Distal Radius Fractures

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.

Injury Patterns

Colles Pattern (most common):

• FOOSH (fall on outstretched hand)
• Wrist in dorsiflexion
• Creates dorsal angulation

Smith Pattern:

• Fall with wrist in flexion
• Or direct blow to dorsum
• Creates volar angulation

Barton Pattern:

• Shear mechanism
• Rim fracture with carpal subluxation
• Volar or dorsal lip involvement

The mechanism determines fracture pattern and treatment approach.

Who Fractures?

Patient Factors:

• Osteoporosis (major)
• Female gender
• Previous fracture
• Low BMI
• Vitamin D deficiency

Environmental:

• Icy conditions
• Poor lighting
• Trip hazards
• Sporting activity

Modifiable risk factors should be addressed to prevent recurrence.

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.

Critical Soft Tissues

Volar Structures:

• Pronator quadratus (muscle)
• Flexor tendons
• Median nerve (carpal tunnel)
• Radial artery

Dorsal Structures:

• Extensor compartments (6)
• EPL around Lister's tubercle
• Posterior interosseous nerve (terminal branch)

TFCC:

• Triangular fibrocartilage complex
• Stabilizes DRUJ
• May be injured with DRF

TFCC integrity assessment is important when evaluating DRUJ instability.

Normal Parameters

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Historic Classifications

AO/OTA Classification (2R3)

Frykman Classification

Based on articular involvement and ulnar styloid fracture:

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.

Warning Signs

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.

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CT Indications

When to CT:

• Complex intra-articular fractures
• Die-punch assessment
• Pre-operative planning for comminuted fractures
• Assessing articular fragments

CT Provides:

• Fragment number and size
• Articular step quantification
• Central depression identification
• Sigmoid notch involvement

CT is particularly useful for surgical planning in complex cases.

Additional Investigations

MRI (rarely acute):

• TFCC assessment
• Scapholunate ligament
• Occult scaphoid fracture

Pre-operative:

• Bone density if osteoporotic concern
• Blood tests as per anaesthetic requirements

Additional investigations are tailored to individual patient needs.

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.

When to Operate

Volar Locking Plate - Operative Technique

Gold Standard for Unstable Fractures

Alternative Fixation

External Fixation:

• Ligamentotaxis for reduction
• Open fractures
• Severe comminution
• Bridge (wrist spanning) or non-spanning

Fragment-Specific Fixation:

• Multiple small plates for specific fragments
• Volar ulnar corner plate
• Radial column plate
• Useful for complex patterns

K-wires:

• Kapandji technique (intrafocal)
• Supplemental fixation
• Low demand patients
• Must protect wires

Alternative fixation methods are selected based on fracture pattern and patient factors.

Postoperative Care

After Volar Plate:

• Removable splint for comfort
• Early finger ROM (immediate)
• Wrist ROM at 2 weeks
• Full ROM by 6 weeks
• Strengthening 6-12 weeks

Follow-up:

• 2 weeks: Wound check, start therapy
• 6 weeks: X-ray, progress activity
• 3 months: Final assessment
• Hardware removal rarely needed

Structured rehabilitation optimizes functional outcomes.

Volar Locking Plate - Standard Approach

FCR (Flexocarpal Radialis) Approach:

The volar approach provides excellent exposure while protecting critical dorsal structures.

Post-operative Assessment

Post-operative radiographs should confirm anatomic restoration of all key parameters.

Surgical Pearls

Key Technical Points:

• Ensure complete reduction before plating
• Restore volar tilt by applying plate and using it as reduction aid
• Distal screws should be in subchondral bone but not articular
• Check all fluoroscopic views before closing
• Test DRUJ stability after fracture fixation

Meticulous attention to plate position and screw length prevents complications.

Distal Radioulnar Joint

Intraoperative DRUJ Assessment:

• Release tourniquet before assessing
• Test stability in supination, neutral, pronation
• Compare translation to opposite side
• Increased translation indicates TFCC injury

If DRUJ Unstable:

• Consider ulnar styloid base fixation
• May need TFCC repair
• K-wire across DRUJ (remove at 6 weeks)
• Immobilize in supination if stable after pinning

DRUJ stability must be confirmed before leaving theatre.

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.

Late Complications

Malunion:

• Dorsal tilt, shortening common
• Causes functional limitation
• May need corrective osteotomy

EPL Rupture:

• 2-6 weeks post-injury
• Lister's tubercle irritation
• EIP-to-EPL tendon transfer

Post-traumatic Arthritis:

• From articular incongruity
• Increased if step over 2mm
• May need wrist fusion/arthroplasty late

CRPS:

• Complex regional pain syndrome
• Burning pain, swelling, color changes
• Early therapy crucial for prevention

Patient education and early mobilization help prevent late complications.

Hardware-Related

Tendon Irritation/Rupture:

• Prominent hardware damages tendons
• Volar: flexor tendons (rare)
• Dorsal: EPL most at risk

Intra-articular Hardware:

• Must check on intraop fluoro
• Remove and revise if present
• Causes arthritis if left

Hardware Failure:

• Rare with modern locking plates
• More common in osteoporotic bone
• May need augmentation techniques

Modern implants have significantly reduced hardware-related complications.

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.

Weeks 2-6

Rehabilitation Progression:

• Begin active wrist ROM at 2 weeks
• Removable splint for comfort
• Formal hand therapy referral
• Progressive forearm rotation

Goals:

• Full finger ROM
• Progressive wrist flexion/extension
• Supination and pronation exercises
• Grip strengthening begins at 4 weeks

Structured therapy optimizes functional recovery.

Beyond 6 Weeks

Return to Function:

• Full ROM expected by 8-12 weeks
• Strengthening continues
• Return to work: 6-8 weeks (light), 10-12 weeks (heavy)
• Sports: 3-4 months

Follow-up Schedule:

• 6 weeks: X-ray, progress activity
• 3 months: Final clinical assessment
• Hardware removal rarely needed (symptomatic only)

Most patients achieve excellent functional outcomes with structured rehabilitation.