3.1 Plain x-rays

In simple fracture patterns, plain AP and lateral x-rays are performed before and after reduction.

3.2 Computed tomography and magnetic resonance imaging

Computed tomography (CT) is often used in multifragmented intraarticular fractures for preoperative planning to assess associated injuries and sometimes for decision making. Computed tomography scans performed after reduction generally provide more information than those performed while the fracture is displaced. In acute DRFs, magnetic resonance imaging (MRI) examination is not of clinical importance.

3.3 Radiographic parameters

Specific radiographic parameters with biomechanical and clinical implications have been developed to assess the radiocarpal joint:

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  Palmar tilt—angle subtended by the line perpendicular to the long axis of the radius and a line drawn from the dorsal to palmar cortex of the distal radius (average: 10–12°) ( Fig 3.6-3 ).

  
  
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  Radial inclination—angle between the longitudinal axis of the radius and a line connecting the radial cortex of the apex of the radial styloid and the central point of the sigmoid notch of the distal radius (average: 22–23°) ( Fig 3.6-4 ).

  
  
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  Radial length—distance between the apex of the radial styloid and the level of the ulnar head at the distal radioulnar joint (DRUJ) (average: 11–12 mm) ( Fig 3.6-5 ).

  
  
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  Ulnar variance—difference in axial length between the central point of the ulnar corner of the sigmoid notch of the distal radius and the most distal extension of the ulnar head on the AP view ( Fig 3.6-6 ).

3.4 Assessment of distal radioulnar joint instability

The distal radioulnar joint is dynamically tested for instability intraoperatively and after anatomical reconstruction of the DRF. In neutral position, the ulna translates in comparison with the uninjured side. The testing of the DRUJ is of high clinical importance, as for example in cases where the DRUJ is stable, the ulnar styloid fracture can be treated nonoperatively.

In stable conditions of the DRUJ, a nonunion of the ulnar styloid is usually asymptomatic. None of the most recent studies demonstrate that acute fixation of ulnar styloid fractures has been beneficial [12]. For very rare cases of chronic ulnar symptoms, results of secondary repair have been encouraging, making late fixation of ulnar styloid in symptomatic patients an acceptable option.

4.1 AO/OTA Fracture and Dislocation Classification and others

There are a number of fracture classifications, such as AO/OTA, Frykman, Melone, Fernandez, Pechlaner, etc, and no single gold standard system. Andersen et al [13] compared the Frykman, Melone, Mayo, and AO/OTA classification systems and reported a low degree of interobserver and intraobserver agreement for plain x-rays. Arealis et al [14] reported that even the use of CT scans does not increase the interobserver or intraobserver reliability for various classification systems.

In scientific papers comparing results of DRFs, the AO/OTA classification is most often used. Eponyms describe the fracture pattern more clearly, as for example a Colles’ fracture defined as dorsally and a Smith′s fracture as palmarly displaced.

4.2 Frequently used eponyms

4.2.1 Colles’ fracture

Colles’ fracture is a fracture of the distal radius with dorsal and radial displacement of the wrist and hand. Dorsal metaphyseal comminution is typical. The fracture is sometimes referred to as a “dinner fork” or “bayonet” deformity due to the shape of the resultant forearm ( Fig 3.6-7 ) [15].

4.2.2 Smith′s fracture

This fracture of the distal radius is also sometimes known as a reverse Colles’ fracture or Goyrand-Smith′s fracture. The distal fracture fragment is displaced palmarly, as opposed to a Colles’ fracture where the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments, and it may or may not involve the articular surface of the wrist joint ( Fig 3.6-8 ). Smith′s fractures are less common than Colles’ fractures [16].

4.2.3 Barton′s fracture

This fracture is an intraarticular fracture of the distal radius with dislocation of the radiocarpal joint. There are two types of Barton′s fractures, ie, dorsal and palmar, the latter being more common. The Barton′s fracture is caused by a fall on an extended and pronated wrist, increasing carpal compression force on the dorsal rim. The intraarticular component distinguishes this fracture from a Smith′s or a Colles’ fracture ( Fig 3.6-9 ) [17].

4.2.4 Chauffeur′s fracture

This intraarticular fracture of the radial styloid process with subluxation of the carpus, which is attached to the styloid fracture fragment, is also known as a Hutchinson′s fracture or backfire fracture. The radial styloid is within the fracture fragment, although the fragment can vary markedly in size. The fracture extends proximally in a variable oblique direction from essentially transverse to almost sagittal from the distal radial articular surface through the lateral cortex of the distal radius, thus separating the radial styloid from the rest of the radius ( Fig 3.6-10 ) [18, 19].

4.3 The three-column concept

This concept by Rikli et al [20] helps understand the fracture pattern in complex and intraarticular DRFs:

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  The radial column includes the radial styloid with the scaphoid facet.

  
  
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  The intermediate column consists of the lunate facet and the sigmoid notch, forming the distal radioulnar joint.

  
  
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  The ulnar column consists of the distal ulna along with the triangular fibrocartilaginous complex (TFCC).

4.4 Distal forearm fractures

Distal ulnar head and/or ulnar neck fractures associated with DRFs are defined as DFFs. Isolated ulnar styloid fractures must be distinguished from distal ulnar fractures (DUF). In 6% of cases, widely displaced DRFs in older adults are associated with DUF [21]. Of those, 13% are grade 1 open fractures according to Gustilo and Anderson, where the distal ulnar shaft penetrates the skin on the ulnar side.

4.5 Fracture dislocations

In these fracture patterns, the carpus follows either the palmar or the dorsal fracture fragment (usually the palmar or dorsal rim fragment of the intermediate column, lunate facet fragment) and leads to a carpal subluxation. Fracture dislocations should be treated operatively even in older adults.

4.6 Practical approach

Instead of using strict classification systems, we usually describe the following parameters:

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  Palmar or dorsal displacement of the distal fracture fragment. As palmarly displaced DRFs, these should be treated operatively.

  
  
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  Intraarticular or extraarticular fracture characteristics help describe the fracture severity.

  
  
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  Metaphyseal comminution results in increased instability.

  
  
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  Palmar or dorsal depression (die-punch fragment) of the intermediate column (lunate facet), the critical corner involving the DRUJ), is a factor ( Fig 3.6-11 ).

  
  
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  Any signs of fracture displacement with small palmar (teardrop) or dorsal rim fracture where the carpus follows the fracture fragment resulting in radiocarpal subluxation ( Fig 3.6-12 ).

  
  
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  Associated fractures of the ulnar column (ie, distal ulnar fracture) ( Fig 3.6-13 ). These increase the instability and require treatment of the ulnar column.

  
  
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  Associated carpal or soft-tissue injuries ( Fig 3.6-14 ). These require additional treatment (eg, suture of intrinsic ligaments).

5.1 Fracture manipulation versus splinting

Historically, displaced DRFs were reduced under local or general anesthesia in the emergency department and then immobilized with a below elbow plaster cast. Fracture reduction was assessed using x-rays after closed reduction and cast application. Nowadays it is controversial if acute DRF should be reduced initially in older adults for the following reasons:

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  Decreased bone mineral density (BMD) is associated with DRF instability and a 50% risk for secondary displacement after closed reduction and casting [23].

  
  
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  There is a high incidence in loss of reduction after cast treatment; 30% displace during the first 10 days and another 29% after 10 days [24].

  
  
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  Closed remanipulation after secondary displacement in patients treated nonoperatively is not successful [25].

  
  
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  There is no correlation identified between fracture classification, initial displacement, or final radiographic outcome in low demand patients, particularly in those with dementia in nursing homes [26].

  
  
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  The risk for displacement with an unacceptable radiographic result increases in patients older than 58 years [23].

  
  
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  Sakai et al [27] reported a significant correlation between increasing displacement of distal fracture fragment and lower BMD.

Patient age has been shown to correlate with fracture instability. Cumulative risk factors for the loss of reduction are:

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  Age greater than 60 years

  
  
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  More than 20° of dorsal angulation or 5 mm of radial shortening

  
  
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  Dorsal comminution

  
  
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  Ulnar fracture or intraarticular radiocarpal involvement [28]

Osteoporosis weakens the metaphyseal bone by decreasing trabecular bone volume, commonly resulting in a large metaphyseal void after reduction, which increases fracture instability [29, 30]. Nesbitt et al [23] reported that age is the only significant risk factor in predicting secondary displacement and instability in DRFs treated by closed reduction and immobilization. Considering these outcomes, the question arises whether reduction of displaced DRFs should be attempted. After reduction, the majority of these fractures will lose reduction and go on to radiographic malunion, but without evidence that this reliably leads to poor functional outcome. In our practice closed fracture reduction by fracture manipulation is indicated only in specific situations such as:

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  Simple fractures with dorsal angulation less than 20° and radial shortening of less than 5 mm, as fracture manipulation is more likely to lead to better anatomical fracture reduction [31].

  
  
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  If patients are polytraumatized.

  
  
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  If surgery is planned, in cases where the soft tissues are at risk or nerves are compressed by fracture fragments.

In most other situations, painful fracture manipulations can be avoided. Finger trap traction and below elbow cast application without any fracture manipulation as initial treatment option for acute DRF is suggested. After decrease of swelling, the cast is changed without any further manipulation. Wrists are immobilized in a short arm cast in a neutral position for 5 weeks. Active finger exercises are started immediately. After cast removal, physiotherapy is recommended.

5.2 Operative versus nonoperative

Several studies have demonstrated a high correlation between the anatomical result and the functional outcome in young, active, and high-functioning patients. Malunion of distal radial fractures can result in posttraumatic wrist arthrosis and unsatisfactory functional outcomes with a deformed and painful wrist [32, 33]. Thus, restoring articular congruity and radial length with open reduction and internal fixation (ORIF) is recommended for the treatment of DRFs in younger patients [34, 35].

The therapeutic choice in FFPs is often inappropriately based on the results of fracture treatment in much younger patients [32]. Distal radial fractures are a good example illustrating how decision making in older patients should differ considerably:

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  Older patients are a heterogenous group and with diverse demands.

  
  
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  Comorbidities contribute to increased perioperative risk.

  
  
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  Consequences of malunited fractures are much less predictable and often clinically insignificant.

Presently, there is no consensus regarding the best treatment for unstable DRFs in the older population [36].

In a single center prospective trial, the authors randomized 73 patients with a displaced and unstable DRF to ORIF with a palmar locking plate or to closed reduction and cast immobilization. There were no significant differences between the groups in terms of the range of motion (ROM) or pain relief during the entire follow-up period (P > .05). Patients in the operative group had lower Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, indicating better wrist function in the early postoperative time period (P < .05), but there were no significant differences between the groups at 6 and 12 months. However, grip strength was significantly better at all times in the operative group (P < .05). Furthermore, dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative than in the nonoperative treatment group at the time of the latest follow-up (P < .05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, P < .05). At the 12-month follow-up examination, the ROM, pain rating, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups ( Case 1: Fig 3.6-15 , Fig 3.6-16 ) [37].

Achieving anatomical reconstruction did not produce any improvement in ROM or ability to perform ADLs [37].

Treatment of DRFs not only depends on patient age but also on geographic variation, local culture, the surgeon′s training, or on the surgeon′s age [38, 39]. Nelson et al [40] reported that even among highly active older adults, distal radius malunion did not affect functional outcomes.

Related posts:

3.5 Olecranon 3.9 Femoral neck 3.16 Tibial shaft 3.14 Periprosthetic fractures around the knee 3.1 Proximal humerus 3.17 Ankle

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