Introduction
Distal radius fractures (DRFs) are one of the most common fractures of the human body. Surgery is appealing to surgeons, and great results have been presented in the literature. The surgeon should know that many fractures respond well to simple casting and that, conversely, surgery is seeded with major complications. Indications should not be taken lightly. The intention of this chapter is to present the general approaches because the complexity of the issue prevents it from being presented in its entirety. Complications can occur with invasive surgery but also with a conservative approach in unstable fractures. Both instances are major sources of patients’ dissatisfaction. The reader is invited to become familiar with the topic here and is referred to treatises and the original papers to gather all the intricacies of the treatments, which in one way or another, the lead author has been lucky enough to contribute to their understanding and treatment. In this chapter, the lead author summarizes the essential approaches and his preferred method and advice, and then an expert team discusses some of the topics to provide broad perspectives.
Essential knowledge
Anatomical points
The radius articular surface has a radial inclination averaging 22 degrees and a volar tilt of 11 degrees. The radial styloid lies distal to the styloid process of the ulna. The articular surface of the distal radius is biconcave and covered with hyaline cartilage. A smooth anteroposterior ridge divides the articular surface into two facets: a triangular lateral facet, which articulates with the scaphoid, and a quadrilateral medial facet, which articulates with the lunate. The medial surface of the distal radius forms a semicircular notch, which articulates with the ulna head—the distal radioulnar joint (DRUJ). This articulation enables the radius to rotate around the ulna. Radial shortening is defined as the distance of proximal migration of the ulna relative to the radius at the DRUJ. Ulnar variance is the length of the ulna compared to the length of the radius at the DRUJ, with normal range between −2 mm and +2 mm.
Clinical presentation, diagnosis, and essential treatment
The reader is referred to classic textbooks and chapters for classification and general presentation. The AO classification (A: extra-articular, B. partial articular, C. complete articular; each having 3 subtype 1, 2, 3) may be the one most often used both clinically and in reports. The Frykman classification was often used previously. Among others used clinically are the Fernandez, McMurtry and Jupiter, Mayo, Jenkins classification. The terms Colles fracture (dorsally angulated extra-articular fracture) and Barton fracture (intraarticular fracture with dorsal displacement of the fragment) are still used to describe fractures. A Smith’s fracture is a palmarly angulated extraarticular DRF, which is less common. A die-punch fracture (a depression fracture of the lunate fossa of the distal radius) or radial styloid fracture may occur.
Many DRFs occur in people over 60 years old after a fall from a standing position. Falling with the hand stretched out and striking the ground is the most common cause of this fracture. Traffic accidents and severe open trauma are other causes. The patient may present with normal appearance in the wrist when the fracture is nondisplaced or minimally displaced, or there may be radial deviation and dorsal angulation of the hand on the forearm if the fracture is angulated. Typical dinner fork deformity, also called a bayonet deformity, results from remarkable dorsal angulation and radiodorsal displacement of the fracture. Pain is a common complaint along with restriction of wrist motion and swelling of the wrist.
On arrival, anteroposterior, lateral, and oblique radiograph views are routinely taken. Plain films are essential in making the diagnosis. Although deformity of the distal radius can be entirely obvious, nondisplaced fractures may be subtle to detect during the physical examination, sometimes presenting as pain and point tenderness without swelling or deformity.
Once the diagnosis of DRF has been made with plain x-rays, the next step is to apply a splint if the fracture is minimally displaced or to reduce it after traction under a hematoma block if the DRF is amenable to cast treatment. Note that if there is a surgical indication, there is no benefit in trialing a reduction, unless a nerve is compressed. A splint should be applied and changed after several days to a full cast to provide additional, ongoing support. Not appreciating that the simplest distal radius fracture can be a source of major complications can put the forearm function (and the surgeon) at high risk.
If a patient complains of unusual pain, particularly when the fingers are passively extended gently, proceed immediately to remove any constricting bandages, feel the tension of the volar forearm compartment, and if hard (or you have any doubt), take the patient immediately to the operating room and release the compartments. The error of not doing so is unforgiving ( Fig. 5.1 ).
A CT scan is not needed in most fractures but is invaluable for assessing intraarticular fractures. I recommend that the surgeon analyze and reformat the supplied images (in DICOM format) in order to be able to assess the deformity and obtain useful information. In complex fractures, I systematically make four cuts in the coronal and five in the sagittal planes ( Fig. 5.2 ).
This set of slices gives a general idea of the fracture and helps to locate step-offs and/or misaligned fragments. Nevertheless, some more work needs to be done to get the maximum from the crude images that the CT scan provides. The first refined information comes from the pure articular view . This is a general overview of the articular surface (like a bird’s eye view) and is helpful for arthroscopy ( Fig. 5.3 ) but can be further used to define the shape of any specific fragment by moving the corresponding axis.
Treatment strategies and methods
Although there are several ways of handling fractures operatively (cast, Kirschner [K] wires, and plates) and there is some overlap, some fractures by definition should be treated with plating, and some should not be operated on at all. Perhaps there is currently a trend to “overplating” in the belief that a better result can be assured. However, correct plating is not easy, and incorrect technique can lead to major complications. By the same token, malunions after surgery may occur and can be avoided by properly executed surgery. Understanding the personality of the fracture and the expected outcome if treated nonoperatively can be of help at the time of decision-making.
Nonoperative treatment
Nonoperative treatment is the most common method of treatment of DRF with the use of a plaster cast, splint, or functional brace. , This is indicated for partial or a non-displaced DRF or a displaced DRF after successful stable reduction with near-normal alignment. The successful reduction usually means complete correction of the dorsal tilt or less than 10 degrees of dorsal tilt, a congruent articular surface with less than 1 mm step-off, less than 2 or 3 mm of radial shortening, and almost normal radial inclination.
For an incomplete or non-displaced fracture, a cast is applied to protect the wrist in resting (or functional) position for 5 weeks. For an incomplete fracture, a splint can be used, which is usually sufficient. For a complete fracture with remarkable swelling of the wrist, a below-elbow dorsal splint, or palmar and dorsal splint is applied, then a cast is applied a few days or a week later. If swelling is not severe, a cast can be applied immediately. The cast is applied to protect the wrist in a position to favor maintenance of reduction, with ulnar deviation and mild to moderate flexion for a typical Colles fracture or in functional position of the wrist for a non-displaced DRF. The cast should not extend distally beyond the metacarpophalangeal joint to allow for full digital motion, and the thumb is left free. If the wrist is initially casted (or splinted) in remarkable flexion, the cast (or splint) need to be changed to the functional position 3 weeks after initial casting or splinting. The duration of casting is usually about 6 weeks, followed by a functional brace for 2 to 3 more weeks if needed.
Although in this chapter fractures in adults is mainly discussed, I will touch briefly on children. The latter most often sustain a stable buckle or greenstick fracture, which does not need surgical treatment at all (a 3-week splinting suffice). The same applies to stable, nondisplaced DRFs in children (4–6 weeks of immobilization). If the fracture is displaced, one has to forecast the spontaneous correction capability that is dependent on the age of the immature patient and the amount of angulation. An epiphysiolysis of the distal radius can be corrected spontaneously by 40 degrees in either plane until the age of 10 years. Older children, however, need an anatomical reduction and K-wire fixation. Contrarily, rotational malalignment will not correct spontaneously and should be treated. A final consideration in children, when the physis is involved, is the risk of post-traumatic growth disturbances. Patients should be closely followed as there may be a need for surgical intervention to prevent major deformities.
In adult patients, undisplaced and stable fractures can be treated conservatively and result in a good functional outcome. The limitations for displacement, which can be regarded as unstable fractures for which surgery is recommended, are >10 to 15 degrees of dorsal tilt, >2 to 5 mm (often said, >3 mm) of radial shortening, <15 degrees of radial inclination, and >2 mm intraarticular step-off ( Table 5.1 ).
| Radiographic Findings or Fracture Types | Surgery Indicated in | |
|---|---|---|
| Initial x-ray deformity |
| Young or elderly active |
| Loss of reduction |
| Young or elderly active |
| Initial fracture |
| All patients |
Some patients may present a large displacement initially, but if the palmar cortex is anatomically reduced, the bone quality good, and the plaster well applied, some patients can heal in anatomical alignment ( Fig. 5.4 ). In these cases, weekly follow-up radiographs for three weeks are justified. , In case of loss of reduction or the inability of closed reduction to achieve acceptable radiological parameters, further displacement is probable, and surgical treatment should be recommended ( Table 5.1 ).
Elderly patients more than 70 years old with a Colles fracture show similar clinical outcomes with conservative treatment in comparison to surgical treatment despite radiographic malunion. , , Only active, functional, high-demand individuals in the elderly population probably benefit from surgical treatment. It is important to understand that the fracture will usually lose alignment after closed reduction and cast fixation in this cohort due to the weak bone quality and with a major dorsal metaphyseal void and dorsal comminution. Therefore, repeated closed reduction under hematoma block may not be beneficial anymore, but simple cast fixation without any fracture manipulation after 15 minutes of longitudinally applied traction. Initially, a splint wrapped with an elastic roller bandage should be applied as it restrains fracture displacement more than elastic roller bandages alone. When swelling has subsided after a few days, definitive casting can begin.
Obviously, some fracture configurations are indications for surgery independent of a patient’s age ( Table 5.1 ): fracture dislocations with a palmarly or dorsally subluxed carpus, open fractures, distal forearm fractures, intraarticularly comminuted fractures, and fractures with impacted lunate facet fragments. Nonoperatively treated unstable fractures will usually end up in a visible deformity, and some patients for cultural and socioeconomic aspects will not tolerate the deformity and rightfully may request surgery. Others will not accept the limitations of a cast. Current volar locking plates (VLP) are associated with minimal complications and provide excellent results in elderly individuals. , Contrarily, demented, severely ill, and permanently brain-damaged patients may not be surgical candidates no matter the type of deformity. The corollary is that understanding the patient’s needs and expectancies is crucial for the surgeon to decide to operate or not, but younger patients do not tolerate a lack of volar cortex “engagement” as those fractures by definition are unstable ( Fig. 5.5 ).
Closed reduction percutaneous pinning
Closed reduction percutaneous pinning (CRPP) is reasonably quick to perform, minimally invasive, and avoids the more expensive implants. However, it has the drawback of not providing stable fixation if the bone is of poor quality (osteoporosis) or if there is extensive comminution. In those instances, open reduction and internal fixation (ORIF) is better.
Several randomized studies and meta-analyses comparing ORIF with closed reduction percutaneous pinning (CRPP) found slightly better patient-reported outcomes in the ORIF group and earlier return to activities, particularly for articular fractures, although the differences were not so large at one year. Nevertheless, one can understand the advantages of CRPP, although they have to outweigh the risks: mainly loss of reduction but also irritation to the radial nerve or tendons from the wires. The patient should be warned that there will be a need for postoperative follow-up visits and radiographic checkups until complete bone healing is noted.
Thus, the decision to use CRPP should be taken based more on a patient’s age, activity level, and associated comorbidities than on the outcomes. Active patients desiring a faster return to function are often good candidates for ORIF. Conversely, an unstable fracture without metaphyseal comminution in a sedentary patient may be best served by CRPP. The integrity of the soft tissue envelope must be taken into account in selecting a treatment modality. Some patients wishing for a minimally invasive procedure and rejecting a plate may benefit enormously from this technique.
When performing CRPP, it is important to appreciate the fracture morphology and fracture stability. Once reduction has been achieved and the volar cortex restored, pins should be placed through small incisions to prevent irreversible radial nerve injuries and tendon spearing or avulsion. The Kapandji technique is an infra-focal technique that places the pins dorsally into the fracture and elevates and buttresses the fracture. The wire is advanced through the opposite volar cortex. Alternatively, pins can be placed in the radial styloid and directed ulnarly to capture the dorsal ulnar corner ( Fig. 5.6 ).
In my view, CRPP definitely has a role in treatment of these fractures, and we should bear in mind that plates result in greater costs and are considerably more invasive. Combinations with cannulated screws may widen the indications and avoid the inconveniences secondary to pin removal. Also, they are sturdy enough as to allow early range of motion ( Fig. 5.7 ). , However, I do think that CRPP should not be pushed too much because there is a high risk of K-wires pulling through. Loss of reduction will occur when there is comminution or complex configurations, even if combined with an external fixator. In those instances of extraarticular fractures, the combination of mini-approaches with plates circumvents these issues and provides rigid fixation. ,
Volar plate fixation
Volar plate with locking screws (so-called volar locking plates, VLP) have been a major step in the management of unstable distal radius fractures. The initial implant system, the Pi plate, was applied on the dorsal surface of the radius, although a complementary volar plate, the so-called Ti plate, was also developed. This led to the realization of the advantages of fewer soft tissue problems by using the VLP concept to effectively stabilize the more common dorsally displaced fractures ( Fig. 5.8 A). , The success in using these approaches is mirrored by wide acceptance worldwide as well as multiple design options. , Furthermore, the additional technology of the variable angle locking screw design has further advanced the safety of the distal radius fixation systems. ,
A second important development in the evolution of internal fixation was the greater understanding of the biomechanical aspects of fracture patterns. This resulted in the development of the specific columns of the distal radius that support functional load bearing and led to several investigators to develop the fragment-specific approach to internal fixation. , Smaller implants evolved to support the specific anatomical features of these columns ( Fig. 5.8 B and C). There are several plates available, and surgeons have their own preferences. I still use the old DVR plate and sometimes the “evolution” Geminis, but other systems are quite popular, and all have their own advantages and disadvantages with which surgeons should familiarize themselves.
Surgical technique
As a rule, my preferred approach to fix a distal radius fracture is through a volar-radial approach. With the addition of the arthroscope, I can control most fragments without the need of violating the extensor tendon compartments. Thus in my practice the dorsal approach is never used. A central approach (ulnar to FCR and radial to the median nerve) has been also recommended; however, not only can the palmar cutaneous branch of the median nerve be severed, but the median nerve is at risk of stretching by the retractor. As a rule, I also prefer an independent incision if the median nerve needs to be released for a concomitant acute carpal tunnel syndrome. There is available an “extensile volar-radial approach” that can deal with both issues (the radius fracture and the carpal tunnel syndrome), but this puts at risk the palmar cutaneous branch of the median nerve. Orbay et al recognizes an extended-FCR approach. The procedure consists of lifting and pronating the shaft of the radius away from the epiphysis (and the forearm) in such a manner that the articular fragments can be reduced indirectly (from proximal to the joint). Having the arthroscope (see below), I found this approach too aggressive in acute fractures but found it has a role when dealing with extraarticular malunions. Unfortunately, the volar approach does not permit reaching the most volar-ulnar corner of the radius. This has not been sufficiently stressed and can be a source of major complications; the most feared is secondary radiocarpal dislocation. The ulnar approach can be used for the rare event of a volar die-punch fracture, but in my experience it is extremely useful when combined with the volar-radial approach in complex fractures (with small volar-ulnar fragments) and in malunions ( Fig. 5.9 ).
For the usual fracture I make a 6 cm incision in the cleft between the FCR and radial artery with a back-cut radially at the level of the wrist proximal crease. Any straight incision past this crease will cause hypertrophy and risks creating a painful scar. I avoid violating the FCR sheath to prevent adherences. This is relatively easy if the dissection is done with a knife. Then, with a bipolar cautery the branches of the radial artery are coagulated. Distally, the transverse carpal branch needs at times to be clipped, but the superficial radial artery can always be spared. One should not miss one or more branches to the pronator quadratus from the deep aspect of the radial artery. They are quite sizable and will cause a hematoma if unattended. The pronator quadratus is reflected ulnarly. The brachioradialis is kept in place. The aim at this stage is to fully expose the whole anterior surface of the radius up to the origin of the volar radiocarpal ligaments. When there is minimal metaphyseal displacement, the procedure is straightforward. After a preliminary reduction, the plate is applied and fixed with a single screw in the elliptical hole of the stem of the plate. The surgeon then pushes the distal fragment volarly so that it adapts to the shape of the plate, thus correcting the dorsal tilt. K-wires are then introduced through the auxiliary holes of the plate in the distal fragment(s). The key step of this part of the operation is to restore the volar cortex ( Fig. 5.10 ).
When the volar cortex has a simple fracture line, mating the volar cortex will restore length and also alignment in the coronal plane. However, if the volar cortex is comminuted, then the reduction of what I call the volar-ulnar keystone is critical. The critical step is to properly align the volar-ulnar fragment and build from there the rest of the fixation: misplacing this fragment will spoil the whole reduction ( Figs. 5.11 and 5.12 ).
Radial translation of the distal segment is the most common error I see, even in extraarticular fractures. The deformity is associated with DRUJ instability. , Ulnar translation of the antero-ulnar fragment will cause ulnar collapse and then ulnar impaction and volar radiocarpal dislocation. Thus, utmost care should be taken to reduce and restore the keystone fragment.
The issue of radial translation was so ignored that only recently Viegas group proposed a maneuver for reduction by interposing an Army/Navy type retractor. For years I have been using a Hohmann retractor acting as a lever and blocking the ulnar displacement of the shaft ( Fig. 5.13 ).
Radial translocation should be actively sought by the surgeon as it is easily missed. It is recognized by noting irregularities in the contour of the radial styloid and the crossing on the lunate of the Ross line : an imaginary line along the ulnar cortex of the distal shaft of the radius. If properly reduced, about 50% of the lunate should be ulnar to it, whereas the opposite happens if not (see also Fig. 5.22 ).
A key point to bear in mind at the time of the plate setting is the “ watershed line .” This line, which corresponds roughly to the distal attachment of the pronator quadratus, marks the distal limit of the plate. Setting the plate distal to it will cause the edge of the plate to project too far anteriorly, causing erosion of the flexor tendons and eventually rupture. Lack of reduction of the distal fragment will cause a similar problem for the flexor tendons (see Fig. 5.14 B below). By the same token, the prominence of the tip of the screws will erode the extensor tendons, and in particular the EPL is at risk in the third compartment. The locking screws should be 1 or 2 mm shorter than the depth gauge readings. Fluoroscopic checks at the end of the procedure are a must.
