2. HISTORY
• First surgeon to recognize these injuries was Pouteau in 1783,
although his work was not widely publicized.
• Later Abraham Colles in 1814 gave the classic description of this
fracture.
• Dupuytren brought attention that this is a fracture rather than a
dislocation as it was previously assumed.
• Barton in 1838 described wrist subluxation consequent to intra-
articular fractures of distal radius which could be dorsal or volar.
• Smith described fracture of distal radius with forward displacement.
3. INTRODUCTION
• Distal radius fractures occur through the distal metaphysis of the
radius.
• It may involve the articular surface frequently involving the ulnar
styloid.
• Most commonly results from a fall on the outstretched hand
1. Forced extension of the carpus
2. Impact loading of the distal radius
4. • Fractures of distal end radius are classified on the basis of :
1. Presence or absence of intra-articular involvement
2. Degree of comminution
3. Dorsal or volar displacement
4. Involvement of distal radio-ulnar joint
5. INCIDENCE
• Fractures of the distal end radius represent approximately 16% of all
fractures treated by orthopaedic surgeons.
• There are three main peaks of fracture incidence :
1. Children aged 5-14 years
2. Males under 50 years (high velocity)
3. Females over 40 years of age (low velocity)
• Elderly – most commonly extra-articular
• Young – most commonly intra-articular
• Most common risk factors for elderly patients are decreased bone
mineral density, female gender & early menopause.
6. ANATOMY
• The epiphysis of the distal radius usually
appears at one year of age, it grows more in
lateral than medial direction and forms the
radial styloid process and three articular
facets (scaphoid, lunate and sigmoid notch).
Distal radius fuses with diaphysis at 17 years
of age in females and 19 years in male.
• The metaphysis is flared distally in both the
AP and the lateral planes with thinner
cortical bone lying dorsally and radially . The
significance of the thinness of these cortices
is that the fractures typically collapse dorso-
radially.
7. • In the anteroposterior plane the strongest bone is found under the
lunate facet of the radius. The line of force passes down the long finger
axis through the capito-lunate articulation and contacts the radius at
this location.
• The “palmar ulnar corner” is often referred to as the keystone of the
radius. It serves as the attachment for the palmar distal radioulnar
ligaments and also for the stout radiolunate ligament. Displacement of
this fragment is associated with palmar displacement of the carpus and
also with loss of forearm rotation.
8. • The medial aspect of distal radius is
triangular and presents an articular
facet at its distal end which is
concave and is called sigmoid notch,
which articulates with the convex
head of the distal ulna. The origin of
TFCC attaches to the distal border of
sigmoid fossa.
• TFCC is the main stabilizer of distal
radioulnar joint in addition to
contributing to ulnocarpal stability.
9.
10. • The dorsal aspect of the distal radius
is narrower than the volar aspect.
• The most prominent ‘V’ shaped crest
on the dorsal aspect is called lister’s
tubercle.
• In axial loading, radius bears 80% of
the load and ulna bears 20% of the
load.
11. LIGAMENTOUS ANATOMY
• Extrinsic ligaments around the distal end radius play an important role in
closed reduction of the fractures (Ligamentotaxis).
• The palmar extrinsic ligaments are attached to the distal radius, and it is
these ligaments that are relied on to reduce the components of a fracture
using closed methods.
12. Applied anatomy
• Jacob and his co-authors interpreted the wrist as consisting of
three distinct columns, each of which is subjected to different
forces and thus must be addressed as discrete elements
13. The radial column, or lateral column
The radial column consists of the scaphoid
fossa and the radial styloid. Because of
the radial inclination of 22 degrees,
impaction of the scaphoid on the articular
surface results in a shear moment on the
radial styloid causing failure laterally at
the radial cortex. The radial column,
therefore, is best stabilized by buttressing
the lateral cortex
14. The intermediate column
The intermediate column consists of the
lunate fossa and the sigmoid notch of the
radius. The intermediate column may be
considered the cornerstone of the radius
because it is critical for both articular
congruity and distal radioulnar function.
Failure of the intermediate column occurs
as a result of impaction of the lunate on
the articular surface with dorsal
comminution. The column is stabilized by
a direct buttress of the dorsal ulnar aspect
of the radius
15. The medial column
The ulnar column consists of
the ulna styloid but also
should include the TFCC and
the ulnocarpal ligaments
16. DIAGNOSIS
• There is usually a history of fall on out-stretched hand.
• Wrist is typically swollen with ecchymosis and is tender.
• Visible deformity of the wrist with hand most commonly displaced in
dorsal direction.
• Adequate and accurate assessment of the neurovascular status of the
hand is performed before any treatment is given out.
• Radiograph of the wrist are taken in AP, Lateral & Oblique views.
• CT scan of wrist can be done to see the extent of intra-articular
involvement & communition.
17. SOME IMPORTANT MEASUREMENTS
• Distal radio-ulnar joint congruity can be seen by the following
measurements-
1. Palmar tilt – normal range is 11 to 12 degrees
2. Radial inclination – normal range is 20 to 23 degrees
3. Ulnar variance – normal range is 0 to -2mm
4. Radial length – normal range is 10 to 12 mm
5. Carpal mal-alignment
18. 1) Volar / Palmar Tilt
• On a true lateral view a line is drawn connecting the most distal points of
the volar and dorsal lips of the radius. The volar or palmar tilt is the angle
created with a line drawn perpendicular to the longitudinal axis of the
radius.
19. 2) Radial Length / Height
• Radial length is measured on the AP radiograph as the distance
between one line perpendicular to the long axis of the radius passing
through the distal tip of the radial styloid & second line intersects
distal articular surface of ulnar head.
20. 3) Ulnar Variance
• This is a measure of radial shortening and should not be confused with
measurement of radial length. Ulnar variance is the vertical distance
between a line parallel to the medial corner of the articular surface of the
radius and a line parallel to the most distal point of the articular surface of
the ulnar head, both of which are perpendicular to the long axis of the radius
21. 4)Radial Inclination
On the AP view the radius inclines towards the ulna. This is measured by the
angle between a line drawn from the tip of the radial styloid to the medial
corner of the articular surface of the radius and a line drawn perpendicular to
the long axis of the radius.
22. 5)Carpal Malalignment
On a lateral view one line is drawn along the long axis of the capitate and one
down the long axis of the radius. If the carpus is aligned, the lines will intersect
within the carpus. If not, they will intersect outwith the carpus
23. • GREATER THAN 2mm articular step-off
• >10 degrees of dorsal tilt
• <15 degrees of radial inclination
• Loss of radial height > 5mm
• Communition of one cortex across midaxial line of lateral xray
• Communition of both dorsal palmar cortices
• Irreducible fracture
• Loss of reduction after attempt to reduce.
INDICATORS OF INSTABILITY
24. CLASSIFICATION
• There is perhaps no other fracture in the orthopaedic literature that
has garnered so many eponyms over time than fractures of the distal
radius.
• Various eponyms are :
1. Colle’s fracture
2. Smith’s fracture
3. Barton’s fracture
4. Chauffer’s fracture / hutchinsons fracture
5. Die punch fracture / lunate load fracture
25. Colle’s fracture
• It is an extra-articular fracture occurs at cortico-cancellous junction of distal end
of radius within 2cm from the articular surface
• The distal fragment is usually displaced dorsally.
• It may extend into DRUJ with six displacements
Impaction
Lateral displacement
Lateral rotation (angulation)
Dorsal displacement
Dorsal rotation (angulation)
Supination.
It may often accompany fracture of the ulnar styloid which signify avulsion of the
TFCC and ulnar collateral ligaments
26.
27. Smith’s fracture/Reverse colle’s fracture
• Occurs at the same level on the distal
radius as a colles' fracture.
• Distal fragment displaced in palmar
(volar) direction with a "garden spade"
deformity.
• Smith's fracture typical deformity:
1. Dorsal prominence of the distal end
of the proximal fragment
2. Fullness of the wrist on the volar side
due to the displaced distal fragment
3. Deviation of the hand toward the
radial side
28. Barton’s fracture
• It is an intrarticular fracture dislocation or subluxation
in which the rim of the distal radius dorsally or volarly
is displaced with the hand and carpus
• There are 2 types
Dorsal barton
volar barton
Dorsal barton
Volar barton
29. Chauffeur’s fracture/hutchinson fracture
• It is an intra-articular fracture involving
the radial styloid, the radius is cleaved
in a sagittal plane and the fragment is
displaced proximally.
• Isolated fracture of the radial styloid
are fairly common from backfiring of
starting handle of car
30. Lunate load/Die punch fracture
• It is an intraarticular fracture with displacement of the
medial articular surface which usually represents a
depression of dorsal aspect of lunate fossa
31. • Ideal classification system should describe:
•Type of injury
•Severity
•Evaluation
•Treatment
•Prognosis
32. Common Classifications
1. Gartland & Werley
2. Frykman (radiocarpal & radioulnar)
3. AO
4. Melone (impaction of lunate)
5. Fernandez (mechanism)
33. Gartland & Werley
1. Simple Colles fracture without intrarticular involvement
2. Comminuted Colles' fractures with intra-articular extension without displacement
3. Comminuted Colles' fractures with intra-articular extension with displacement
4. Extra-articular, undisplaced
35. Melone’s classification
Type I: Stable fracture without displacement. This
pattern has characteristic fragments of the radial
styloid and a palmar and dorsal lunate facet.
Type II: Unstable “die punch” with displacement of
the characteristic fragments and comminution of
the anterior and posterior cortices
• Type IIA: Reducible
• Type IIB: Irreducible (central impaction
fracture)
Type III: “Spike” fracture. Unstable. Displacement
of the articular surface and also of the proximal
spike of the radius
Type IV: “Split” fracture. Unstable medial complex
that is severely comminuted with separation and
or rotation of the distal and palmar fragments
Type V: Explosion injury
effect of the impaction of the lunate on the
radial articular surface to create four
characteristic fracture fragments
37. Classification – Fernandez (1997)
1. Bending- metaphysis fails under
tensile stress (Colles, Smith)
Extra-articular
2. Shearing- fractures of joint surface
Intra articular
(Barton, radial styloid)
38. 3. Compression - intraarticular fracture with
impaction of subchondral and metaphyseal bone
(die-punch)
Complex articular fracture & radial pilon fracture
4. Avulsion- fractures of ligament attachments
(ulna, radial styloid)
5. Combined complex - high velocity injuries
39. Preserve hand and wrist function
Realign normal osseous anatomy
promote bony healing
Avoid complications
Allow early finger and elbow ROM
Goals of treatment
40. RATIONALE FOR TREATMENT
The goal of treatment of these fractures is a
wrist that provides sufficient pain-free motion
and stability to permit vocational and daily
activities in all age groups without the
propensity for future degenerative changes in
the young
43. Indications for Closed Treatment
Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement- acceptable
alignment
44. Technique of Closed Reduction
Anesthesia (pain relief & decrease muscle spasm)
• Hematoma block
• Intravenous sedation
• Bier block
Traction: finger traps and weights or manual traction
Reduction 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.
45. Post reduction management
1. Take x-ray immedaitely after the application of the
cast. If reduction is not satisfactory, another attempt to
acheive accurate reduction should be made.
2. If there is any circulatory embarrassment, split the cast
along the dorsum of its entire length.
3. Elevate the arm with the fingers pointing towards the
ceiling for the first 48 hrs.
4. Take x ray again on the 5th and 10th days ,check for
maintanance of position.
5. Institute physical therapy, heat, gentle massage, water
massage and active exercises for the fingers, elbow and
shoulder.
46. • Exercise programme:
1) Maximum extension of all digits
2) Opposition of the thumb
3) The grasp or fist exercise with all finger flexing to the
palmar creases or as near as possible to it
4) The claw exercise with the MCP joint of the fingers
kept extended but the IP joint maximally flexed
5) The table top exercise with the MCP joint maximally
flexed but the IP joint extended
6) Abduction and adduction of all fingers
7) Plus use shoulder and elbow is a must
47. Complications
• Failure or loss of reduction
• Skin complications
• Tendon adhesions and entrapement
• Carpal tunnel syndrome due to excessive palmar flexion
• Nerve complications
• Vascular injury
48. Indications for Surgical Treatment
1. High-energy injury with instability
2. Comminuted displaced intraarticular fracture
3. Open injury
4. Radial inclination < 15°
5. Articular step-off, or gap > 2mm
6. Dorsal tilt > 10 °
7. DRUJ incongruity
8. Failed closed reduction
49. 1.Percutaneous direct pinning
• Aim of this procedure is to fix the mobile fragment to
the opposite cortex proximal to the fracture
• Direct pinning of the fragments especially the
intermediate column through the distal ulna add
stability to the DRUJ and medial half of articular surrface
• Application is extrafocal where entry point of k wire is
away from fracture site mainly 2 types a)transulnar
b)transradial
• Indications-a)nonarticular displaced b)articular
nondisplaced c)articular displaced,all of which are
reducible and stable after reduction
• Contraindications are severe osteoporosis,severe
communition,soft tissue interruption and chauffer
fracture
50. AFTERTREATMENT
The arm is immobilized in a cast below the elbow with
the forearm and wrist in neutral position. The Kirschner
wires that have been cut off just beneath the skin are
removed at 6 weeks. The wrist is supported with a
removable static splint, and gradual range-of-motion
exercises are permitted
51.
52. 2.Kapandji technique of intrafocal pinning with pins for
nonarticular fracture
• In intrafocal pinning a smooth k-wire is inserted after a
manual reduction,through a short skin incision,directly
into the fracture line
• Secondary displacement is made impossible by
immediate contact of the distal fragment with the arum
nut of the pins which are working as an abutement,not
as a resistant component
53. Kapandji technique of “double
intrafocal wire fixation” to reduce
and maintain distal radial
fractures. A 0.045- or 0.0625-inch
Kirschner wire is introduced into
the fracture in a radial to ulnar
direction. When the wire reaches
the ulnar cortex of the radius, it is
used to elevate the radial
fragment and recreate the radial
inclination. This wire is then
introduced into the proximal
ulnar cortex of the radius for
stability. A second wire is
introduced at 90 degrees to the
first in a similar manner to restore
and maintain volar tilt.
55. Spanning (Ligamentotaxis)
•A spanning fixator is one which fixes distal
radius fractures by spanning the carpus;
I.e., fixation into radius and metacarpals
•Bridging external fixation allows
distraction across the radiocarpal joint and
directly neutralizes axial load.
•Ligamentotaxis of the fracture fragments
•Adjunctive fixation and supplemental
bone grafting results in earlier union.
56. Addition of percutaneous pinning improve the stability of external
fixation and prevent loss of reduction
58. 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.
•Indication : extra-articular or minimal intra-
articular dorsally displaced fractures with
metaphyseal instability
•Contraindication : lack of space for pins in the
distal fragment. 1 cm of intact volar cortex
required for purchase of pins
62. Open Reduction and Internal Fixation
Open reduction of articular fractures of the distal radius
is indicated in active patients with good bone quality
when anatomic restoration of the joint surface cannot
be achieved by closed manipulation, ligamentotaxis, or
percutaneous reduction maneuvers or as an alternative
to percutaneous fixation at the preference of the
patient or surgeon.
63. Dorsal plating
• Internal fixation using a dorsal plate has several
theoretical advantages.
• Technically familiar to most surgeons, the approach
avoids the neurovascular structures on the palmar side.
• Further, the fixation is on the compression side of most
distal radius fractures and provides a buttress against
collapse.
• Initial reports of the technique demonstrated successful
outcomes with the theoretical advantages of earlier
return of function and better restoration of radial
anatomy than was seen with external fixation.
64. •However, there were increasing reports of extensor
tendon ruptures because of prominent hardware,
particularly at Lister tubercle.
•The more distally the plate is applied on the dorsum of
the wrist, the more proximally the distal screws need to
be directed to avoid articular penetration.
•This oblique orientation of the screws allows the distal
fragment to displace palmarly.
•The palmar displacement of the fragment is particularly
problematic because it results in
(1) incongruity at the distal radioulnar joint and
(2) prominence of the hardware dorsally with the
tendency for extensor tenosynovitis or tendon rupture
65. Operative Technique
• A longitudinal incision is centered over the fracture in line with the ulnar aspect of
Lister tubercle.
• The extensor retinaculum is incised in a z-plasty manner that allows for one limb to
be placed over the plate and the second limb to be repaired over the extensor
tendons to prevent bow-stringing of the tendons with wrist extension.
• The extensor pollicis longus tendon is dislocated from its position at the tubercle
and subperiosteal dissection is performed radially and ulnarly.
• Care should be taken to preserve all of the dorsal fragments for re-establishment
of radial length.
• Traction is then applied by either an assistant or by the use of finger traps with
weights suspended off the end of the table.
• Care should be taken to ensure that the hand is not pronated relative to the
forearm.
69. Volar Plate Fixation
Regardless of the displacement of the distal
fragment (dorsal, volar, radial), volar plating of both
articular and nonarticular fractures is an effective
fixation method that may reduce some of the soft
tissue complications associated with dorsal plating.
Advantages of palmar exposure and volar plating
include the following
70. Operative technique
• Palmar plates may be applied through either a flexor carpi radialis
(FCR)/radial artery interval or through a midline flexor
tendon/ulnar neurovascular bundle interval. The FCR/radial artery
approach is preferable for (1) fixation of dorsally displaced
fractures with dorsal comminution and (2) fixation of partial
articular fractures (articular shear fractures). The skin incision is
centered over the FCR, with care being taken to avoid injury to the
palmar cutaneous branch of the median nerve that lies ulnar to
the tendon. The radial artery is mobilized, and dissection is carried
radially by releasing the brachioradialis tendon from the radial
styloid.
71. The second surgical approach to the palmar radius is the flexor
tendon/ulnar neurovascular bundle interval. The skin incision is
centered over the ulnar border of the palmaris longus, the flexor
tendons are mobilized radially, and the ulnar neurovascular
bundle is taken ulnarly. With this approach the pronator
quadratus is released from the ulna. The incision may be
extended distally to release the transverse carpal ligament,
particularly if the patient had any median nerve symptoms
preoperatively. This incision is preferred when the majority of the
comminution is at the palmar lunate facet.
72.
73.
74. • Minimal volar comminution facilitates reduction of dorsally displaced
fractures.
• Anatomic reduction of the volar cortex facilitates restoration of radial
length, inclination, and volar tilt.
• Avoidance of additional dorsal dissection helps preserve the vascular
supply of comminuted dorsal fragments
• Because the volar compartment of the wrist has a greater cross-sectional
space and the implant is separated from the flexor tendons by the pronator
quadratus, the incidence of flexor tendon complications is lessened.
• The use of fixed-angle volar plate designs avoids screw “toggling” in the
distal fragment and thus reduces the danger of secondary displacement
• When stabilized with a fixed-angle internal fixation device that uses
subchondral pegs or screws, control of shortening and late displacement of
articular fragments are improved and the need for bone grafting reduced
ADVANTAGES
75. Complications
• Locking plates is the potential for articular penetration
with distal plate position on the palmar surface of the
radius
• Collapse of the fracture also can lead to joint penetration
by the distal screws especially in osteopenic
patients
• Extensor tendon problems can be caused by penetration
76. Complications of Distal radius fractures
1) Chronic Regional Pain Syndrome
2) Nonunion
• Nonunion of distal radius fractures is rare but presents unique
treatment challenges because of the associated pain, joint
contractures, tendon imbalance or rupture, and occasional severe
bony deformity
• nonunion of ulnar styloid process fractures in conjunction with distal
radius fractures is quite common and yet is rarely symptomatic
• Treatment of distal radius nonunion must be individualized and based
on the patient's symptoms, functional deficit, and bony substance