Introduction

Distal radius fractures are common orthopaedic conditions and these represent a large percentage of injuries treated in the emergency room, office, and operating room settings. The distal radius articular surface and its alignment require special attention, as does the ligamentous stability of the distal radioulnar joint (▶Video 28.1, ▶Video 28.2).

I. Preoperative

1. 
   

   History

   
   
   
   
   1. 
      

      The mechanism of injury dictates the degree of injury severity. Attempts must be made to quantify both the amount of energy transmitted through the distal radius as well as the direction of the force transmitted.

      
      
   2. 
      

      Associated injuries more proximal to the distal radius should be assessed. The surgeon must ask about pain in the forearm, elbow, and shoulder.

   
   
2. 
   

   Physical exam

   
   
   
   
   1. 
      

      Always search entire extremity for signs of direct trauma, such as open wounds, bruising, or lacerations. Open fractures often include small skin lacerations that can be found on the ulnar wrist where the ulna styloid has penetrated through the skin.

      
      
   2. 
      

      Functional evaluation and point tenderness is noted on the entire extremity.

      
      
   3. 
      

      Thorough neurological examination of the median, ulnar, and radial nerves is imperative. This includes fine sensation and carpal tunnel syndrome findings.

      
      
   4. 
      

      Complete vascular examination is necessary but frequently normal.

   
   
3. 
   

   Anatomy

   
   
   
   
   1. 
      

      Osseous:

      
      
      
      
      1. 
         

         The radius bows laterally allowing for rotation around the straight ulna.

         
         
      2. 
         

         Articular surfaces include scaphoid and lunate facets separated by an interfacet prominence (sagittal ridge), and the sigmoid notch as part of the distal radioulnar joint (DRUJ; ▶ Fig. 28.1 ).

         

         
         
      3. 
         

         The radial bow and DRUJ relationships are necessary for proper forearm rotation.

      
      
   2. 
      

      Soft tissue:

      
      
      
      
      1. 
         

         Brachioradialis tendon inserts on the radial side of the styloid as the floor of the first dorsal compartment. It often acts as a deforming force in unstable fractures.

         
         
      2. 
         

         Pronator quadratus covers the volar distal surface of both the radius and ulna.

         
         
      3. 
         

         The triangular fibrocartilagenous complex (TFCC) stabilizes the DRUJ through superficial, and more important, deep ligaments.

         
         
         
         
         • 
           

           i. The superficial ligaments attach to the ulnar styloid, which is often fractured with distal radius fractures.

           
           
         • 
           

           ii. Deep ligaments run from the fovea of the ulna to the volar and dorsal rims of the sigmoid notch.

         
         
      4. 
         

         The radius and ulnar are strongly connected by the interosseous membrane ligaments.

         
         
      5. 
         

         Multiple extrinsic wrist ligaments stabilize the carpus. The dorsal radiocarpal ligament is a potential deforming force in comminuted intra-articular fractures.

      
      
   3. 
      

      Nerve and artery:

      
      
      
      
      1. 
         

         Anterior interosseous nerve (AIN) enters the pronator quadratus muscle proximally.

         
         
      2. 
         

         The median nerve runs volar to the distal radius with the profundus tendons between the two.

         
         
      3. 
         

         Ulnar nerve runs the length of the forearm deep to the flexor carpi ulnaris (FCU) muscle and tendon to just proximal to the wrist flexion crease where is passes into Guyon’s canal radial to the tendon and the pisiform.

         
         
      4. 
         

         Radial artery runs along the side of the forearm in close proximity to the radial metaphysis. A volar accessory branch crosses over the flexor carpal radialis (FCR) at the wrist flexion crease.

   
   
4. 
   

   Imaging

   
   
   
   
   1. 
      

      Radiographs—these are mainstay in assessment of distal radius fractures.

      
      
      
      
      1. 
         

         It is imperative that adequate wrist X-rays are obtained. If possible, obtain a zero-rotation posterior-anterior (PA) view, a lateral view, and a fossa lateral view.

         
         
      2. 
         

         Normal distal radius parameters:

         
         
         
         
         • 
           

           i. Radial height: 13 mm.

           
           
         • 
           

           ii. Radial inclination: 23 degrees.

           
           
         • 
           

           iii. Volar tilt: 11 degrees.

           
           
         • 
           

           iv. Teardrop angle: 70 degrees. A 45 degree pronated oblique view may help assess the dorsal ulnar cortex of the dorsal lunate fossa and the dorsal margin of the sigmoid notch.

         
         
      3. 
         

         Contralateral X-rays may help identify normal variant anatomy.

         
         
      4. 
         

         Fracture of the distal radius within 7.5 cm of the articular surface has been shown to be associated with a higher incidence of Galeazzi fracture and DRUJ injury.

      
      
   2. 
      

      Computed tomography (CT) scans—although not always necessary, CT can be useful (after closed reduction) for assessment of intra-articular involvement and surgical planning purposes.

      
      
   3. 
      

      Magnetic resonance imaging (MRI) studies—usually not necessary for most distal radius fractures but MRI can be useful in evaluating soft-tissue injuries including TFCC and scapholunate ligament injuries.

   
   
5. 
   

   Classification: Intraobserver and interobserver reliability is variable in most systems, so treatment indications based on classifications alone are difficult. Specific fracture-type eponyms are commonly utilized. Priority should focus on stable versus unstable patterns that require fixation.

   
   
   
   
   1. 
      

      AO/OTA classification:

      
      
      
      
      1. 
         

         Typically higher inter/intraobserver reliability than most other systems.

         
         
      2. 
         

         Good for description, but prognosis and treatment are not easily addressed.

      
      
   2. 
      

      Eponyms:

      
      
      
      
      1. 
         

         Volar/dorsal Barton fractures—partial articular fractures through oblique shear force. The carpus displaces with the fracture fragment making this an unstable fracture amenable to buttress plate fixation (▶ Fig. 28.2 ).

         

         
         
      2. 
         

         Chauffeur’s fracture—shear fracture line through the scaphoid facet exiting the radial metadiaphyseal cortex (▶ Fig. 28.3 ).

         

         
         
         
         
         • 
           

           i. Longitudinal load and pull of the brachioradialis often displace the main radial styloid fragment.

           
           
         • 
           

           ii. Buttress or interfragmentary fixation is necessary.

         
         
      3. 
         

         Colles’ fracture (▶ Fig. 28.4 )—metaphyseal fracture with dorsal angulation and displacement.

         

         
         
         
         
         • 
           

           i. Often fragility fracture and cortical comminution present a significant concern for fracture stability.

         
         
      4. 
         

         Smith’s fracture—metaphyseal fracture with volar angulation and displacement (▶ Fig. 28.5 ).

         

         
         
      5. 
         

         Galeazzi fractures are fractures of the radius with an associated DRUJ disruption. These fractures can be of either distal radius or the radial shaft (▶ Fig. 28.6 ).

         

      
      
   3. 
      

      Column theory:

      
      
      
      
      1. 
         

         Characterization of fracture patterns that reference three columns (▶ Fig. 28.7 ).

         

         
         
      2. 
         

         Stabilization must be evaluated and treated appropriately for all three columns. Particular attention is given to the intermediate column consisting mostly of the lunate facet and its supportive bone.