Distal Radius Fractures

Distal radius fractures are one of the most common fractures encountered in practice and are often associated with falling onto an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand. These fractures are most frequently seen in older individuals, especially women. In this population, these fractures are related to an increase in falls due to gait instability with aging and associated osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis. In younger individuals, distal radius fractures are usually related to high-energy trauma. Individuals often present with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and a dinner fork deformity of the distal forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm. Diagnosis is clinical and confirmed with x-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays of the wrist. Treatment can be operative or nonoperative depending on the age of the individual, articular involvement, and degree of displacement or angulation.

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Distal Radius Anatomy

  • The radius is the lateral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones of the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm. This bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones is responsible for the vast majority of the axial load.
  • The distal radius:
    • Has approximately 20 degrees of radial inclination and 5–10 degrees of volar tilt
    • Articulates with the distal ulna through the distal radioulnar joint (DRUJ)
    • Articulates with the scaphoid and lunate bones of the wrist at the radiocarpal joint
  • The DRUJ:
    • Is primarily responsible for pronation and supination of the wrist
    • Contains a ligamentous complex, the triangular fibrocartilage complex (TFCC), which may be injured in association with a distal radius fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures

Overview

Epidemiology

  • Prevalence:
    • Distal radius fractures: 17.5% of all fractures in adults
    • Hand and forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm fractures account for 1.5% of ED visits.
    • Radius and/or ulna fractures: 44% of hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand and forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm fractures
  • Characteristics:
    • Ages of individuals who most commonly present:
      • Middle-aged to elderly due to low-energy mechanisms (fall on outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand) as a result of increased bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones fragility
      • Young individuals due to high-energy mechanisms (e.g., car accidents, sports injury)
    • More common in females (F:M ratio is 2–3:1)

Etiology

  • In the elderly: fall on outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand is the most common mechanism.
  • In younger individuals:
    • High-energy trauma directly to the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones 
    • Compression load driving the scaphoid or lunate into the distal radius (e.g., punching a hard surface)

Related videos

Clinical Presentation and Diagnosis

Clinical presentation

History:

  • Individual often reports:
    • Falling on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand 
    • Wrist pain Wrist Pain Hand and wrist pain is very common among the general population. Up to 30% of adults will have hand pain during their lives, and half of all cases progress to chronic pain. The causes of hand and wrist pain can be classified into mechanical (e.g., fractures, inflammation, ligament tear), neurologic (e.g., nerve entrapment), and systemic (e.g., autoimmune arthritis). Hand and Wrist Pain with associated swelling and deformity
  • Assess for previous fragility fractures as well as the degree of energy involved in the injury.

Physical exam:

  • Evaluate for deformity and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin integrity:
    • Dinner fork deformity: dorsal angulation, displacement and impaction of distal segment of the radius 
    • Absence of this deformity does not exclude fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Evaluation of the wrist:
    • Range of motion: supination, pronation, flexion, and extension
    • Palpation of the ulna and radial surfaces for areas of tenderness and displacement
    • Palpation of anatomical snuffbox to evaluate for scaphoid fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Careful neurovascular examination: 
    • Radial and ulnar pulses with capillary refill 
    • Evaluation of sensory and muscular function of median, ulnar, and radial nerves
    • Index and thumb sensations should always be assessed because of increased risk of injury to median nerve with distal radius fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures 
  • Evaluate for associated injuries: 
    • Carpal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures/dislocations
    • DRUJ injuries
    • Carpal ligament injuries
    • Digit tendon injuries
Colles fracture

Colles fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand:
Classic dinner fork deformity with posterior displacement clearly visible.

Image: “Colles fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand” by Sylvain Letuffe. License: Public Domain

Diagnosis

Diagnosis is clinical; however, imaging is needed for confirmation and evaluation of severity.

  • X-rays: 
    • Anteroposterior (AP) and lateral, with optional oblique
    • Evaluate six A’s:
      • Anatomy involved
      • Involvement of Articular surface
      • Alignment of the fragments
      • Degree of Angulation
      • Apex
      • Presence of Apposition
    • Acquire images of the joints above and below the injury; imaging is repeated after reduction if reduction is required.
    • Findings suggestive of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
      • Radial shortening of ≥ 5 mm
      • Radial inclination change of ≥ 5 degrees
      • Articular step-off of ≥ 2 mm
      • Volar tilt with dorsal angulation of ≥ 5 degrees
  • CT scan: 
    • May be used to evaluate intraarticular involvement 
    • Useful for surgical planning
  • Frykman classification of distal radius fractures:
    • Types I/II: do not involve the joint; complications are rare once treated 
    • Types III/IV: involving the radiocarpal joint
    • Types V/VI: involving the DRUJ
    • Types VII/VIII: involve both radiocarpal and DRUJ; tend to be very unstable

Specific examples of distal radius fractures

  • Colles fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
    • A common fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the distal radius, often low-energy
    • Generally extraarticular and dorsally displaced
  • Smith fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
    • Considered a reverse Colles fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures 
    • Distal radius angulation is in the palmar direction.
    • Often seen if the fall occurs on a flexed wrist
  • Die-punch fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Fracture of the distal radius resulting from an axial loading force
    • Intraarticular fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the lunate fossa of the distal radius
  • Barton fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
    • Intraarticular fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures/subluxation involving the dorsal or volar rim of the distal radius
    • Often appears as a triangular fragment of the distal radial styloid on x-ray
  • Hutchinson fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (chauffeur’s fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures): 
    • Fracture through the base of the radial styloid
    • Occurs with forced hyperextension of the wrist

Management

Management, whether nonsurgical or surgical, is based on the type of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (based on articular involvement and displacement) and the age and activity level of the individual.

Nonsurgical management

  • Splinting:
    • Often used initially to allow swelling to decrease before casting
    • Simple splint (volar or sugar tong style) can be done for fractures with minimal/no displacement or after an adequate closed reduction ( x-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays before and after reduction should be assessed) 
    • In a sugar tong splint, the elbow is flexed to 90 degrees, with neutral positioning of the wrist
  • Swelling and pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management:
    • Circumferential casting should not be done in the acute setting because continued swelling may contribute to neurovascular injury (distal ischemia and carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome most common).
    • Elevation and ice are helpful to reduce swelling and to assist in pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control for a properly reduced or nondisplaced fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.
    • Active range of motion of shoulder and fingers are allowed and encouraged.
    • Pain management should be tailored to the individual’s needs, using the smallest amount of the least potent medication possible.
Forearm sugar tong splint

Forearm sugar tong splint:
A simple splint, the sugar tong splint is indicated in distal radius and ulnar fractures that are not displaced. The splint impedes pronation/supination and immobilizes the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint.

Image by Lecturio.

Surgical management

Surgical management is indicated in the presence of:

  • Significant displacement or substantial articular involvement as demonstrated by:
    • Intraarticular step-off of the distal radius
    • Increased dorsal tilt
    • Loss of radial length
  • Neurovascular compromise without resolution after reduction
  • Inadequate reduction
  • Associated instability

Prognosis

  • Prognosis is favorable.
  • The majority of individuals resume their previous level of activity.
  • Some individuals have resultant loss of motion, instability, and posttraumatic degenerative joint disease.

Differential Diagnosis

  • Scaphoid fractures: A fall on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand is associated with carpal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones injuries. Physicians should specifically evaluate for scaphoid fractures by palpating the anatomical snuffbox area of the wrist. Range of motion is usually not restricted, and swelling/deformity of the wrist are usually minimal. Diagnosis is clinical, combined with radiographic findings. Treatment varies based on severity, ranging from surgical fixation to immobilization in a short- arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm thumb spica cast with the wrist in slight extension for 4–6 weeks.
  • Triangular fibrocartilage complex injury: ligamentous joint that stabilizes the radioulnar juncture and commonly injured with falls on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand. Symptoms include pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain over the ulnar aspect of the wrist, increasing with forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm rotation and ulnar deviation. Management is primarily nonsurgical, involving NSAIDs, ice, and splinting.
  • Wrist sprain: common term for a strain of the radiocarpal ligaments. Presentation is typically with acute wrist pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with minimal restriction of movement, usually after trauma. Management is conservative and supportive only. A sprained wrist can only be a diagnosis of exclusion, after all other pathologic processes have been ruled out.
  • Carpal fractures: common injuries that often occur secondary to falls. Fractures of the capitate, lunate, and trapezoid usually present with swelling, tenderness, and reduced range of motion of the wrist. Surgical repair may be indicated, depending on which bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones is fractured.

References

  1. Meena, S., Sharma, P., Sambharia, A.K., Dawar, A. (2014). Fractures of distal radius: an overview. J Family Med Prim Care 3:325–332. https://pubmed.ncbi.nlm.nih.gov/25657938/ 
  2. Chung, K.C., Spilson, S.V. (2001). The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 26:908–915. https://pubmed.ncbi.nlm.nih.gov/11561245/ 
  3. Lawson, G.M., Hajducka, C., McQueen, M.M. (1995). Sports fractures of the distal radius—epidemiology and outcome. Injury 26:33–36. https://pubmed.ncbi.nlm.nih.gov/7868207/ 
  4. O’Neill, T.W., UK Colles’ Fracture Study Group, et al. (2001). Incidence of distal forearm fracture in British men and women. Osteoporos Int 12:555–558. https://pubmed.ncbi.nlm.nih.gov/11527052/ 
  5. Gutow, A.P. (2005). Avoidance and treatment of complications of distal radius fractures. Hand Clin 21:295–305. https://pubmed.ncbi.nlm.nih.gov/16039441/ 
  6. Bozentka, D.J., et al. (2002). Digital radiographs in the assessment of distal radius fracture parameters. Clin Orthop Relat Res 397:409–413. https://pubmed.ncbi.nlm.nih.gov/11953635/ 
  7. Lafontaine, M., Hardy, D., Delince, P. (1989). Stability assessment of distal radius fractures. Injury 20:208–210. https://pubmed.ncbi.nlm.nih.gov/2592094/

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