Distal Radius Fractures in Orthopedics

Wrist & Hand Injuries

• Wrist and hand injuries are a common orthopaedic concern.
• Distal radial fractures are a frequent injury.
• Distal radial fractures have a bimodal distribution. Younger patients may experience high-energy trauma, while older individuals may be affected by low-energy falls.
• Distal radius fractures are more prevalent in women over 50.
• Distal radius fractures can predict future fractures.
• A DEXA scan is advised for women with a distal radius fracture.

Frykman Classification

• This system categorizes distal radius fractures based on ulnar fracture presence and intra-articular involvement.
• Fracture types are numbered (I-VIII).
  • Extraarticular fracture types are numbered I and II
  • Intraarticular fractures involving the radiocarpal joint are numbered III and IV.
  • Intraarticular fractures involving the distal radioulnar joint are numbered V and VI.
  • Intraarticular fractures involving both the radiocarpal and distal radioulnar joints are numbered VII and VIII.

Types of Fractures

• Colles fracture: Low-energy injury, dorsally displaced, extraarticular fracture.
• Smith fracture: Low-energy fracture, volarly displaced, extraarticular fracture.

Diagnosis

• History of trauma.
• Patient pain.
• Swelling and deformity present.

Imaging

• X-rays are a fundamental diagnostic tool.
• CT scans are pivotal for evaluating intra-articular involvement and surgical planning.
• MRI scans are useful for assessing soft tissues, especially in cases of distal radioulnar joint (DRUJ) or scapholunate ligament injuries.

Nonoperative Treatment

• Closed reduction with a cast immobilization is suitable for extraarticular and minimally displaced fractures.
• Physical therapy provides no significant benefit over home exercises for simple fractures treated with cast immobilization.

Operative Treatment

• Surgical fixation (CRPP, external fixation, or ORIF).

• Indications for surgical intervention include:

  • Radiographic findings of instability.
  • Displaced intraarticular fractures.
  • Vola or dorsal comminution.
  • Severe osteoporosis.
  • Progressive loss of volar tilt or radial length after conservative treatment.
  • Associated ulnar styloid fracture.

• Percutaneous pinning is a technique used for mild angulation in extraarticular fractures.

• External fixation is often combined with percutaneous pinning or plate fixation for unstable wrist joints.

• Open reduction and internal fixation (ORIF) is recommended for fractures with significant articular displacement (greater than 2mm), comminution, and associated distal ulnar shaft fractures.

Complications

• Median nerve neuropathy (carpal tunnel syndrome, CTS) from immobilization, especially common with high-energy trauma, is a key complication.
  • Prevention of prolonged wrist flexion and ulnar deviation is important.
  • Acute carpal tunnel release is a potential treatment for progressive symptoms.
• Ulnar nerve neuropathy is possible in DRUJ injuries.
• EPL rupture is a potential complication in nondisplaced fractures.
• Radiocarpal arthrosis frequently develops in young adults if articular step-off exceeds 1-2 mm.
• Malunion and nonunion of the wrist are potential problems.
• Compartment syndrome is possible.

Scaphoid Fractures

• Scaphoid fractures account for 15% of acute wrist injuries and 60% of all carpal fractures.
• The waist of the scaphoid makes up 65% of these types of breaks. Proximal third comprises 25% and distal third accounts for 10%.

Anatomy

• The wrist comprises two rows of bones important for motion and force transfer.
• Specific bones of the wrist include capitate, hamate, lunate, scaphoid, triquetrum, pisiform, trapezoid, and trapezium.

Pathoanatomy

• Axial loading forces across a hyper-extended and radially deviated wrist are the primary cause of many injuries.
• These injuries are commonly found in contact sports.

Blood Supply

• The primary blood supply to the proximal 80% of the scaphoid is from the dorsal carpal branch of the radial artery.
• The distal 20% is supplied by the superficial palmar arch (branch of volar radial artery).

Mayo Classification

• This method classifies scaphoid fractures based on the location of fracture (distal third, middle third, and proximal third).

Russe Classification

• The Russe Classification system categorizes scaphoid fractures based on their fracture lines which vary in direction (horizontal oblique, transverse, or vertical oblique).

Provocative Tests

• Anatomic snuffbox tenderness, scaphoid tubercle tenderness (volarly), and scaphoid compression test are indicators for scaphoid fracture, with high specificity and sensitivity.

Diagnosis (cont'd)

• History of the injury, physical exam, and relevant imaging are crucial for diagnosis.
• History can include trauma, pain, swelling, deformity. Exam might include wrist swelling, ecchymosis, hematoma, gross deformity, pain with resisted pronation.
• Provocative tests should aid in confirming diagnosis and identifying the fracture or problems with the related tissues.
• Important tests include a normal range of motion (active and passive), and neurovascular tests.

Imaging (continued)

• Radiographs for scaphoid fractures should include AP and lateral views, and a scaphoid view at 30° wrist extension and 20° ulnar deviation.
• If radiographs are negative but a high clinical suspicion for a scaphoid fracture exists, a repeat x-ray should be performed in 14-21 days.
• MRI and bone scans can be necessary if the x-ray is unsuccessful in identifying the fracture

Treatment (continued)

• Nonoperative treatment is typically done with a thumb spica cast. Indications include stable, nondisplaced fractures. Outcomes depend on the fracture's characteristics. If stable and nondisplaced, 90% of patients have a union rate.
• Operative treatment is used for unstable fractures.
  • Indications include displaced intra-articular fractures.
  • Fracture fixation may include percutaneous screw fixation, or open reduction and internal fixation (ORIF), or external fixation.
• Outcomes for surgical treatment are higher but vary depending on the procedures done and the characteristics of the fracture.

Complications (continued)

• Complications following treatment can include nonunion (5-15%) and malunion (humpback deformity).
• Avascular necrosis of the proximal pole may occur.
• Wrist osteoarthritis and chronic regional pain syndrome are potential consequences.

Flexor Tendon Injuries

• Injuries to flexor tendons are a critical consideration in wrist and hand injuries.
• Key tendons in the hand include FDP, FDS, and FPL.
• Key tendons in the wrist include FCR and FCU.
• An important concept about tendon injuries is the Zones of Injury.
  • Proper diagnosis, treatment, and rehabilitation protocols are important for successful outcomes.

Treatment and Rehabilitation

• Treatment and rehabilitation are important concepts for these injuries and require specialized understanding of the anatomy and clinical assessment aspects of the injuries.
• Nonoperative treatment for partial lacerations may be enough, with early range of motion.
• Operative treatment is indicated for lacerations exceeding 60% tendon width.
  • Timing of operation is very critical, with ideal repair within 2-3 weeks.
  • Post-operative rehabilitation includes mobilization.
  • Potential complications include tendon adhesions.

Test your knowledge on distal radius fractures with this quiz that covers common causes, classifications, imaging techniques, and treatment recommendations. Dive into the details of evaluation and management strategies for wrist injuries, including surgical interventions and complications.