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Distal Radius Fracture

Distal radius fractures — assessment, casting, and indications for surgical fixation.

Overview

Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1]. Early diagnosis and treatment of complications are important to avoid long-term consequences [1]. Combined median and ulnar nerve palsy related to distal fractures of the radius is exceedingly rare [2]. Combined median and ulnar nerve palsy requires a standardised management strategy [2].

The management of distal radius fractures is undergoing a renaissance with novel locking plate designs resulting in a rethinking of the contemporary approach to fracture fixation [6]. External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius [10]. External fixation supplemented with percutaneous pins yields reliably good results for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low reoperation rate for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low complication rate for displaced distal radius fractures [10].

Bone graft substitutes are primarily used to provide structural stability in distal radius fractures [9]. Bone graft substitutes may facilitate early return to function in distal radius fractures [9]. The risk of nonunion is minimal in distal radius fractures [9]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8]. A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7]. Die punch fragment size is not an indicator of the need for or use of a dorsal approach in distal radius fracture fixation [17].

Anatomy & Pathophysiology

Osseous

The metaphyseal collapse ratio (MCR) is a radiographic parameter that reliably measures metaphyseal comminution [11]. This metric is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11]. In patients undergoing extra-articular distal radius fracture fixation with volar locking plates, a certain degree of radial height loss occurs [7]. Bone graft substitutes are primarily used to provide structural stability in distal radius fractures where the risk of nonunion is minimal [9].

Ligamentous & Articular

Optimal outcomes in forearm fracture-dislocations depend on restoration and maintenance of anatomic alignment [4]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. The size of a die punch (DP) fragment is not an indicator of the need for or use of a dorsal approach in distal radius fracture fixation [17].

Vascular & Neural

Combined median and ulnar nerve palsy is an exceedingly rare complication of distal radius fractures [2]. Pronation increases the proximal 'safe zone' of the posterior interosseous nerve, minimizing the risk of iatrogenic injury [18].

Imaging & Classification

CT scans do not significantly improve inter- and intra-observer agreement for AO, Fernandez, and Universal classification systems for distal radius fractures [20]. Some surgeons use radiographic factors other than measures of deformity to determine recommendations for surgery [12].

Classification

AO: CT scans do not significantly improve inter- and intra-observer agreement for this classification system [20].

Fernandez: CT scans do not significantly improve inter- and intra-observer agreement for this classification system [20].

Universal: CT scans do not significantly improve inter- and intra-observer agreement for this classification system [20].

Metaphyseal Collapse Ratio (MCR): This novel radiographic parameter provides a reliable measure of metaphyseal comminution [11]. The MCR is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11].

Other Considerations: Some surgeons use radiographic factors other than measures of deformity to determine recommendations for surgery in distal radius fractures [12].

Clinical Presentation

Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1]. Early diagnosis and treatment are important to avoid long-term consequences of distal radius fracture complications [1]. Combined median and ulnar nerve palsy related to distal fractures of the radius is exceedingly rare [2].

Soft tissue complications: Tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome [15]. Complications associated with soft tissues may be more problematic than the bone injury itself in distal radius fractures [15].

Neurovascular assessment: Pronation effectively increases the proximal 'safe zone' of the posterior interosseous nerve [18]. The forearm should be placed in pronation to minimize the risk of iatrogenic injury to the posterior interosseous nerve [18].

Associated injuries: Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes [16]. Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [16]. Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken [19]. Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention if not distinguished from Monteggia fractures [19]. Early recognition and treatment of Essex-Lopresti injury is associated with improved outcomes [21].

Radiographic evaluation: Metaphyseal collapse ratio is a novel radiographic parameter that provides a reliable measure of metaphyseal comminution [11]. Metaphyseal collapse ratio is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11]. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery in distal radius fractures [12].

Fracture characteristics: A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8].

Investigations

Early diagnosis and treatment of complications associated with distal radius fractures are important to avoid long-term consequences [1]. Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management [4]. Soft tissue complications encountered during the management of distal radius fractures include tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome [15]. Complications associated with soft tissues may be more problematic than the bone injury itself [15].

Plain radiography: Combined median and ulnar nerve palsy related to distal radius fractures is exceedingly rare [2]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. Metaphyseal collapse ratio is a novel radiographic parameter that provides a reliable measure of metaphyseal comminution [11]. Metaphyseal collapse ratio is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11]. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery [12]. Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken [19]. Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention [19].

Other Considerations: Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes [16]. Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [16].

Treatment

Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1]. Early diagnosis and treatment are important to avoid long-term consequences of distal radius fracture complications [1]. Combined median and ulnar nerve palsy related to distal fractures of the radius is exceedingly rare [2]. Combined median and ulnar nerve palsy complicating distal radius fractures require a standardised management strategy [2]. Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management [4]. Restoration and maintenance of anatomic alignment are key principles in the treatment of forearm fracture–dislocations [4].

Operative

Indications: There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery in distal radius fractures [12]. Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8].

Surgical Approach / Technique: External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius [10]. External fixation supplemented with percutaneous pins yields reliably good results for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low reoperation rate for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low complication rate for displaced distal radius fractures [10].

Implant Selection: Superior radiological results were attained with volar plating compared to k-wiring for distal radius fractures [13]. Superior radiological results with volar plating did not correlate with a better functional outcome compared to k-wiring at 32 months follow up [13]. A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7]. Bone graft substitutes are primarily used to provide structural stability in distal radius fractures [9]. Bone graft substitutes are used to perhaps allow early return to function in distal radius fractures [9]. The risk of nonunion is minimal in distal radius fractures [9].

Complications

Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1]. Early diagnosis and treatment of complications are important to avoid long-term consequences [1].

Nerve palsy: Combined median and ulnar nerve palsy related to distal fractures of the radius is exceedingly rare [2]. Combined median and ulnar nerve palsy requires a standardised management strategy [2].

Soft tissue complications: Soft tissue complications encountered during the management of distal radius fractures include tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome [15]. Complications associated with soft tissues may be more problematic than the bone injury itself in distal radius fractures [15].

Other Considerations: Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management [4]. Restoration and maintenance of anatomic alignment are key principles for optimal outcomes in forearm fracture–dislocations [4]. A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8]. Bone graft substitutes are primarily used to provide structural stability in distal radius fractures [9]. Bone graft substitutes may facilitate early return to function in distal radius fractures [9]. The risk of nonunion in distal radius fractures is minimal [9]. External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius [10]. External fixation supplemented with percutaneous pins yields reliably good results for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low reoperation rate for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low complication rate for displaced distal radius fractures [10].

Recovery

Prevention of complications associated with distal radius fractures should be the treating surgeon's primary concern [1]. Early diagnosis and treatment of complications are important to avoid long-term consequences [1]. Combined median and ulnar nerve palsy related to distal radius fractures is exceedingly rare [2]. Combined median and ulnar nerve palsy complicating distal radius fractures requires a standardised management strategy [2]. Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management [4]. Restoration and maintenance of anatomic alignment are key principles for optimal outcomes in forearm fracture–dislocations [4].

A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures [7]. An associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture [8]. Clinicians should be cautious in electing operative treatment for patients with an ulnar styloid fracture [8]. Bone graft substitutes are primarily used to provide structural stability in distal radius fractures [9]. Bone graft substitutes are used to perhaps enable early return to function in distal radius fractures [9]. The risk of nonunion is minimal in distal radius fractures [9].

External fixation supplemented with percutaneous pins is an excellent option for treating displaced fractures of the distal radius [10]. External fixation supplemented with percutaneous pins yields reliably good results for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low reoperation rate for displaced distal radius fractures [10]. External fixation supplemented with percutaneous pins has a low complication rate for displaced distal radius fractures [10]. Metaphyseal collapse ratio is a novel radiographic parameter that provides a reliable measure of metaphyseal comminution [11]. Metaphyseal collapse ratio is significantly correlated with other radiographic parameters that predict distal radius fracture instability [11].

Volar plating attains superior radiological results compared to k-wiring for distal radius fractures [13]. Superior radiological results with volar plating do not correlate with a better functional outcome compared to k-wiring at 32 months follow up [13]. Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes [16]. Delayed diagnosis of intrinsic carpal ligament injuries leads to arthritis within 10 years if not treated [16].

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. (10.1016/j.hcl.2014.12.002)
  • [Paper] Combined median and ulnar nerve palsy related to distal fractures of the radius are exceedingly rare but require a standardised management strategy. (10.1016/j.otsr.2018.04.026)
  • [L5] Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management, with restoration and maintenance of anatomic alignment being the key principles. (10.1016/j.hcl.2015.01.010)
  • [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. (10.1016/j.hcl.2005.04.001)
  • [Paper] A certain degree of radial height loss is noted in patients undergoing fracture fixation with volar locking plate for extra-articular distal radius fractures. (10.1016/j.otsr.2021.102842)
  • [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. (10.1016/j.injury.2017.08.061)
  • [L4] Bone graft substitutes are primarily used to provide structural stability and perhaps early return to function in distal radius fractures, where the risk of nonunion is minimal. (10.1016/j.hcl.2012.02.004)
  • [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. (10.1016/j.hcl.2009.08.008)
  • [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. (10.1016/j.otsr.2013.05.002)
  • [Paper] There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery. (10.1007/s12593-014-0164-0)
  • [L3] Although superior radiological results were attained with volar plating, these results did not correlate with a better functional outcome compared to k-wiring at 32 months follow up. (10.1016/j.injury.2015.08.040)
  • [L5] This review focuses on soft tissue complications encountered during the management of distal radius fractures, including tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, and complex regional pain syndrome, noting that complications associated with soft tissues may be more problematic than the bone injury itself. (10.1016/j.hcl.2009.11.002)
  • [L5] Early accurate diagnosis of intrinsic carpal ligament injuries provides for best outcomes, while delayed diagnosis leads to arthritis within 10 years if not treated. (10.1016/j.hcl.2015.01.003)
  • [Paper] DP fragment size is not an indicator of the need for or use of a dorsal approach in DRF fixation. (10.1055/s-0040-1712328)
  • [Paper] Pronation effectively increases the proximal 'safe zone' of the nerve, suggesting the forearm should be placed in pronation to minimize the risk of iatrogenic injury. (10.1016/j.injury.2015.01.028)
  • [L4] Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken, and pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention. (10.1016/j.injury.2005.08.028)
  • [Paper] CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems. (10.1016/j.injury.2014.06.017)
  • [L5] Early recognition and treatment is associated with improved outcomes. (10.1016/j.hcl.2020.07.012)

References

[1] Management of Complications of Distal Radius Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.002

[2] Combined median and ulnar nerve palsy complicating distal radius fractures. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.04.026

[4] Management of Complications of Forearm Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.010

[6] Distal Radius Fractures. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.04.001

[7] Loss of radial height in extra-articular distal radial fracture following volar locking plate fixation. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102842

[8] Does concomitant ulnar styloid fracture and distal radius fracture portend poorer outcomes? A meta-analysis of comparative studies. Injury. 2017. DOI: 10.1016/j.injury.2017.08.061

[9] The Use of Bone Grafts and Substitutes in the Treatment of Distal Radius Fractures. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.02.004

[10] External Fixation of Distal Radius Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.08.008

[11] Distal radius fracture metaphyseal comminution: A new radiographic parameter for quantifying, the metaphyseal collapse ratio (MCR). Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.05.002

[12] Radiographs Versus Radiographic Measurements in Distal Radius Fractures. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-014-0164-0

[13] Volar plate versus k-wire fixation of distal radius fractures. Injury. 2016. DOI: 10.1016/j.injury.2015.08.040

[15] Soft Tissue Complications of Distal Radius Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.11.002

[16] Management of Complications of Ligament Injuries of the Wrist. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.003

[17] The Die Punch Fragment: Analysis of Fragment Geometry and Need for Fixation. Journal of Hand and Microsurgery. 2022. DOI: 10.1055/s-0040-1712328

[18] The course of the posterior interosseous nerve in relation to the proximal radius: Is there a reliable landmark?. Injury. 2015. DOI: 10.1016/j.injury.2015.01.028

[19] When is a Monteggia fracture not a Monteggia fracture?. Injury Extra. 2007. DOI: 10.1016/j.injury.2005.08.028

[20] Does the CT improve inter- and intra-observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures?. Injury. 2014. DOI: 10.1016/j.injury.2014.06.017

[21] The Essex-Lopresti Injury:. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.012

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