DISTAL RADIUS FRACTURES
Most Common Fracture | Volar Plate | Restore Alignment | Watch for Instability
KEY CLASSIFICATION SYSTEMS
Critical Must-Knows
- Normal radiographic parameters: Volar tilt 11-15°, radial inclination 22°, radial length 11-12mm
- Instability criteria: Over 20° dorsal tilt, over 5mm shortening, intra-articular involvement
- Volar locking plate is gold standard for unstable fractures
- Median nerve at risk - monitor for acute carpal tunnel
- EPL rupture late complication - avoid prominent dorsal hardware
Examiner's Pearls
- "DRUJ stability crucial - assess after fracture fixation
- "Volar Barton = shear fracture, needs buttress plate
- "Die-punch = lunate facet, associated with DRUJ injury
- "Elderly osteoporotic - consider augmentation techniques
Clinical Imaging
Imaging Gallery
Additional Clinical Examples
Critical Distal Radius Points
Radiographic Parameters
Know the normal values: Volar tilt 11-15°, Radial inclination 22°, Radial length 11-12mm, Ulnar variance neutral. Loss of these = instability.
Acute Carpal Tunnel
Median nerve symptoms require urgent attention. If present with swollen wrist and severe pain, consider emergent carpal tunnel release with fracture fixation.
DRUJ Assessment
Test DRUJ stability after every fixation. Unstable DRUJ may indicate TFCC or ulnar styloid base fracture. May need separate treatment.
EPL Rupture
Late complication (weeks post-injury). Occurs from Lister's tubercle irritation. Avoid prominent dorsal hardware. Treat with EIP-to-EPL transfer.
At a Glance: Quick Decision Guide
| Pattern | Stable? | Treatment |
|---|---|---|
| Extra-articular, minimal displacement | Yes | Cast immobilization 6 weeks |
| Dorsal tilt over 20°, shortening over 5mm | No | Volar locking plate |
| Intra-articular, step over 2mm | No | ORIF - restore articular surface |
| Volar Barton (volar shear) | No | Volar buttress plate |
| Smith fracture (volar angulation) | No | Volar plate (buttress mode) |
| Die-punch (lunate facet) | No | ORIF, elevate fragment, check DRUJ |
| Open fracture or compartment syndrome | Emergency | Urgent debridement, fasciotomy, fixation |
RADIUSInstability Criteria
Memory Hook:RADIUS fracture instability - if any of these, consider fixation!
VRIRadiographic Parameters
Memory Hook:VRI - Volar tilt, Radial inclination, Index (length)!
COLLESFracture Types
Memory Hook:Remember COLLES and its variations for exam classification questions!
COMPLEXComplications
Memory Hook:COMPLEX complications - watch for all of these post-DRF!
Overview and Epidemiology
Demographics
Bimodal Distribution:
- Young adults: High-energy trauma (sports, MVA)
- Elderly (over 50): Low-energy falls (osteoporotic)
Incidence:
- Most common fracture treated by orthopaedic surgeons
- Over 640,000 annually in USA
- Peak incidence: 60-69 years in women
- Increasing with aging population
These demographic patterns inform screening and prevention strategies.
Anatomy
Distal Radius Anatomy
Key Landmarks:
- Scaphoid fossa: Articulates with scaphoid
- Lunate fossa: Articulates with lunate
- Sigmoid notch: Articulates with ulna (DRUJ)
- Lister's tubercle: Dorsal prominence, EPL passes around it
- Radial styloid: Most radial projection
Articulations:
- Radiocarpal joint (scaphoid, lunate)
- DRUJ (distal radioulnar joint)
- Both must be addressed in treatment
Anatomic restoration of these articulations is essential for optimal function.
Classification
Historic Classifications
Eponymous Fracture Types
| Type | Description | Key Feature |
|---|---|---|
| Colles | Dorsal angulation, extra-articular | Dinner fork deformity |
| Smith | Volar angulation (reverse Colles) | Garden spade deformity |
| Barton (Volar) | Volar lip with carpal subluxation | Shear mechanism |
| Barton (Dorsal) | Dorsal lip with carpal subluxation | Less common |
| Chauffeur's | Radial styloid fracture | Intra-articular, ligament avulsion |
| Die-punch | Lunate facet depression | Associated DRUJ injury |
History
History Taking
Mechanism:
- FOOSH (fall on outstretched hand) - classic
- High-energy vs low-energy
- Hand position at impact (extension vs flexion)
Associated Symptoms:
- Pain and swelling
- Deformity (dinner fork)
- Numbness (median nerve)
- Weakness
Patient Factors:
- Age and hand dominance
- Occupation and hobbies
- Functional demands
- Osteoporosis history
Patient factors strongly influence treatment decisions.
Examination
Physical Examination
Inspection:
- Deformity (dorsal dinner fork, volar garden spade)
- Swelling extent
- Skin integrity (open fracture?)
- Ecchymosis
Palpation:
- Point tenderness at fracture site
- Carpal bones (scaphoid especially)
- DRUJ (tenderness = injury)
- Ulnar styloid
Neurovascular:
- Median nerve (thenar sensation, thumb opposition)
- Ulnar nerve (small finger sensation, interossei)
- Radial artery pulse
- Capillary refill
Document neurovascular status before and after any reduction attempt.
Investigations
Standard Radiographs
Essential Views:
- PA (posteroanterior) wrist
- True lateral wrist
- Oblique views if needed
What to Measure:
- Volar tilt (lateral view)
- Radial inclination (PA view)
- Radial length/ulnar variance (PA view)
- Articular step-off
- DRUJ congruity
Standard radiographs are sufficient for most treatment decisions.
Management
Conservative Treatment
Indications:
- Stable, minimally displaced fractures
- Acceptable alignment (see criteria below)
- Low functional demand patients
- Contraindications to surgery
Acceptable Alignment:
- Volar tilt loss under 10° (slight dorsal tilt OK)
- Radial shortening under 3mm
- Radial inclination loss under 5°
- No articular step over 2mm
- Congruent DRUJ
Technique:
- Closed reduction under hematoma block
- Below-elbow cast or sugar-tong splint
- 6 weeks immobilization
- Weekly X-rays for first 2-3 weeks
Close follow-up is essential to detect loss of reduction early.
Surgical Technique
Volar Locking Plate - Standard Approach
FCR (Flexocarpal Radialis) Approach:
Step-by-Step Technique
5-6cm longitudinal incision along FCR tendon. Retract FCR ulnarly, flexor pollicis longus radially. Incise pronator quadratus in L-shape at radial border and elevate subperiosteally ulnarly to expose fracture site.
Clear fracture site of hematoma. Use ligamentotaxis by longitudinal traction. Reduce volar tilt using freer elevator or bone tamp to elevate dorsal cortex. Provisional K-wire fixation to hold reduction. Check on C-arm PA and lateral.
Position volar locking plate on volar surface. Plate must be proximal to watershed line (volar lip of radius). Insert proximal cortical screw first to attach plate. Check alignment. Insert distal locking screws - aim for subchondral bone.
Critical views: PA - screws not in joint, radial inclination restored. Lateral - volar tilt restored, screws not beyond dorsal cortex. Skyline view (20° tilted lateral) - confirm no dorsal screw prominence.
The volar approach provides excellent exposure while protecting critical dorsal structures.
Complications
Early Complications
Acute Carpal Tunnel:
- Median nerve compression from swelling/hematoma
- May occur at presentation or post-reduction
- Urgent release if progressive
Compartment Syndrome:
- Forearm compartments at risk
- Monitor closely post-injury
- Fasciotomy if diagnosed
Loss of Reduction:
- Common in unstable patterns
- Weekly X-rays important
- May need operative stabilization
Early recognition allows timely intervention.
Postoperative Care
First 2 Weeks
Immediate Post-operative:
- Volar splint in neutral position
- Elevation to reduce swelling
- Ice application
- Finger ROM exercises (immediate)
Wound Care:
- Check dressing at 2-3 days
- Suture removal at 10-14 days
- Monitor for infection signs
Activity Guidance:
- No lifting with affected hand
- Active finger exercises hourly
- Shoulder and elbow ROM to prevent stiffness
Early finger movement is essential to prevent stiffness.
Outcomes and Prognosis
Expected Outcomes
Outcomes by Treatment
| Parameter | Conservative | Volar Plate |
|---|---|---|
| Union rate | 95% | 98% |
| Functional ROM | Variable | 85-90% of normal |
| Return to work | 8-12 weeks | 6-8 weeks |
| Complication rate | Higher malunion | Hardware related |
| Patient satisfaction | Good (stable) | Excellent |
Prognostic Factors
Favorable
- Extra-articular fracture
- Anatomic reduction achieved
- Young patient with good bone
- Stable pattern
- Compliant with therapy
Unfavorable
- Intra-articular comminution
- Articular step over 2mm
- Osteoporotic bone
- Malunion
- Associated DRUJ injury
Evidence Base
Volar Plate vs Conservative (DRAFFT Trial)
- In patients over 50 with dorsally displaced fractures, volar locking plate showed no significant difference in PRWE scores at 12 months compared to cast treatment after manipulation.
Articular Step-off and Osteoarthritis
- Classic study showing articular incongruity over 2mm significantly increases risk of post-traumatic arthritis. Step over 2mm at final follow-up correlated with radiographic OA.
External Fixation vs Volar Plate
- Volar locking plate showed better radiographic outcomes and faster functional recovery than external fixation for unstable distal radius fractures.
EPL Rupture Following DRF
- EPL rupture occurs in 0.5-3% of distal radius fractures, typically 2-6 weeks post-injury. Associated with Lister's tubercle prominence or dorsal plate placement.
DRUJ Instability in DRF
- DRUJ instability present in up to 30% of distal radius fractures. Associated with ulnar styloid base fractures and TFCC tears. Often improves with radius fixation.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Elderly Colles Fracture
"A 72-year-old woman fell on her outstretched hand. X-rays show a dorsally angulated distal radius fracture with 20° dorsal tilt, 4mm shortening, and no intra-articular extension. She is otherwise healthy and lives independently."
This is an unstable Colles-type fracture in an independent elderly woman. The dorsal tilt of 20 degrees and 4mm shortening exceed acceptable parameters for conservative management.
Assessment: My assessment would include neurovascular status, specifically median nerve function, and skin integrity.
Management: My treatment recommendation would be volar locking plate fixation given: the instability criteria are met, she has functional demands as an independent lady, and anatomic reduction is important for optimal outcome.
Technique: The surgical technique would involve FCR approach, pronator quadratus elevation, fracture reduction, volar locking plate application with distal locking screws, and DRUJ stability assessment. I would check fluoro for screw position avoiding the joint.
Post-operative: She would commence immediate finger exercises, wrist ROM at 2 weeks, and therapy for 6-8 weeks.
Key Teaching Point: The DRAFFT trial showed equivalent outcomes for low-demand patients, but this lady's independence makes her higher functional demand.
Volar Barton Fracture
"A 45-year-old male motorcyclist has a distal radius fracture with volar rim involvement. The X-ray shows the carpus subluxed volarly with the volar rim fragment."
This is a volar Barton fracture - a partial articular fracture involving the volar rim with carpal subluxation. This is ALWAYS an operative injury as it is inherently unstable and the carpus will follow the rim fragment.
Mechanism: Typically shear from axial load with the wrist in flexion or direct impact.
Management: Urgent surgical stabilization with a volar buttress plate. The key principle is that the plate acts as a buttress to prevent the rim fragment (and carpus) from displacing volarly.
Technique: Using the standard FCR approach, I would reduce the articular surface, provisionally fix with K-wires, then apply a buttress plate with screws placed specifically to buttress the rim fragment. The plate is positioned more distally than for standard fractures. I would confirm reduction arthroscopically or with fluoroscopy and check for associated ligament injuries.
Prognosis: Post-operatively, immobilization for 2 weeks then progressive ROM. Prognosis is generally good with anatomic reduction.
Delayed EPL Rupture
"A 58-year-old woman had a minimally displaced distal radius fracture treated in cast 6 weeks ago. She now presents unable to extend her thumb at the IP joint. The fracture has healed."
This is EPL (extensor pollicis longus) rupture, a recognized complication occurring 2-6 weeks after distal radius fracture. The mechanism is attritional rupture from the tendon rubbing against Lister's tubercle, which may be prominent or irregular after fracture.
Examination: I would confirm inability to extend the thumb IP joint with the wrist in neutral, and there may be a palpable gap over the dorsum. This occurs even with undisplaced fractures.
Treatment: Surgical EIP (extensor indicis proprius) to EPL tendon transfer. The EIP tendon is harvested and tunneled subcutaneously to the thumb and sutured to the EPL stump distally. This restores thumb extension reliably.
Outcome: Post-operative therapy for 6 weeks. I would counsel the patient that outcome is generally excellent with independent thumb extension restored.
MCQ Practice Points
Parameters Question
Q: What are the normal radiographic parameters of the distal radius?
A: VRI - Volar tilt 11-15°, Radial inclination 22° (15-25°), radial length (Index) 11-12mm. Ulnar variance should be neutral.
Instability Question
Q: What parameters indicate an unstable distal radius fracture?
A: RADIUS - Radial shortening over 5mm, Angulation over 20°, Dorsal comminution, Intra-articular step over 2mm, Ulnar fracture, Sixty and older.
Barton Question
Q: What is a volar Barton fracture and how is it treated?
A: A shear fracture of the volar lip of the distal radius with carpal subluxation. Treated with volar buttress plate - the plate prevents the fragment (and carpus) from displacing.
EPL Question
Q: A patient presents 5 weeks after distal radius fracture unable to extend their thumb IP joint. What is the diagnosis and treatment?
A: EPL rupture from attritional wear at Lister's tubercle. Treatment is EIP-to-EPL tendon transfer.
DRUJ Question
Q: What structures stabilize the DRUJ and how is stability assessed?
A: Primary stabilizer is the TFCC. Assess by stabilizing the radius and translating the ulna dorsally and volarly. Compare to opposite side. Increased translation = instability.
Australian Context
ED Presentation
- Very common ED presentation
- After-hours manipulation and cast common
- Short stay unit for observation
- Orthopaedic outpatient follow-up
Surgical Setting
- Day surgery for volar plate
- Local/regional anaesthesia popular
- WALANT technique growing
- Cost-effective outpatient surgery
Medicolegal Considerations
- Document neurovascular status pre/post-reduction
- Explain conservative vs operative outcomes
- Consent for CRPS risk and stiffness
- Warn about EPL rupture risk
Consent Points
- Malunion risk if conservative
- Tendon irritation/rupture
- Hardware removal possibility
- Stiffness requiring therapy
- CRPS risk
DISTAL RADIUS FRACTURES
High-Yield Exam Summary
Normal Parameters (VRI)
- •Volar tilt: 11-15°
- •Radial inclination: 22° (15-25°)
- •Radial length: 11-12mm
- •Ulnar variance: Neutral
Instability Criteria (RADIUS)
- •Radial shortening over 5mm
- •Angulation over 20°
- •Dorsal comminution
- •Intra-articular step over 2mm
- •Ulnar fracture
- •Sixty and older
Fracture Types
- •Colles: Dorsal angulation (dinner fork)
- •Smith: Volar angulation (reverse Colles)
- •Barton: Rim fracture + carpal subluxation
- •Die-punch: Lunate facet depression
- •Chauffeur: Radial styloid
Treatment Principles
- •Stable, aligned: Cast 6 weeks
- •Unstable: Volar locking plate
- •Barton: Buttress plate
- •Check DRUJ after fixation
Key Complications
- •Acute carpal tunnel: Urgent release
- •EPL rupture: EIP transfer
- •Malunion: Corrective osteotomy
- •CRPS: Early therapy
DRUJ Assessment
- •Always test after fixation
- •Compare translation to opposite side
- •TFCC is primary stabilizer
- •Ulnar styloid base fracture = instability marker