3 Patient–Accident–Fracture Classification of Acute Distal Radius Fractures in Adults
Abstract
The patient–accident–fracture (PAF) classification of acute distal radius fractures (DRF) in adults was designed because there is not yet enough evidence in the literature to support the use of any classification systems in this particular field.
It was the author’s opinion that there was a need for the identification of more homogeneous groups of patients with DRF. Although the pathology remains a keystone factor, the extent of pretherapeutic radiological work-up and treatment options would match in priority the health status and functional needs of the patient.
The authors propose an innovative method to analyze and stratify acute DRF in adults. A one-page user-friendly chart includes criteria related to the patient (P), the energy of the accident (A), and the pathology of the fracture (F), including associated osseous/ligamentous ulnar and carpal lesions.
The preliminary results of the prospective use of the PAF chart in 1,650 consecutive adult patients (16 to 102 y) with unilateral acute DRF from a single academic upper extremity-specialized orthopaedic unit are presented.
A total of six homogeneous groups of patients is described. The relevance of this classification regarding the pretherapeutic radiological work-up and treatment options is discussed on an expert opinion basis. Specific studies of these groups may provide the guidelines that are currently lacking regarding the management of DRF.
3.1 Introduction
There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. 1 – 3
However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of pretherapeutic radiological work-up and the choice of treatment would best match the needs of the patient. 4
The purpose of this prospective epidemiological study based on 1,650 patients (1,650 wrists) was: (1) to propose a simple practical method allowing for a comprehensive analysis of DRF at the acute stage and (2) to identify from our preliminary results several homogeneous groups of patients within a wide array of acute DRF from an academic upper extremity-specialized orthopaedic center.
3.2 Material and Methods
From September 2008 to May 2018, a total of 1,650 consecutive patients presenting at our academic upper extremity-specialized surgery unit with acute unilateral DRF were included in a prospective epidemiological study. Criteria related to the patient, the accident, and the fracture type with associated injuries were included in a one-page chart that was previously described (▶Fig. 3.1). 5
3.2.1 Patient
Beside his/her age and gender, each patient was characterized by his/her general health status (normal 3, with comorbidities 2, or dependent 1). We arbitrarily defined by an interview at the acute stage the functional needs of the patient as maximum 3, intermediate 2, or minimal 1. All possible combination of general health status (1 to 3) and functional needs (1 to 3) could be encountered. Only patients “1–1,” “2–2,” or “3–3” were included in the present study.
3.2.2 Accident
The amount of energy of the accident may be an indirect predictor of the magnitude of the pathology of DRF, especially in terms of associated bony and/or ligamentous injuries. We defined high-energy accidents as 3 (such a fall from a roof or motorcycle high-velocity accident), medium-energy accidents as 2 (such as fall while playing tennis), and low energy accident as 1 (such as a simple fall). Polytraumatized and polyinjured patients were individualized from monoinjured patients because the treatment of DRF may not be a priority in the former.
3.2.3 Fracture
Distal Radius Fracture
The open or closed nature of the DRF and the presence of an acute associated carpal tunnel syndrome were recorded as well as the main Association for Osteosynthesis (AO) classification type “A,” “B,” or “C.” In addition, several anatomical factors that could have an influence on the prognosis and treatment such as distal radius comminution, distal fracture line, impaction, and cartilage defect were included. 2 , 6
A total of four extra-articular displacement criteria were defined on the initial PA views (Fig. 3.1). The radial inclination was defined by three classes around a “1” category where the radial inclination was considered as within normal limits (15–30°). Radial shortening was defined within three classes of ulnar variance, class 1 (less than 2 mm of positive ulnar variance) being considered as acceptable. The presence or absence of proximal diaphyseal irradiation of the fracture line was recorded. Radial translation (or radial shift) of the radius epiphysis with respect to the radius diaphysis was recorded.
Another four extra-articular displacement criteria were defined on the initial lateral view. The tilt of the distal radius in a dorsal or volar direction was recorded within three classes around an acceptable “1” class (0–15°). Anterior or posterior translation of the distal radius epiphysis with respect to the diaphysis was recorded within three classes around a “1” nontranslated position. Anterior, posterior, or circumferential comminution was recorded as it is a major prognosis factor in DRF. 6 , 7 Articular sagittal widening was also recorded as it has recently proven to be simple standard X-ray criteria suggesting a severe involvement of the articular radiocarpal aspect of the distal radius, which should be refined by a computed tomography (CT) scan.
An extra-articular displacement severity (EDS) score was defined as the sum of radial inclination, ulnar variance, dorsal or volar radial tilt, and sagittal translation figures. This score was comprised between 4 (acceptable displacement) and 12 (maximal distal radius epiphyseal displacement). An EDS of 5 to 8 defined a displaced DRF, whereas an EDS of 9 to 12 defined a severely displaced DRF according to extra-articular criteria.
Within the intra-articular group of DRF, four criteria were defined from the initial standard X-rays or emergency CT scan if available. The radiocarpal and distal radioulnar joint (DRUJ) articular step-off and gaps were defined as three classes. The step-off and gap of the sigmoid notch of the distal radius could only be defined from transverse CT scan slices. A step-off of less than 1 mm (class 1) was considered as acceptable. Step-off of 2 mm (class 2) or 3 mm or more (class 3) characterized significant or major intra-articular displacements. A gap of less than 1 mm (class 1) was considered as acceptable. Gaps of 2 mm (class 2) or 3 mm or more (class 3) characterized significant or major intra-articular displacements.
When only standard radiographs were available, a simple 6 points intra-articular radiocarpal displacement severity score was defined as the addition of the step-off and gap classes at the radiocarpal level.
When a CT scan was available, a 12 points intraarticular displacement severity (CT-IDS) score was defined as the sum of the radiocarpal and sigmoid notch step-off and gap classes at both radiocarpal and sigmoid notch spots. The CT-IDS was comprised between 4 (acceptable displacement) and 12 (maximal intra-articular displacement). A CT-IDS of 5 to 8 defined a displaced intra-articular DRF, whereas a CT-IDS of 9 to 12 defined a severely displaced intra-articular DRF.
Transverse CT scan slices were used to record the number of major fragments according to Medoff classification. 8 The presence of localized impaction, central impaction separation, or complete destruction of the radial distal surface was recorded. If applicable, arthroscopic findings (osteoarticular loose bodies, triangular fibrocartilage complex [TFCC], and scapholunate or lunotriquetral ligaments tears) were recorded.
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