Bali sa Distal Radius

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Fractures of the distal radius are among the most common fractures seen in the emergency department [11].
• Patients of advanced age with osteoporosis have an increased fracture risk during low-energy falls [11].
• Fracture patterns vary depending on the mechanism of injury [11].
• The goals of all treatment for distal radius fractures are to optimize comfort and function [11].
• Survival rates after distal radius fractures were notably lower than those expected for individuals of the same age and gender in standard populations [17].
• Displaced fractures are less well tolerated in young patients than in older people, especially in terms of dorsal tilt and radial shortening [20].
• Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern, with early diagnosis and treatment being important to avoid long-term consequences [2].
• Open fractures of the distal radius commonly have associated injuries, and their treatment often requires multiple surgical procedures [7].
• Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare but require a standardised management strategy [13].
• The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Distal Radius Fractures is unable to make any strong recommendations, with nearly two-thirds of categories being “inconclusive” or “limited” after review of the evidence [35].
• The most recent Cochrane Review concludes that there remains insufficient evidence from randomized controlled trials to determine which methods of treatment are the most appropriate for the more common types of distal radius fractures in adults [35].
• The best method of operative fixation of distal radius fractures remains unclear [35].

Treatment Options¶

• Treatment options for distal radius fractures include closed reduction and cast immobilization, closed reduction and percutaneous pinning with or without external fixation, and ORIF [11].
• Most open fractures and volar shearing fractures are best treated operatively [11].
• Surgical treatment indications relate to infirmity, functional demands, tolerance of deformity, and personal preferences [11].
• Injury and patient characteristics meriting a discussion of surgical treatment include loss of reduction, including ulnar variance 5 mm or more positive; dorsal articular tilt ≥15° (ie, volar apex angulation); and loss of radial inclination >10° [11].
• Injury and patient characteristics meriting a discussion of surgical treatment include an articular gap or step of 2 mm or more [11].
• Injury and patient characteristics meriting a discussion of surgical treatment include unstable volar extra-articular fractures (Smith fracture) [11].
• Injury and patient characteristics meriting a discussion of surgical treatment include fractures with associated neurovascular injuries [11].
• Injury and patient characteristics meriting a discussion of surgical treatment include fractures with associated intercarpal ligament injuries [11].
• Multiple trauma, such as bilateral distal radius fractures or the need to use crutches for a leg injury, is a relative indication for surgical treatment [11].
• Volar fixation represents a valuable treatment modality for the most frequent types of unstable fractures of the distal radius in young and elderly patients [3].
• Fixation with volar locking plates is the gold standard treatment for extra-articular distal radius fractures in active elderly patients [82].
• Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes [22].
• Implant removal following operative distal radius fracture treatment can improve the functional outcome of the hand and forearm [4].

Non-Operative Management¶

• Current best evidence suggests initial displacement determines the final alignment regardless of the time of immobilization, so wrist splints or short arm casts are usually used, and the elbow and forearm are usually left free unless there is severe radioulnar joint injury/disruption [11].
• Displaced fractures are immobilized for 4 to 6 weeks after acceptable closed reduction [11].
• It is important to encourage elevation, digital range of motion, and functional use of the limb to avoid stiffness of the fingers and forearm and to limit swelling [11].
• Nondisplaced distal radius fractures are associated with occasional extensor pollicis longus rupture, usually about 4 to 6 weeks after injury [11].
• Volarly displaced extra-articular fractures (Smith fractures) can be treated with reduction and casting if no comminution is present and a good reduction is obtained [11].
• Nondisplaced or minimally displaced radial styloid fractures may be treated nonsurgically [11].

Operative Management¶

• Closed reduction and percutaneous pinning with or without external fixation utilizes 0.62-inch or 1.6-mm K-wires [11].
• Bridging external fixation can be used to protect pin fixation or to provide ligamentotaxis [11].
• Full incisions over the radius and index metacarpal at the time of fixator pin placement minimize the risk of iatrogenic injury to the superficial branch of the radial nerve or tethering of the first dorsal interosseous muscle [11].
• The external fixator and pins typically remain in place for 6 to 8 weeks [11].
• Bone graft or bone void fillers can be used to structurally support bone defects and perhaps allow earlier removal of the fixator [11].
• Volar locking plates make it possible to stabilize dorsally displaced fractures from through the volar Henry approach (through the sheath of the flexor carpi radialis tendon) [11].
• Potential pitfalls of volar locking plates include intra-articular screw placement and application to inappropriate fracture patterns with prominent implant placement which may lead to tendon rupture [11].
• The most common tendon to rupture following application of a volar plate is the flexor pollicis longus, due to volar extension of the plate beyond the so-called watershed line, meaning the tendon may rub directly against the edge of the plate [11].
• Dorsal tendons such as the extensor pollicis longus and extensor digitorum communis can fray and rupture from prominent screw tips following volar insertion [11].
• Dorsal plates or constructs are now preferred for dorsal shearing fractures and complex articular fractures (in combination with volar plates) [11].
• Distraction (or bridge) plate fixation is increasingly utilized for complex articular fracture, those with complex metaphyseal or diaphyseal fragmentation in particular [11].
• A distraction plate is applied between the index or long finger metacarpal and the shaft of the radius (as with external fixation), applied with distraction, and removed about 3 months after injury [11].
• Application of the bridge/distraction plate should not be a substitute for accurate ORIF [11].
• External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius, with reliably good results, a low reoperation rate, and a low complication rate [19].
• Non-bridging external fixation offers a reliable method of maintaining radiological reduction of Older type II/III fractures of the distal radius and gives a good functional outcome after 1 year [9].
• External fixation maintained radial length more effectively than pins and plaster in patients followed for 2 years, but was associated with higher initial costs (20 times) and a greater number of minor complications [31].
• A brachioradialis splitting approach sparing the pronator quadratus has been utilized for over 6 years in the treatment of all fractures of the distal radius requiring volar plating without the requirement for further incisions [10].
• The best indication for double dorsal plates on distal radius fractures is for metaphyso-diaphyseal fractures with dorsal displacement, comminution and articular involvement [62].
• Combined internal and external fixation can be successfully used in the specific subset of severe AO-C3 distal radius fractures, though it is technically demanding [39].
• Intra-articular displacement (or diastasis) greater than 2 mm in radial styloid fractures is an indication for surgery [11].
• Compression screw fixation with partially threaded 3.5- or 4.0-mm cancellous screws can effectively compress the fragments and maintain the reduction of radial styloid fractures [11].
• Alternative fixation options for radial styloid fractures include K-wires and fragment-specific pin plate and screw fixation [11].
• The distal radioulnar joint is assessed following stabilization of the radius, with slightly greater laxity than the opposite uninjured wrist being expected based on preoperative examination [11].
• Only frank dislocation with forearm rotation merits surgery to stabilize the distal radioulnar joint [11].
• The presence of a displaced fracture at the base of the ulnar styloid is not in itself an indication for surgical fixation, and clinical stability of the DRUJ must be elucidated and compared with the normal contralateral side when possible [11].
• The Fernandez osteotomy is a reliable method for the treatment of malunited distal radius fractures [50].
• Bone grafting from the distal radius is effective with minimal complications and is a practical adjunct to reconstructive hand procedures [48].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The distal radius articular surface is biconcave and features scaphoid and lunate facets [89].
• The distal radioulnar joint (DRUJ) articulates with the ulna at the sigmoid notch [89].
• Lister tubercle is a small dorsal prominence that serves as a landmark for the dorsal approach to the wrist and is a cause of attritional rupture of the extensor pollicis longus (EPL) after distal radius fracture [89].
• The distal radial metaphysis has thin cortex and is vulnerable to bending forces [89].
• In a normal wrist with neutral ulnar variance, the distal radius bears 80% of the axial load [89].
• The carpus consists of two rows of eight bones that bridge the forearm and hand, providing movement at the wrist joint while retaining stability [51].
• The proximal carpal row includes the scaphoid, lunate, and triquetrum, which act as a key intercalated segment between the forearm and the distal carpal row [51].
• The distal carpal row includes the trapezium, trapezoid, capitate, and hamate [51].
• The trapezium articulates with the first metacarpal, the trapezoid with the second, the capitate with the third, and the hamate with the fourth and fifth metacarpals [51].
• The capitate and trapezoid are tightly connected to the metacarpals, whereas there is 30 to 40 degrees of flexion–extension and rotation at the metacarpotrapezial joint [51].
• The scaphoid is a small, irregular S-shaped tubular bone located in the proximal carpal row on the radial aspect of the wrist [85].
• The scaphoid lies at a 45-degree plane to the longitudinal and horizontal axis of the wrist [85].
• The scaphoid has a reduced capacity for periosteal healing and an increased tendency for delayed union and nonunion due to its surface being extensively covered with articular cartilage (over 80%) [85].
• The scaphoid acts as a midcarpal joint “bridge” linking and synchronizing the motions of the proximal and distal carpal rows [85].
• The distal end of the radius is fractured at the corticocancellous junction, approximately 2 cm from the wrist, in typical low-energy dorsally displaced fractures [24].

Ligamentous Anatomy¶

• Extrinsic ligaments of the carpus connect the carpal bones to the forearm bones proximally and the metacarpals distally [87].
• The extrinsic palmar radiocarpal ligaments include the transverse carpal, radioscaphocapitate, radioscapholunate, radial collateral, long radiolunate, and short radiolunate ligaments [87].
• The extrinsic ulnocarpal ligaments include the ulnotriquetral, ulnolunate, and ulnocapitate ligaments [87].
• Strong oblique extrinsic palmar radial ligaments prevent the carpus from translating medially on the angulated slope of the distal radius through two V-shaped ligamentous bands [87].
• The space of Poirier is an interval of capsular weakness over the capitolunate articulation where maximal space is seen when the wrist is dorsiflexed [87].
• The arcuate ligament forms a support sling for the midcarpal region, particularly the head of the capitate, improving midcarpal movement and delivering carpal stability [87].
• Intrinsic ligaments connect individual carpal bones to one another and include palmar midcarpal, proximal interosseous, and distal interosseous ligaments [87].
• The scapholunate ligament is an intrinsic ligament with dorsal, palmar, and proximal portions [96].
• The lunotriquetral ligament is an intrinsic ligament with dorsal, palmar, and proximal portions [96].
• The radioscapocapitate ligament does not attach to the scaphoid bone itself but crosses the waist, acting as a sling that allows rotation [85].
• There are no tendon attachments to the scaphoid [85].

Vascular Anatomy¶

• The blood supply of the scaphoid arises from the dorsal distal pole, meaning the proximal pole has a poor blood supply and is less likely to heal than the distal pole [34].
• The dorsal branch of the scaphoid blood supply enters via foramina along the spiral groove and dorsal ridge, supplying 70% to 80% of the scaphoid proximally, including the proximal pole [85].
• The volar branch of the scaphoid blood supply enters via the scaphoid tubercle and supplies the remaining 20% to 30% of the distal scaphoid [85].
• The waist of the scaphoid has minimal or no perforating vasculature [85].
• No vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [85].
• Proximal scaphoid fractures are associated with at least temporary disruption of the interosseous blood supply to the proximal pole [85].
• The incidence of avascular necrosis following carpal bone injury is related to complex intraosseous blood supply, with the scaphoid, capitate, and about 20% of lunates supplied by a single vessel increasing their risk [92].

Pathomechanics and Deformity¶

• The brachioradialis insertion on the radial styloid acts as a deforming force in distal radius fractures [89].
• In a Colles' fracture, the distal fragment is shifted and tilted both dorsally and towards the radial side [24].
• Ulnar translation of the proximal portion of the radius is a commonly overlooked and unrecognized deformity of distal radius fractures [6].
• Deformities of distal radius fractures have a significant influence on the biomechanics of the wrist motors [84].
• With increased dorsal tilt, the range of wrist motion becomes more restricted and abnormalities of carpal alignment during wrist motion become apparent [100].
• Grip strength is determined by the final alignment of the radiocarpal joint in both the coronal and sagittal planes [93].
• Two patterns of carpal instability are recognized: dorsal intercalated segmental instability (DISI) and volar intercalated segmental instability (VISI) [32].
• In DISI, the lunate is torn from the scaphoid and tilts backwards [32].
• In VISI, the lunate is torn from the triquetrum and tilts forwards [32].
• Injuries to adjacent soft-tissue structures occur in approximately one-half of distal radius fractures and in almost all intra-articular fractures [103].
• The most common associated soft-tissue injuries in distal radius fractures are the triangular fibrocartilage complex (TFCC), scapholunate ligament, and lunotriquetral ligament, in descending order of frequency [103].
• Fractures of the radial styloid may be associated with scapholunate ligament injuries because the intra-articular fracture line extends into the joint at that level [11].
• Compression fractures in osteoporotic bone may result in shortening of the radius relative to the ulna (positive ulnar variance) and displacement of the distal radioulnar joint (DRUJ) [132].
• Ligament strains around the wrist are more common than generally recognized and may be a source of pain and weakness long after the fracture has healed [132].

Normal Radiographic Parameters¶

• Radiographic measurement of an intact distal radius shows an average of 22 to 23 degrees of radial inclination [21].
• Radiographic measurement of an intact distal radius shows an average of 11 to 12 mm of radial height [21].
• Radiographic measurement of an intact distal radius shows an average of 11 to 12 degrees of volar tilt [21].
• Radiographic measurement of an intact distal radius shows ± 2 mm of ulnar variance [21].
• Normal wrist alignment parameters are radial inclination of 22 degrees, volar tilt of 11–12 degrees, and radial length of 11–12 mm [53].
• The "11:11:22 rule" defines normal radial height as 11 mm, volar tilt as 11 degrees, and radial inclination as 22 degrees [89].

Classification¶

Historical and Eponymous Systems¶

• Eponymous descriptions such as Colles and Smith have served as guidelines for 150 years [33].
• Pouteau described a variety of forearm fractures and defined the mechanism of injury as occurring during a fall on the outstretched hand as opposed to direct injury [159].
• Orthopaedic surgeons often prefer eponymous, historical systems because the naming convention succinctly communicates the salient features of common fracture patterns [133].
• Eponymous systems are often used incorrectly and more broadly than intended, creating confusion [133].
• Eponymous systems are not comprehensive and do not include all fractures [133].

AO/OTA Classification¶

• The AO/Orthopaedic Trauma Association (OTA) classification system is familiar to orthopaedic surgeons and is used frequently in clinical studies [133].
• In the AO/OTA classification, Type A fractures are extra-articular, including Colles and Smith patterns [133].
• In the AO/OTA classification, Type B denotes partial articular fractures, including volar and dorsal Barton patterns [133].
• In the AO/OTA classification, Type C includes complete articular fractures where no portion of the articular surface is contiguous with the shaft [133].
• The AO/OTA classification is comprehensive and has moderate intraobserver and interobserver reliability [133].
• The AO/OTA classification involves 144 subtypes, making it cumbersome to use [133].
• Reliability of the AO/OTA classification decreases with subtyping [133].
• Numerous distal radius classification systems exist, yet there is no consensus as to their reliability or value in treatment planning [133].

Frykman Classification¶

• Frykman's classification was devised to take into account the prognostic value of the fracture typing [152].
• In a series of 26 patients with unstable, comminuted fractures treated with external fixation, 80% were Frykman types VII and VIII, 15% were type V and VI, and 5% were type II [68].
• In a study of distal forearm fractures in Zaragoza, the Frykman classification categorized extra-articular fractures as types I and II, intra-articular fractures involving the radiocarpal joint as types III and IV, intra-articular fractures involving the distal radioulnar joint as types V and VI, and intra-articular fractures involving both joints as types VII and VIII [78].

Other Classification Systems¶

• The Barzullah working classification of distal radius fractures has good characteristics compared to already studied classification systems among orthopaedic residents [56].
• The MEU classification describes all possible combinations of the three components of the fracture and is useful for both prognosis and treatment [131].
• In the MEU classification, a metaphyseal fracture entering the distal radio-ulnar joint (M') and a displaced ulnar fracture (U > 1) affect functional outcome and must be included [134].
• The comprehensive classification of fractures (CCF) by Muller et al. was used to classify distal radial fractures in a study of elderly women [59].
• Gartland and Werley classified comminuted intraarticular fractures of the distal radius as type 3 [152].
• Depalma followed the same classification as Gartland and Werley for comminuted intraarticular fractures [152].
• Lidstrom classed comminuted intraarticular fractures of the distal radius as type 2E [152].
• In the AO classification, comminuted intraarticular fractures of the distal radius are types C2 and C3 [152].

Reliability and Imaging¶

• A cadaver model study provided data to aid in the interpretation of clinical studies of acute distal radius fractures based on plain radiography [15].
• The use of CT was evaluated for its effect on inter- and intra-observer agreement for the AO, Fernandez, and Universal classification systems for distal radius fractures [154].

Clinical Presentation¶

History and Mechanism¶

• The typical history for a distal radius fracture involves a fall onto an outstretched hand [116].
• Some distal radius fractures result from higher energy injuries [116].
• The most common mechanism of injury for distal radial fractures is a fall onto the outstretched hand, usually on ice [26].
• The risk factors for distal radius fractures are the same as those for other osteoporotic fractures, with the main risk factor being low bone mineral density [58].
• Low bone mineral density is a predictor of future fractures [58].
• Clinical risk factors such as a history of prior fracture, endocrine disease, and certain medications place patients at a higher risk of fracture [58].
• Older adults who sustain distal radius fractures have impaired postural stability compared with similar aged individuals who have not sustained fractures [58].
• Fitter older patients who sustain distal radius fractures have more preserved reflexes, allowing them to outstretch their hand to break their fall [58].

Physical Examination¶

• Patients present with associated pain, swelling, and often visible deformity at the wrist [116].
• The most typical pattern of deformity is dorsal angulation at the distal radius accompanied by compensatory flexion of the carpus, resulting in a "dinner fork" deformity [116].
• In patients with less deformity, there may only be local tenderness and pain on wrist movements [24].
• When there is no obvious deformity but clinical suspicion remains high, point tenderness or pain with percussion at the distal radius can aid in diagnosis [116].
• Physical examination should include a thorough inspection of the skin to evaluate for open wounds, which most commonly occur on the volar ulnar side [116].
• A thorough neurologic examination is required to rule out acute carpal tunnel syndrome [116].
• Patients should be asked about numbness or paresthesias to look for median or ulnar nerve injury [116].
• Additional details of the history should focus on other areas of pain in the ipsilateral limb to rule out concomitant injury [116].
• The distal radioulnar joint is assessed following stabilization of the radius, and slightly greater laxity than the opposite uninjured wrist is to be expected [11].

Imaging¶

• Standard scaphoid radiographs are used for primary assessment to detect displacement and associated fractures [52].
• Provocative stress tests may be required to demonstrate dynamic radiocarpal instability [52].
• In cases of ulnar translation, the radiographic appearance is often dramatic with the lunate positioned just distal to the ulna and a large space between the radial styloid and the scaphoid [52].
• A decrease in the ulnocarpal index may provide the only clue to diagnosis in cases where ulnar shift is subtle [52].
• CT may be required to better define associated bony injuries [52].
• MRI can be used to determine the extent of ligamentous disruption [52].
• CT scans can identify intra-articular extension of distal radius fractures that are not evident on plain films [26].
• CT scans detail residual step-deformities and postreduction metaphyseal cavities resulting from local crush of fracture fragment displacement [26].
• Axial CT scans allow further identification of fracture characteristics and insight into fracture mechanism [26].
• Radiographic parameters associated with injury to the distal radioulnar joint include fracture of the base of the ulnar styloid, widening of the distal radioulnar joint on the AP wrist radiograph, dislocation of the ulna relative to the radius on a true lateral wrist radiograph, and more than 5 mm of shortening of the radius relative to the ulna [36].
• Radial shaft fracture line obliquity greater than 30° is a statistically significant predictor of distal radioulnar joint instability [36].
• A true lateral view of the wrist, in which the pisiform overlies the volar third of the scaphoid, is required to assess distal radioulnar joint alignment [36].
• Surgeons using radiographic measures of deformity to make treatment decisions may find that agreement on treatment recommendations improves if they are provided with radiographs rather than precise numeric radiographic measurements [106].
• Surgeons that received measurements only recommended operative treatment significantly more often but were less likely to agree than surgeons evaluating actual radiographs [106].
• CT scan and radiography have similar levels of interobserver agreement for classification and indication of treatment for distal radius fractures [113].
• There are fewer indications of nonsurgical treatment when CT scan is analyzed compared to x-ray [113].

Associated Injuries¶

• Open fractures of the distal radius commonly have associated injuries [7].
• Associated fractures of the distal radius and ulna are relatively common but poorly recognized injuries, with an incidence of 5.6% of all Colles’ fractures requiring manipulation or operative treatment [18].
• The frequency of distal ulna fractures associated with distal radius fractures is 9% [41].
• In fresh distal radius fractures, associated lesions of the ulnar head are frequent [38].
• The association of a scaphoid fracture with a distal radius fracture in children remains rare [12].
• Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare [13].
• In the setting of isolated radial styloid fractures, intercarpal ligament injuries must be suspected [11].
• The presence of an associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [47].
• Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [47].
• The presence of a displaced fracture at the base of the ulnar styloid is not in itself an indication for surgical fixation [11].
• Clinical stability of the distal radioulnar joint must be elucidated and compared with the normal contralateral side when possible [11].
• Radiocarpal instability may occur acutely, develop gradually, or be observed as a late sequela of a perilunate dislocation [52].
• Most patients with radiocarpal instability sustain an associated injury, with disruption to the ipsilateral distal radioulnar joint common [52].
• Complete intra-articular distal radius fractures in young active patients must be considered as a generally multi-tissue traumatic entity [25].
• Osteochondral fracture of the distal end of the radius is rare [63].

Investigations¶

Radiography and Measurements¶

• The standard radiographic series for distal radius fractures includes posteroanterior (PA), lateral, and oblique views [110].
• Radial height is measured on the PA view as the distance between two parallel lines drawn perpendicular to the radial shaft, one at the distal end of the ulnar head and the other at the radial styloid [110].
• The average radial height is between 11 and 12 mm, with a normal range of 8–18 mm [110].
• Radial inclination is measured on the PA view as the angle between a line perpendicular to the radial shaft and a line connecting the distal end of the distal radioulnar joint (DRUJ) to the radial styloid [110].
• The average radial inclination is between 22 and 23 degrees, with a normal range of 12–30 degrees [110].
• Volar tilt is measured on a true lateral view as the angle between a line perpendicular to the radial shaft and a line connecting the volar and dorsal rims of the distal radius [110].
• The average volar tilt is between 11 and 12 degrees, with a normal range of 0 to 28 degrees [110].
• Ulnar variance is the vertical distance between two lines drawn perpendicular to the long axis of the radius, one parallel to the medial corner of the articular surface of the radius and the other parallel to the most distal aspect of the articular surface of the ulnar head [110].
• Carpal malalignment is assessed by drawing a line down the long axis of the capitate and a separate line down the long axis of the radius, which should overlap or intersect within the carpus in normal alignment [110].
• The teardrop angle is measured on the lateral view as the angle between the radial shaft and the central axis of the teardrop, which is the U-shaped outline of the volar lip of the distal radius [110].
• The teardrop angle averages 70 degrees in normal radii [110].
• A teardrop angle less than 45 degrees is associated with articular gap and step-off on CT [110].
• Anteroposterior (AP) distance is measured on the lateral view as the distance between the apices of the dorsal and volar rims of the lunate facet [110].
• Forearm rotation affects radiographic measurements, with pronation reducing apparent radial length by up to 0.5 mm compared with a neutral rotation view [110].
• A 5-degree rotational change results in a 1.6-degree change in volar tilt on the lateral view [110].
• All radiographic measurements for distal radius fractures should be taken on a true lateral view with the radius and ulna superimposed [110].
• The dorsal tangential view is obtained by flexing the wrist and positioning the forearm tangential to the C-arm beam to assess for dorsal cortical screw penetration [110].
• The radial incline view is taken on the lateral view with the C-arm adjusted to match the radial inclination to provide a view of the articular surface of the radius [110].
• Metaphyseal collapse ratio (MCR) is a radiographic parameter that provides a reliable measure of metaphyseal comminution and correlates with other parameters predicting distal radius fracture instability [166].
• Patients with significant radial shortening at initial presentation are those who will malunite with radial shortening [66].
• A radiographically intact dorsal radial cortex may identify a minority of fractures that are resistant to mal-union in dorsal angulation [43, 44].

Advanced Imaging¶

• CT scans can identify intra-articular radiocarpal extension in distal radius fractures that appear normal or show only lip fractures on plain films [26].
• CT scans detail residual step-deformities and postreduction metaphyseal cavities resulting from local crush of fracture fragment displacement that are not appreciated on plain films [26].
• CT is used for preoperative planning of intra-articular fractures [53].
• MRI is used to rule out injuries to carpal ligaments, such as lunotriquetral and scapholunate ligaments, or the triangular fibrocartilage complex (TFCC) [53].
• CT may be required to better define associated bony injuries in cases of radiocarpal instability [52].
• MRI can be used to determine the extent of ligamentous disruption in radiocarpal instability [52].
• In cases of complex injury patterns, CT may be necessary for radiographic evaluation [36].
• A true lateral view of the wrist, in which the pisiform overlies the volar third of the scaphoid, is required to assess distal radioulnar joint (DRUJ) alignment [36].
• Radiographic parameters associated with DRUJ injury include fracture of the base of the ulnar styloid, widening of the DRUJ on the AP wrist radiograph, dislocation of the ulna relative to the radius on a true lateral wrist radiograph, and more than 5 mm of shortening of the radius relative to the ulna [36].
• Radial shaft fracture line obliquity greater than 30° is a statistically significant predictor of DRUJ instability [36].
• Arthroscopy improves intra-articular reduction without altering extra-articular reduction in patients with intra-articular fractures of the distal radius [167].
• Arthroscopy allows for assessment and treatment of injuries discovered during the management of intra-articular distal radius fractures [167].
• Plain radiograph step and gap measurements for intra-articular fracture of the distal radius can be evaluated for accuracy and reproducibility using a cadaver model [15].
• Data from cadaver models can aid in the interpretation of clinical studies of acute distal radius fractures based on plain radiography [15].

Associated Injuries and Specific Pathologies¶

• A lunatum fracture accompanying a radial styloid fracture on a normal bone seems to be an exceptional lesion [168].
• The presence of apparently simple fractures should not preclude careful detailed observation of all available radiographs to detect associated injuries such as lunate subluxation [163].
• Bone mineral density (BMD) in the R10 and R3 regions are potential indicators of a distal radius fracture in women over 80 years old [30].
• BMD in the U10 and U3 regions are indicators of an ulnar styloid fracture in women in their fifties [30].
• Techniques described for reduction when ulnar translation of the proximal portion of the radius is present have proved to be reliable methods [6].

Diagnostic Algorithms and Clinical Assessment¶

• An algorithm with a multi-modality approach involving history, examination, and conventional radiographic examination can be applied to acute wrist trauma to establish a diagnosis [57].
• Standard scaphoid radiographic views detect most carpal injuries [97].
• The DISI pattern is most commonly associated with displaced scaphoid fractures and scapholunate dissociation [97].
• Perilunate dislocations can be missed in the assessment of carpal injuries [97].
• Assessment of Gilula's lines can aid in the diagnosis of perilunate dislocations [97].
• CT is useful in the diagnosis of suspected carpal fractures and assessment of union [97].
• MRI is useful in detecting suspected fractures and avascular necrosis (AVN) of the carpus [97].
• Wrist arthroscopy can be used as an aid to the diagnosis of ligament injuries and fracture displacement [97].
• Live/video fluoroscopic evaluation of the wrist provides diagnostic clarity for dynamic instability with sensitivities reported between 86% and 95% and specificity between 80% and 97% for diagnosing scapholunate ligament injury [97].
• Ultrasound scanning (USS) provides an additional tool for the detection of carpal ligament injuries, although the technique is operator dependent [97].
• The most constant and dependable sign of carpal injury is well-localized tenderness [108].
• Anatomical snuffbox tenderness is a sign of scaphoid injury [108].
• Tenderness distal to Lister's tubercle is a sign of scapholunate and lunate injury [108].
• Tenderness on the dorsal margin, fingerbreadth distal to the ulnar head, is a sign of triquetral, lunotriquetral ligament, and triquetrohamate ligament injury [108].
• The scaphoid shift test is diagnostic of scapholunate disruption if a "clunk" is felt as the scaphoid subluxates dorsally out of the scaphoid fossa [108].
• The midcarpal shift test is diagnostic of midcarpal instability if a "clunk" is felt as the lunate reduces from the palmarflexed position [108].
• Lunotriquetral ballottement is diagnostic of lunotriquetral instability or arthritis if painful [108].
• The lunotriquetral shear test is diagnostic of lunotriquetral instability if it reproduces the patient's pain along with palpable crepitation or clicking [108].
• Four standard views for scaphoid fracture assessment include neutral posteroanterior (PA), lateral, 45-degree radial oblique (supinated AP), and 45-degree ulnar oblique (pronated AP) views [108].
• Additional extension and flexion views are advocated for detecting intercarpal ligament injury [108].
• A clenched-fist view can be added if there is a suspicion of a scapholunate injury [32].
• In the normal carpus, a line drawn through the axis of rotation parallel with the anatomic axis of the forearm passes through the head and base of the third metacarpal, the capitate, the radial aspect of the lunate, and the center of the lunate fossa of the radius in the coronal plane [108].
• In the sagittal plane, a line passes through the longitudinal axis of the index finger metacarpal, capitate, lunate, and radius, with the scaphoid lying on an axis at a 45-degree angle to this line [108].
• Standard radiographs should demonstrate a constant space between the scaphoid, lunate, and triquetrum throughout the range of wrist motion [108].
• If initial X-rays are 'normal' but clinical diagnosis suggests fracture, the wrist should be immobilized and treated according to the clinical diagnosis [32].
• 10–15% of scaphoid fractures are not visible on initial X-rays [32].
• Early MRI reduces uncertainty and streamlines care for suspected scaphoid fractures [32].
• If MRI is not available, repeated X-rays are needed 2 weeks later to detect shifting of the bones and resorption at the fracture line [32].
• If there is still doubt after a further 2 weeks, X-ray again [32].
• CT is more sensitive for diagnosing a scaphoid fracture than X-rays [34].
• MRI is the definitive way to confirm or exclude a diagnosis of scaphoid fracture if the technique is available [34].
• CBCT is less sensitive in the detection of carpal fractures than MRI and is not an equivalent tool to exclude scaphoid fractures [164].

Treatment¶

General Principles and Indications¶

• Distal radius fractures are heterogeneous injuries that require individualized management [70].
• For young patients, restoration of bony anatomy is the priority of treatment [54].
• For elderly patients, restoring height, tilt, and inclination is not necessary or sufficient to achieve pain relief and good function [54].
• Surgery is indicated for unstable fractures, open fractures, fractures with certain associated injuries, and high-energy injuries in young patients [60].
• Instability may be defined as the presence of a fracture criterion predictive of instability, inadequate initial closed reduction, or loss of reduction during follow-up [60].
• The presence of three or more of the following factors before reduction is predictive of secondary displacement after closed reduction: dorsal comminution, dorsal angulation >20°, ulnar styloid fracture, intra-articular extension, and age older than 60 years [60].
• AAOS clinical practice guidelines recommend surgery for postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm [60].
• Injury and patient characteristics meriting a discussion of surgical treatment include loss of reduction with ulnar variance 5 mm or more positive, dorsal articular tilt ≥15°, and loss of radial inclination >10° [11].
• A 2020 meta-analysis showed that median term DASH scores and grip strength favored surgical treatment over nonsurgical management, although there was no difference for patients older than 60 years [60].
• The best method of operative fixation of distal radius fractures remains unclear due to ongoing controversy and insufficient evidence from randomized controlled trials [35].

Non-Operative Management¶

• Current best evidence suggests initial displacement determines the final alignment regardless of the time of immobilization [11].
• Wrist splints or short arm casts are usually used for immobilization, and the elbow and forearm are usually left free unless there is severe radioulnar joint injury or disruption [11].
• If a fracture is undisplaced, a dorsal splint is applied for 1–2 days until swelling resolves, then the cast is completed [24].
• The cast for an undisplaced fracture can usually be removed after 4 weeks to allow mobilization [24].
• Displaced fractures must be reduced under anaesthesia using haematoma block, Bier’s block, or axillary block [24].
• Reduction involves applying traction in the length of the bone to disimpact fragments, then pushing the distal fragment into place by pressing on the dorsum while manipulating the wrist into moderate flexion, ulnar deviation, and pronation [24].
• A dorsal plaster slab is applied extending from just below the elbow to the metacarpal necks and two-thirds of the way round the circumference of the wrist [24].
• Flexion and ulnar deviation of 20 degrees in each direction is adequate for immobilization [24].
• Extreme positions of flexion and ulnar deviation must be avoided during immobilization [24].
• The arm is kept elevated for the next day or two, and shoulder and finger exercises are started as soon as possible [24].
• If fingers become swollen, cyanosed, or painful, the bandage should be split [24].
• The position must be checked by X-ray 7 days later and again at 14 days [24].
• If a fracture redisplaces in the cast, remanipulation usually fails and surgery is considered [24].
• The fracture usually unites in about 5 weeks, and the slab may be discarded and exercises begun even in the absence of radiological proof of union [24].
• Nonsurgical treatment is an option for nondisplaced or minimally displaced radial styloid fractures [11].
• In a prospective cohort of 129 patients older than 55 years, ulnar positivity >2 mm was associated with worse patient-reported outcomes at 1 year regardless of treatment type [60].
• Shortening of >5 mm weakens the wrist and substantially limits rotation [60].

Operative Management: Percutaneous Pinning and External Fixation¶

• Closed reduction and percutaneous pinning is most effective when used to treat unstable extra-articular or minimally articular distal radius fractures [138].
• Percutaneous pinning becomes more challenging when treating comminuted fractures [138].
• At least two pins should be used for percutaneous pinning, and many surgeons use three or more pins [138].
• At least 1.6-mm (0.062 in.) K-wires should be used for percutaneous pinning [138].
• A combination of two radial styloid pins and one dorsal ulnar pin is the strongest biomechanically [138].
• External fixation maintained radial length more effectively than pins and plaster in patients followed for 2 years [31].
• External fixation was associated with higher initial costs (20 times) and a greater number of minor complications compared to pins and plaster [31].
• Outcomes of patients with complex unstable intraarticular fractures are similar regardless of whether they are treated with a static bridging external fixator or a dynamic non-bridging external fixator [75].
• External fixation is an effective method of treating complex fractures of the distal radius that are not amenable to closed reduction or open reduction and internal fixation [147].
• External fixation is most frequently used for severely comminuted articular fractures that are not amenable to closed treatment or ORIF [135].
• Nonspanning external fixation crosses only the fracture and not any joints, utilizing pins proximal to the fracture and in the distal fracture fragment [135].

Operative Management: Open Reduction and Internal Fixation (ORIF)¶

• Volar locking plates make it possible to stabilize dorsally displaced fractures from through the volar Henry approach [11].
• The most common tendon to rupture following application of a volar plate is the flexor pollicis longus, due to volar extension of the plate beyond the so-called watershed line [11].
• Dorsal plates or constructs are now preferred for dorsal shearing fractures and complex articular fractures [11].
• A distraction plate is applied between the index or long finger metacarpal and the shaft of the radius, applied with distraction, and removed about 3 months after injury [11].
• The average PRWE score was 14 for surgical treatment of redisplaced fractures in patients older than 60 years, which compares favorably with prior studies of adult patients of all ages [16].
• Intramedullary implants for dorsally displaced extra-articular or simple intra-articular distal radius fractures may offer good radiological and functional outcomes without hardware irritation in elderly patients [81].
• The PEEK volar locking plate was shown to be a safe and effective treatment for distal radius fractures [115].
• The results indicate that combined internal and external fixation can be successfully used in the specific subset of severe AO-C3 distal radius fractures [39].
• Fragment-specific fixation may be utilized in patients with highly comminuted or unusual fracture patterns where typical plate fixation methods will not suffice and closed reduction is not possible [135].
• A higher complication rate was found in the fragment-specific fixation group compared to volar locked plating, with transient radial neuropraxia being the most common complication [135].
• The brachioradialis splitting approach sparing the pronator quadratus has been utilized for over 6 years in the treatment of all fractures of the distal radius requiring volar plating without the requirement for further incisions [10].
• Careful attention to surgical technique during VLP fixation, such as proper placement proximal to the watershed line, is important to prevent implant prominence and potential complications such as flexor tendon irritation and rupture [70].
• Reduction of the lunate facet and ensuring DRUJ congruence in the treatment of distal radius fractures are paramount for the restoration of forearm supination [70].
• The authors prefer volar locked plate fixation except in specific instances where other fixation methods allow better control of fracture fragments or fractures are too highly comminuted for volar plating [112].
• Dorsal shearing injuries or fractures with significant articular comminution are addressed dorsally to allow better visualization of articular surfaces, elevation of depressed articular fragments, and bone grafting when required [112].
• When using dorsal plating, care is taken to repair the extensor retinaculum over the plate leaving the EPL transposed [112].
• Highly comminuted and unstable injuries are often treated with a dorsal spanning plate or external fixator, depending on the ease of reduction and physical demands of the patient [112].
• Dorsal spanning plates preclude reduction once applied, so they are preferable in cases where the reduction holds easily or can be provisionally pinned [112].
• External fixation allows manipulation after application so is preferred when the reduction is difficult and may require further manipulation or is not easily pinned [112].
• In patients who are active or need to weight-bear immediately, dorsal spanning plates can allow quick return to activity while the fracture heals [112].
• The management of distal radius fractures is in the midst of a renaissance with novel locking plate designs resulting in a rethinking of the contemporary approach to fracture fixation [45].
• Open distal radius fractures are managed with prompt initiation of intravenous antibiotics and surgical débridement and irrigation [60].
• In a 2020 retrospective study of 90 open distal radius fractures, 74% were managed with immediate ORIF at the time of irrigation and débridement [60].
• Immediate definitive treatment for open distal radius fractures provides satisfactory outcomes [60].
• Intra-articular displacement (or diastasis) greater than 2 mm is an indication for surgery in radial styloid fractures [11].
• Compression screw fixation with partially threaded 3.5- or 4.0-mm cancellous screws can effectively compress the fragments and maintain the reduction in radial styloid fractures [11].
• The techniques described for ulnar translation of the proximal portion of the radius have proved to be reliable methods to accomplish reduction [6].

Complications and Adverse Outcomes¶

• Complications in the treatment of distal radius fractures have been reported in frequencies ranging from 6% to 80% [42].
• Carpal tunnel syndrome is one of the most common complications of distal radius fractures and can be acute, subacute, or delayed as much as 25 years [42].
• Acute carpal tunnel syndrome is characterized by progressive pain and neurologic symptoms in the median nerve distribution and necessitates urgent surgical release [42].
• Median nerve contusion is not progressive and improves over time [42].
• Ulnar nerve injury is much less common and is most often a neuropraxia that resolves spontaneously [42].
• In the setting of open injuries or complete ulnar palsy, exploration may be warranted [42].
• Complex regional pain syndrome (CPRS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction [28].
• Malunion remains a common cause of residual disability after distal radial fractures [21].
• Not all distal radial malunions are symptomatic, especially malunions in elderly patients with low functional demands [21].
• Posttraumatic wrist deformities in younger, active patients may be sufficiently disabling to warrant surgical correction [21].
• Malunion can be caused by failure to achieve or maintain an accurate reduction or by inadequate duration or type of immobilization [21].
• Reduction is most difficult to obtain and maintain in fractures with marked comminution, severe osteoporosis, or disruption of the distal radioulnar ligaments [21].
• Older patients had more malunions than younger patients, with a mean age of 60 years for patients with malunions versus 51 years for those without [21].
• Malunion occurs commonly in distal radius fractures, particularly in elderly patients managed nonoperatively [46].
• Treatment of malunion should focus on the symptomatic patient and not on radiographic appearance [46].
• Some authors have argued that in cases of intra-articular malunion, early treatment may be warranted before there is evidence of degeneration [46].
• A malunion of the distal radius is defined as radial inclination <10 degrees, volar tilt >20 degrees or dorsal tilt >20 degrees, radial height <10 mm, ulnar variance >2+ mm, or intra-articular incongruity or diastasis >2 mm [46].
• Malunion can result in decreased grip strength, limitations in range of motion, pain, and cosmetic deformity which is unacceptable to patients [46].
• Corrective osteotomy designed to restore normal radiocarpal and distal radioulnar relationships is indicated for symptomatic malunion [46].
• More recent data support intervention as early as 6 weeks for malunion correction, resulting in a technically less challenging case and a shorter overall period of patient disability [46].
• Surgical procedures designed to correct malunions of the distal radius rarely result in a normal wrist [46].
• Deficits in range of motion and grip strength after malunion correction rarely exceed 70% of the contralateral limb [46].
• An associated ulnar styloid fracture does not affect the outcomes of a

Complications¶

General Complication Rates¶

Nerve Injury¶

• In the setting of open injuries or complete ulnar palsy, exploration may be warranted for ulnar nerve injury [42].
• Early surgical decompression was successful in all three cases of progressive ulnar nerve palsy following fractures of the distal radius [83].

Tendon Injury¶

Malunion¶

• In one study, malunion was found to be associated with higher arm-related disability regardless of age [21].
• Older patients had more malunions than younger patients, with a mean age of 60 years for those with malunions versus 51 years for those without [21].
• Malunion can result in decreased grip strength, limitations in range of motion, pain, and cosmetic deformity [46].
• Following corrective osteotomy for malunion, range of motion and grip strength rarely exceed 70% of the contralateral limb [46].

Joint Degeneration and Arthrosis¶

• Radiocarpal arthrosis after intra-articular distal radius fractures can be expected to worsen over time [29].
• Laboratory studies showed that 20 to 30 degrees of dorsal tilt altered the force distribution across the radiocarpal joint, and this degree of deformity should be considered a prearthritic condition [21].
• More than 10 degrees of dorsal tilt leads to decreased wrist flexion [21].
• 6 mm of radial shortening causes dysfunction of the distal radioulnar joint [21].
• Fractures with more than 25 or 30 degrees of angulation in the frontal or sagittal plane or 6 mm or more of radial shortening were likely to become symptomatic [21].
• Patients with constitutional joint laxity may develop midcarpal instability with a dorsal tilt of only 10 to 15 degrees [21].
• Significant changes to distal radioulnar joint mechanics as well as ligament lengthening occur with malunion of the distal radius [21].

Associated Injuries and Complications¶

• The frequency of distal ulna fractures associated with distal radius fractures is 9%, which is slightly higher than the previously estimated 5.9% [41].
• An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [47].
• Complex regional pain syndrome greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction [28].
• Injury to the distal radius has been described as a trigger to the onset of Dupuytren’s disease [157].

Surgical and Hardware Complications¶

• Potential pitfalls of volar plating include intra-articular screw placement and application to inappropriate fracture patterns with prominent implant placement which may lead to tendon rupture [11].
• External fixation maintained radial length more effectively than pins and plaster but was associated with higher initial costs (20 times) and a greater number of minor complications [31].
• Very rare complications such as insufficiency fractures could occur at the distal metaphysis and diaphysis of the radius following a Sauve-Kapandji procedure [40].

Recovery¶

Functional Outcomes and Long-Term Prognosis¶

• Not all distal radial malunions are symptomatic, especially in elderly patients with low functional demands, for whom no further treatment is indicated [21].
• Complex regional pain syndrome (CRPS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work, and patient satisfaction [28].
• The average PRWE score was 14, which compares favorably with prior studies of adult patients of all ages treated for a distal radius fracture [16].
• Incomplete remodelling after Salter-Harris type II fracture of the distal radius does not have any long-term negative effect on mobility of the wrist and grip strength [55].
• Whether the ulnar styloid fracture heals with bone or not did not measurably affect wrist function after conservative treatment of distal radial fracture [65].
• Ulnar styloid fracture decreases supination strength after conservative treatment of distal radial fracture [65].

Radiographic Criteria and Deformity Parameters¶

• Radiographic measurement of alignment of an intact distal radius shows an average of 22 to 23 degrees of radial inclination [21].
• Radiographic measurement of alignment of an intact distal radius shows an average of 11 to 12 mm of radial height [21].
• Radiographic measurement of alignment of an intact distal radius shows an average of 11 to 12 degrees of volar tilt [21].
• Radiographic measurement of alignment of an intact distal radius shows an average of ± 2 mm of ulnar variance [21].
• Intraarticular incongruity in the radiocarpal joint of more than 2 mm is likely to be associated with a poor functional outcome [21].
• A 1- to 2-mm step-off at the distal radioulnar joint is likely to be associated with a poor functional outcome [21].
• Dorsal angulation of more than 20 degrees and radial inclination of less than 10 degrees are likely to be associated with a poor functional outcome [21].
• Loss of sagittal tilt of 20 to 30 degrees is likely to be associated with a poor functional outcome [21].
• Significant articular incongruity and radial shortening are more consistently correlated with the development of symptoms than are other measurements [21].
• Laboratory studies showed that 20 to 30 degrees of dorsal tilt altered the force distribution across the radiocarpal joint, which should be considered a prearthritic condition [21].
• There was no radiographic evidence of posttraumatic degenerative changes in fractures that healed with anatomic joint congruity or with an articular step-off up to 1 mm, except in one patient who had development of rapid joint deterioration [170].

Complications and Associated Injuries¶

Implant and Surgical Outcome Specifics¶

• All the distal radial fractures united without major complications, and all patients returned to their work or daily activities within a short time period without any additional surgical treatment, except for removal of implants in three patients [80].
• Bone unions occurred in all patients as assessed after an average follow-up period of 3.7 months for volar rim fractures treated with dual plating [171].
• At follow-up (more than 48 months), most patients (92%) displayed excellent and good results based on Mayo modified wrist scores for arthroscopic-assisted treatment in athletes [136].
• At follow-up, 19 patients had excellent and eight patients good results according to the Mayo modified wrist score for arthroscopically-assisted reduction of intra-articular fractures [149].
• The clinical results on follow-up were good to excellent, with minimal joint stiffness and satisfactory functional outcomes of the wrist and elbow for Kapandji pinning and LCP fixation [49].

Key Evidence¶

• [Paper] Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern, with early diagnosis and treatment being important to avoid long-term consequences. [2] (10.1016/j.hcl.2014.12.002)
• [L3] This method represents a valuable treatment modality for the most frequent types of unstable fractures of the distal radius in young and elderly patients. [3] (10.1053/jhsu.2002.32081)
• [L4] Implant removal following operative distal radius fracture treatment can improve the functional outcome of the hand and forearm. [4] (10.1177/1558944716660555ba)
• [Paper] The techniques described in this article have proved to be reliable methods to accomplish reduction when ulnar translation of the proximal portion of the radius is present. [6] (10.1097/bth.0b013e31817d54e8)
• [L4] Open fractures of the distal radius commonly have associated injuries, and their treatment often requires multiple surgical procedures. [7] (10.1053/jhsu.2002.30073)
• [L3] Non-bridging external fixation offers a reliable method of maintaining radiological reduction of Older type II/III fractures of the distal radius and gives a good functional outcome after 1 year. [9] (10.1177/1753193409102457)
• [L4] They have utilized this approach for over 6 years in the treatment of all fractures of the distal radius requiring volar plating without the requirement for further incisions. [10] (10.1097/bth.0000000000000104)
• [L4] The association of a scaphoid fracture with a distal radius fracture in children remains rare. [12] (10.1016/j.main.2008.11.004)
• [Paper] Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare but require a standardised management strategy. [13] (10.1016/j.otsr.2018.04.026)
• [Paper] These data can aid in the interpretation of clinical studies of acute distal radius fractures that are based on plain radiography. [15] (10.1016/j.jhsa.2004.04.019)
• [L4] The average PRWE score was 14, which compares favorably with prior studies of adult patients of all ages treated for a distal radius fracture. [16] (10.1053/jhsu.2002.34007)
• [L3] Survival rates after distal radius fractures were notably lower than those expected for individuals of the same age and gender in standard populations. [17] (10.1053/jhsu.2002.36995)
• [L4] Associated fractures of the distal radius and ulna are relatively common but poorly recognized injuries, with an incidence of 5.6% of all Colles’ fractures requiring manipulation or operative treatment. [18] (10.1016/s0266-7681(05)80094-4)
• [L1] External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius, with reliably good results, a low reoperation rate, and a low complication rate. [19] (10.1016/j.hcl.2009.08.008)
• [Paper] Displaced fractures are less well tolerated in young patients than in older people, especially in terms of dorsal tilt and radial shortening. [20] (10.1016/j.hansur.2016.03.005)
• [L4] Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes. [22] (10.1142/s2424835520500034)
• [Paper] Complete intra-articular distal radius fractures in young active patients must be considered as a generally multi-tissue traumatic entity. [25] (10.1016/j.hansur.2016.09.007)
• [L3] [26] (10.1016/0363-5023(92)90326-k)
• [Paper] Complex regional pain syndrome (CPRS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction. [28] (10.1016/j.hansur.2016.03.010)
• [L2] Radiocarpal arthrosis after intra-articular distal radius fractures can be expected to worsen over time. [29] (10.1016/j.jhsa.2006.01.008)
• [L4] The BMD in the R10 and R3 are potential indicators of a distal radius fracture in women over 80 years old, whereas the U10 and U3 are indicators of an ulnar styloid fracture in women in their fifties. [30] (10.1016/j.jhsa.2003.09.016)
• [L1] External fixation maintained radial length more effectively (significantly in those patients followed for 2 years) but was associated with higher initial costs (20 times) and a greater number of minor complications. [31] (10.1016/s0266-7681(05)80095-6)
• [L5] The authors note that while eponymous descriptions like Colles and Smith have served as guidelines for 150 years, renewed enthusiasm for defining fracture morphology is driven by increased prevalence in young adults, better understanding of joint kinematics, and the need for objective outcome measures. [33] (10.1016/s0363-5023(97)80110-4)
• [L4] Dans les fractures fraîches du radius distal, les lésions associées de la tête ulnaire sont fréquentes. [38] (10.1016/j.main.2012.10.027)
• [L4] The results indicate that this surgical strategy, though technically demanding, can be successfully used in this specific subset of difficult to treat distal radius fractures. [39] (10.1016/s0363-5023(05)80090-5)
• [L5] Surgeons should be aware that very rare complications such as insufficiency fractures could occur at the distal metaphysis and diaphysis of the radius following this procedure. [40] (10.1142/s2424835518720153)
• [L3] The study provides new epidemiological data showing that the frequency of distal ulna fractures (DUF) associated with distal radius fractures (DRF) is 9%, which is slightly higher than the previously estimated 5.9%. [41] (10.1016/j.hansur.2016.09.005)
• [L3] A minority of fractures are resistant to mal-union in dorsal angulation and may be identified by a radiographically intact dorsal radial cortex. [43] (10.1016/0266-7681(89)90116-2)
• [L3] A minority of fractures are resistant to mal-union in dorsal angulation and may be identified by a radiographically intact dorsal radial cortex. [44] (10.1016/0266-7681_89_90116-2)
• [Paper] The management of distal radius fractures is in the midst of a renaissance with novel locking plate designs resulting in a rethinking of the contemporary approach to fracture fixation. [45] (10.1016/j.hcl.2005.04.001)
• [L1] Based on this meta-analysis, an associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture and clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture. [47] (10.1016/j.injury.2017.08.061)
• [L4] Bone grafting from the distal radius is effective with minimal complications and is a practical adjunct to reconstructive hand procedures. [48] (10.1016/s0363-5023(03)00364-2)
• [L3] The clinical results on follow-up were good to excellent, with minimal joint stiffness and satisfactory functional outcomes of the wrist and elbow. [49] (10.1097/bth.0000000000000221)
• [L4] According the authors experience the Fernandez osteotomy is a reliable method for the treatment of malunited distal radius fractures. [50] (10.1016/s0363-5023(03)80304-0)
• [L4] The incomplete remodelling does not have any long-term negative effect on mobility of the wrist and grip strength. [55] (10.1016/s0363-5023(03)80352-0)
• [L4] Barzullah working classification of distal radius fractures presented in this study has good characteristics compared to those of already studied classification systems among orthopaedic residents. [56] (10.1142/s2424835516500028)
• [L3] [57] (10.1016/0266-7681(93)90112-s)
• [L4] [59] (10.1016/j.jhsb.2004.05.002)
• [L4] The best indication for double dorsal plates on distal radius fractures is for metaphyso-diaphyseal fractures with dorsal displacement, comminution and articular involvement. [62] (10.1016/j.main.2005.12.006)
• [L5] Although osteochondral fracture of the distal end of the radius is rare, we should, for the sake of early diagnosis and therapy, consider that any joint might sustain this kind of injury. [63] (10.1016/0363-5023(93)90097-m)
• [L3] Whether the ulnar styloid fracture heals with bone or not did not measurably affect wrist function. [65] (10.1177/1753193415583067)
• [L3] The patients who will malunite with radial shortening are those with significant radial shortening at the initial presentation. [66] (10.1016/0266-7681(94)90247-x)
• [L4] [68] (10.1016/0266-7681_89_90115-0)
• [L1] This study demonstrated that the outcomes of patients with complex unstable intraarticular fractures of the distal radius are similar, regardless of whether they are treated with a static bridging external fixator or a dynamic non-bridging external fixator. [75] (10.1016/s0266-7681(03)00083-4)
• [L4] [78] (10.1016/s1297-3203(03)00057-x)
• [L4] All the distal radial fractures united without major complications, and all patients returned to their work or daily activities within a short time period without any additional surgical treatment, except for removal of implants in three patients. [80] (10.1016/j.jhsb.2004.09.004)
• [L4] The findings of this study indicate that intramedullary implants for dorsally displaced extra-articular or simple intra-articular distal radius fractures may offer good radiological and functional outcomes without hardware irritation in elderly patients. [81] (10.1142/s2424835516500089)
• [Paper] Fixation with volar locking plates is the gold standard treatment for extra-articular distal radius fractures in active elderly patients. [82] (10.1016/j.hansur.2016.02.014)
• [L4] Early surgical decompression was successful in all three cases of progressive ulnar nerve palsy following fractures of the distal radius. [83] (10.1016/0266-7681(91)90022-g)
• [L5] We conclude that deformities of distal radius fractures have a significant influence on the biomechanics of the wrist motors. [84] (10.1053/jhsu.1999.jhsu24a0121)
• [L3] Grip strength is determined by the final alignment of the radio-carpal joint, in both the coronal and the sagittal planes. [93] (10.1016/0266-7681_88_90090-3)
• [L4] With increased dorsal tilt, the range of wrist motion became more restricted and abnormalities of carpal alignment during wrist motion became apparent. [100] (10.1016/0363-5023(93)90242-u)
• [Paper] [106] (10.1007/s12593-014-0164-0)
• [L3] [113] (10.1177/1558944716660555bl)
• [L4] The PEEK volar locking plate was shown to be a safe and effective treatment for distal radius fractures. [115] (10.1016/j.hansur.2016.10.112)
• [L3] This classification, describing all possible combinations of the three components of the fracture, is useful for both prognosis and treatment. [131] (10.1016/j.main.2007.09.002)
• [L3] Additionally, a metaphyseal fracture entering the distal radio-ulnar joint (M') and a displaced ulnar fracture (U > 1) affect functional outcome and must be included in the classification. [134] (10.1016/j.hansur.2016.03.008)
• [Paper] All fractures healed without malunion or nonunion, and at follow-up (more than 48 months), most patients (92%) displayed excellent and good results, based on Mayo modified wrist scores. [136] (10.1016/j.main.2015.10.191)
• [L4] External fixation is an effective method of treating complex fractures of the distal radius that are not amenable to closed reduction or open reduction and internal fixation. [147] (10.1016/0363-5023(91)90002-s)
• [L4] At follow-up, 19 patients had excellent and eight patients good results according to the Mayo modified wrist score. [149] (10.1016/s0266-7681(98)80065-x)
• [L4] [152] (10.1016/0266-7681(94)90094-9)
• [Paper] [154] (10.1016/j.injury.2014.06.017)
• [L4] [157] (10.1016/0266-7681(92)90096-k)
• [Paper] Pouteau described a great variety of different kinds of forearm fractures and defined the mechanism of injury as occurring during a fall on the outstretched hand as opposed to direct injury. [159] (10.1016/j.main.2004.09.004)
• [L5] This case illustrates the important principle that the presence of apparently simple fractures should not preclude careful detailed observation of all available radiographs. [163] (10.1016/0266-7681(94)90162-7)
• [L5] However, they acknowledge that CBCT is less sensitive in the detection of carpal fractures than MRI and therefore not an equivalent tool to exclude scaphoid fractures. [164] (10.1177/1753193418758846)
• [Paper] Metaphyseal collapse ratio, a novel radiographic parameter, was found to provide a reliable measure of metaphyseal comminution, and to be significantly correlated with other radiographic parameters that predict distal radius fracture instability. [166] (10.1016/j.otsr.2013.05.002)
• [L3] Arthroscopy improves intraarticular reduction without altering extra-articular reduction in patients with intraarticular fractures of the distal radius, and it allows for assessment and treatment of any injuries discovered. [167] (10.1016/j.hansur.2017.03.003)
• [L5] A lunatum fracture on a normal bone seems to be an exceptional lesion when it accompanies a radial styloid fracture. [168] (10.1016/j.hansur.2016.10.142)
• [L4] Although our follow-up time is not long (average, 4 years), there was no radiographic evidence of posttraumatic degenerative changes in fractures that healed with anatomic joint congruity or with an articular step-off up to 1 mm, except in the one patient who had development of rapid joint deterioration. [170] (10.1016/0363-5023(91)90001-r)
• [L4] Bone unions occurred in all patients as assessed after an average follow-up period of 3.7 months. [171] (10.1142/s0218810417500447)

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