative treatment. A large proportion
of these fractures occur in elderly people that may have less requirement for strenuous
use of their wrists. Some of these patients tolerate severe deformities and minor loss
of wrist motion very well even without reduction of the fracture. In this low demand group
only a short period of immobilization is indicated as rapid mobilization improves functional
outcome. In younger patients the injury requires greater
force and results in more displacement particularly to the articular surface. Unless an accurate
reduction of the joint surface is obtained, these patients are very likely to have long
term symptoms of pain, arthritis, and stiffness. Surgery
Contemporary surgical options have improved treatment of this injury. Techniques include
Open Reduction Internal Fixation, external fixation, percutaneous pinning, or some combination
of the above. Significant advances have been made in operative open reduction and internal
fixation. Two newer treatment are fragment specific fixation and fixed angle volar plating.
These attempt fixation rigid enough to allow almost immediate mobility, in an effort to
minimize stiffness and improve ultimate function, although there has been no demonstration of
improved final outcome from early mobilization. Although restoration of radiocarpal alignment
is thought to be of obvious importance the exact amount of angulation, shortening, intra
articular gap/step which impact final function are not exactly known. The alignment of the
distal radioulnar joint is also important as this can be a source of a pain and loss
of rotation after final healing and maximum recovery.
Prognosis varies depending on dozens of variables. If the anatomy is not properly restored, function
may remain poor even after healing. Restoration of bony alignment is not a guarantee of success,
as there are significant soft tissue contributions to the healing process.
An arthroscope can be used at the time of fixation to evaluate for soft tissue injury.
Structures at risk include the triangular fibrocartilage complex and the scapholunate
ligament. Scapholunate injuries in radial styloid fractures where the fracture line
exits distally at the scapholunate interval should be considered. TFCC injuries causing
obvious DRUJ instability can be addressed at the time of fixation.
Incidence Distal fracture of the radius is the most
commonly occurring fracture in adults. It is common in the elderly because of the frequent
osteopenia and osteoporosis in this age group. This is also a common injury in children which
may involve the growth plate. A similar fracture in children involving the growth plate is
called a Salter-Harris fracture. In young adults, the injury is often very severe because
it requires greater force to produce the injury. References
External links Frykman
Melone Universal.
ShowYourCase.com - Volar Barton's distal radius fracture.
Orthopaedic Trauma Association Fracture Classification Radius and Ulna
Wheeless' Textbook of Orthopaedics Fractures of the Radius
Wheeless' Textbook of Orthopaedics Closed Reduction of Distal Radius Fractures - Good
account and list of references. NLM MeSH entry on Colles' Fracture