Distal Radius Fractures in Adults

31/5/2014 Distal radius fractures in adults

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Official reprint from UpToDate www.uptodate.com ©2014 UpToDate

AuthorDavid J Petron, MD

Section EditorPatrice Eiff, MD

Deputy EditorJonathan Grayzel, MD, FAAEM

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Distal radius fractures in adults

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Apr 2014. | This topic last updated: Nov 14, 2013.

INTRODUCTION — The distal radius is the most common fracture site in the upper extremity. Such injuries account for

approximately one-sixth of fractures treated in US emergency departments [1]. The Colles fracture is the most common.

Familiarity with wrist anatomy and the natural history of major fracture types is essential for appropriate management of

distal radius fractures [2]. This topic review will discuss the evaluation and management of distal radius fractures in adults.

Other wrist injuries are discussed elsewhere. (See "Evaluation of the adult with acute wrist pain" and "Overview of carpal

fractures".)

EPIDEMIOLOGY AND RISK FACTORS — A review of over 1.4 million US emergency department (ED) visits found that

hand and forearm fractures account for 1.5 percent of all visits [1]. Of these, fractures of the radius and/or ulna comprise the

largest portion (44 percent).

The majority of distal radius fractures occur as isolated injuries in two distinct populations: youth involved in sport who

sustain a relatively high-energy fall, and seniors with osteoporotic bone who sustain a low-energy fall.

Athletics — The cause of wrist fractures among young people varies according to the local popularity of different physical

activities. A Scottish study of distal radius fractures related to sport found that football (ie, soccer) produced 50 percent of

fractures [3]. Play on artificial turf increased the likelihood of fracture by a factor of five. Skiing, dancing, and rugby caused

12, 9, and 7 percent of wrist fractures, respectively. More severe injuries occurred as a result of skiing, horseback riding, and

dancing.

The increasingly popular sport of snowboarding has a high rate of associated extremity fractures, including those of the

distal radius. Physicians at a Japanese hospital caring for more than 10 ski areas evaluated over 5000 snowboarders for

injuries [4]. They found most distal radius fractures occurred in patients in their twenties (82.3 percent) without extensive

snowboarding experience (42 percent novices; 48 percent intermediates). Ninety-four percent of patients had not received

professional instruction, and 87 percent were not wearing protective equipment. Although less likely to be injured, more

experienced snowboarders were more likely to sustain a complex intraarticular fracture.

Geriatric population — Both age and gender play a role in the risk of distal radius fracture. At 50 years of age, a white

woman living in the United States or Northern Europe has approximately a 15 percent lifetime risk of a distal radius fracture;

a man in the same regions has a lifetime risk of just over 2 percent [5].

One large, prospective study of distal radius fractures among Caucasian women with osteoporosis, over the age of 65,

involved in low-energy falls, found three statistically significant, independent risk factors: decreased bone density at the

distal radius (RR = 1.8), a history of recurrent falls (RR = 1.6), and previous fracture after age 50 (RR = 1.3) [6]. For women

over 75 years of age, dementia was an additional risk factor. Use of oral estrogen was found to be protective, and

intraarticular fractures were more than twice as frequent in women with diabetes.

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Among elderly men, distal radius fracture appears to be an early and sensitive marker of skeletal fragility [7]. More than any

other fracture type, distal radius fractures correlate with a higher absolute risk for hip fracture in men (among women spinal

compression fracture correlates more closely). A smaller study found shorter-than-expected life expectancy among patients

with distal radius fractures when compared with peers of comparable age, gender, and comorbidities [8]. After sustaining

this fracture, men were twice as likely to die as women with the same injury and did so almost twice as quickly. (See

"Epidemiology and etiology of osteoporosis in men".)

Although older patients sustaining low-energy distal radius fractures represent an important population for osteoporosis

screening and treatment, the opportunity is often squandered. One Canadian study evaluated osteoporosis follow-up and

treatment in a group of 156 patients who sustained a low-energy distal radius fracture [9]. They found that 32 percent of

patients were receiving osteoporosis treatment before their injury, but after fracturing their radius only 21 percent more

received osteoporosis screening, and only a few more began receiving a bisphosphonate or hormone replacement therapy.

(See "Prevention of osteoporosis" and "Screening for osteoporosis".)

ANATOMY — The anatomy of the wrist is reviewed in detail separately. (See "Anatomy and basic biomechanics of the

wrist".)

MECHANISM OF INJURY — The most common mechanism of distal radius fractures is Falling On an Out-Stretched Hand

(sometimes abbreviated as FOOSH), with the wrist in extension. Minimal force is needed to produce a distal radius fracture

in osteoporotic bone, and injury can occur after a fall from standing height or lower.

In healthy young patients, distal radius fractures often occur after violent injuries directly to the bone or by a compression

load driving the scaphoid or lunate into the distal radius, producing a "die-punch" fracture [2]. Such high-energy fractures are

more likely to be comminuted and intraarticular, and to occur in association with other significant injuries.

CLINICAL PRESENTATION AND PHYSICAL EXAMINATION — The patient with a distal radius fracture usually describes

falling onto their outstretched hand or sustaining a blow to the wrist and complains of wrist pain, and possibly deformity. In

addition to standard inquiries about the mechanism of injury, the clinician should ask about any previous wrist injuries or

surgery, and any resultant abnormal anatomy [10]. Also important are medical conditions affecting the injured extremity,

such as carpal tunnel syndrome or peripheral vascular disease.

The clinician should inspect the injured extremity for swelling, deformity, and evidence of a possible open fracture. Swelling

may or may not have developed by the time of presentation. Obvious deformities, such as the classic "dinner-fork" deformity

(figure 1) associated with Colles' fractures, can occur, but the extremity may appear normal.

Examination includes an assessment of neurovascular status, including motor and sensory function of the median, radial,

and ulnar nerves. Particular attention should be paid to sensation in the thumb and index fingers because acute median

nerve compression is common, especially with severely displaced fractures. The clinician should assess circulation by

palpating the radial pulse and testing capillary refill of the nail beds and fingertips. (See 'Indications for orthopedic

consultation or referral' below.)

Range of motion of the wrist, including supination, pronation, flexion, and extension should be evaluated if possible. Ulnar

deviation with palpation of the anatomic snuffbox is important to ascertain the presence of a scaphoid fracture. Clinical

evaluation of a distal radioulnar joint (DRUJ) injury associated with a distal radius fracture is difficult. Ulnar-sided wrist pain

and tenderness may be present due to a DRUJ or ulnar styloid injury.

In order not to miss associated injuries, the clinician should examine the involved extremity in its entirety, particularly the

elbow and shoulder joints. A detailed description of the examination of the wrist and other joints is found elsewhere. (See

"Scaphoid fractures" and "Evaluation of the adult with acute wrist pain" and "Evaluation of elbow pain in adults".)

RADIOGRAPHIC FINDINGS — When reading radiographs of distal radius fractures, clinicians should seek to answer four

important questions:

Is there loss of normal anatomy (eg, fracture displacement or angulation, loss of radial height)? (see 'Anatomic

landmarks and measurements' below).

●

Is there involvement of the radiocarpal or distal radioulnar joint?●

If joints are involved, is there discontinuity of the articular surface (ie, articular step-off) or diastasis (ie, separation) of

the articular fragments?

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Anatomic landmarks and measurements — Accurate assessment of standard radiographs is essential for appropriate

management [11,12]. Radiographic evaluation of the distal radius includes true posterior-anterior (PA) and true lateral

projections. Oblique radiographs often are included as a supplemental view [13]. Each view contains a small number of

important landmarks and measurements for proper interpretation.

Posterior-anterior (PA) x-ray — Landmarks on the PA projection include the radial and ulnar styloids, the distal

radioulnar joint (DRUJ), and the radiocarpal joint, including the proximal carpal bones. Important radiographic measurements

include radial inclination, radial height, and ulnar variance.

Lateral x-ray — In a true lateral projection (image 3), the radius and ulna should be superimposed, and the pisiform

projected over the distal pole of the scaphoid. If the pisiform is found dorsal to the scaphoid, the patient is in relative

pronation; if found palmar, the patient is in relative supination. Normally, the lunate is seated within the fossa of the distal

radius, and the curvature of their articular surfaces should correspond. The central axis of the lunate should be collinear with

the central axis of the radius. Palmar migration is a sign of radiocarpal instability [13].

The most important measurement on a lateral projection is palmar tilt (ie, volar tilt). AP distance may also be helpful.

Classification — Distal radius fractures can be described using either a fragment-specific classification [13] or the standard

Frykman classification. The Frykman classification system divides the fractures among four main groups based upon joint

involvement. Within each major grouping, fractures with even numbers involve a concomitant ulnar styloid fracture. Frykman

categories are:

Two common eponyms associated with distal radius fractures are Colles and Smith. Colles' fractures involve dorsal

Are high-risk features present (eg, severe comminution, articular step-off >2 mm, fracture-dislocation)? (see 'Indications

for orthopedic consultation or referral' below).

●

Radial inclination (image 1 and figure 2) is the angle between one line drawn perpendicular to the long axis of the

radius and a second line drawn between the distal tip of the radial styloid and the central reference point (CRP). The

CRP lies midway between the palmar ulnar corner and the dorsal ulnar corner of the distal radius (image 2). The

average angle is approximately 20 to 25 degrees, although there are slight gender differences (24.7 ± 2.5 for women;

22.5 ± 2.1 for men) [13]. The angle is often smaller with distal radius fractures.

●

Radial height (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of

the radial shaft: one through the distal tip of the radial styloid and the second through the CRP. Normal height averages

11.6 ± 1.6 mm [13]. The measured height is often smaller with distal radius fractures.

●

Ulnar variance (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of

the radial shaft: one through the distal articular surface of the ulnar head and the second through the CRP. Normally,

the radial surface is distal to the ulnar surface by 1 to 2 mm (negative ulnar variance) [13]. When the ulnar surface is

distal to the radial surface (positive ulnar variance), the biomechanics of the wrist can be impaired, especially if the

distance is 5 mm greater than the contralateral wrist.

●

Palmar tilt (image 3 and figure 3) is the angle formed by the intersection of one line perpendicular to the longitudinal

axis of the radial shaft and a second line drawn through the apices of the palmar and the dorsal rims of the radius. The

normal palmar tilt on a standard lateral projection averages 11.2 ± 4.6 degrees and does not differ between genders

[13]. A smaller palmar tilt as a result of fracture is a risk factor for subsequent pain and disability.

●

AP distance (image 3 and figure 3) lies between the apices of the dorsal and palmar rims of the radius. Normally, AP

distance should be slightly larger than the width of the lunate, and it averages 19.1 ± 1.7 mm. It is significantly larger in

males (20.4 ± 1.1) versus females (17.8 ± 1.7) [13]. It can increase as a result of axial impaction injuries and suggests

articular step-off.

●

Types I/II: Completely extraarticular; complications are uncommon once anatomic alignment has been achieved (image

4A-C)

●

Types III/IV: Extend into the radiocarpal joint (image 5A-B)●

Types V/VI: Extend into the distal radioulnar joint (DRUJ) (image 6)●

Types VII/VIII: Involve both radiocarpal and DRUJ articular surfaces and are highly unstable (image 7)●

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displacement of the distal radius fragment (image 4A-C); Smith's fractures involve palmar displacement of the distal radius

fragment.

Fracture dislocations — Two major types of radiocarpal fracture dislocations exist: Barton's and Hutchinson's.

Barton's fractures are separated into palmar and dorsal. They are best seen on lateral radiographs (image 8). Palmar

Barton's fractures occur when the palmar radiocarpal ligaments avulse a radial fragment and displace the radiocarpal unit

volarly. In a dorsal Barton's fracture, the dorsal radiocarpal ligaments avulse a radial fragment and displace the radiocarpal

unit dorsally. In both types, the distal radius fragment maintains articulation with the carpus, accounting for the dislocation

and instability. Closed reduction can be attempted, but these fractures are very unstable and reduction is usually lost.

Barton's fractures generally require operative fixation [14,15].

A second type of fracture dislocation carries the eponym of Hutchinson's fracture, and it is also called the chauffeur's

fracture (image 9). The typical mechanism is a direct blow to the radial styloid (such as might have occurred when the

starting crank of an early automobile suddenly reversed with a backfire striking the chauffeur's wrist), or a fall back onto an

outstretched hand held in ulnar deviation and supination. Such mechanisms cause the radioscaphocapitate ligament to

avulse a large fragment of the radial styloid. This injury frequently results in concomitant lunate dislocation or scapholunate

dissociation.

DIAGNOSIS — Definitive diagnosis of a distal radius fracture is made on the basis of diagnostic imaging studies, typically

plain radiographs of the wrist. Radiographs are obtained when the diagnosis is suspected on the basis of a suggestive

history, often involving a fall onto an outstretched hand, and examination findings, including pain, tenderness, and possibly

deformity at the wrist.

DIFFERENTIAL DIAGNOSIS — The mechanism most often responsible for distal radius fractures, fall onto an outstretched

hand, is associated with a number of other injuries that should be considered when evaluating patients with acute wrist pain

from direct trauma. These injuries include fractures of the scaphoid and other carpal bones, injury to the distal radioulnar

joint (DRUJ) or triangular fibrocartilage complex, and ligamentous injuries, which manifest differently depending upon the

involved ligaments (eg, lunate or perilunate dislocation, scapholunate dissociation). Scaphoid injuries are common and often

associated with tenderness in the anatomic snuffbox (picture 1).

Although clinical findings may vary somewhat depending upon the injury, there is substantial overlap in the presentations of

many of the injuries listed here. Furthermore, two or more injuries may occur simultaneously as a result of the same trauma.

Therefore, the only reliable method for distinguishing among injuries is diagnostic imaging, typically starting with plain

radiographs of the wrist. The diagnostic approach to patients with acute wrist pain and the diagnosis and management of

other major injuries that may be sustained by falling onto an outstretched wrist are discussed separately. (See "Scaphoid

fractures" and "Overview of carpal fractures" and "Evaluation of the adult with acute wrist pain".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Many distal radius fractures can be managed by

knowledgeable primary care clinicians. Conditions requiring emergent referral to an orthopedic surgeon include the following:

In cases of neurologic or vascular compromise, immediate closed reduction of any displaced fracture should be performed,

after providing analgesia, to attempt to alleviate symptoms. Persistent deficits despite reduction mandate emergent referral

to an appropriate surgeon, or transfer if such care is unavailable.

Unstable fractures and those at high risk for complications should also be referred to an orthopedic surgeon. The following

conditions warrant orthopedic referral:

Open fractures●

Fractures associated with an acute neuropathy or compartment syndrome●

Fractures associated with circulatory compromise in the hand (vascular surgical consultation may also be required in

this circumstance)

●

Palmarly displaced (eg, Smith's) fractures (see 'Classification' above)●

Articular step-off greater than 2 mm●

Large ulnar styloid fractures (ie, most or all of the styloid) with displaced fragments at the styloid base; these have an

increased risk of distal radioulnar joint (DRUJ) instability [16,17]

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The parameters for instability are poorly defined in the literature and vary with patient age and functional demands. Clinicians

should be particularly concerned about patients who are physiologically young and have sustained high-energy, comminuted

injuries. The presence of the following conditions on initial radiographs suggests fracture instability and the need for referral

[20,21]:

Multiple scoring systems have been developed to predict instability in fractures of the distal radius [22-25]. However, these

formulas have tended to underestimate fracture instability, and their use is not recommended. Instead, we suggest referral

for any of the factors listed above.

INITIAL TREATMENT — Recognition of emergent conditions and the decision of whether to perform a fracture reduction

comprise the most important steps in the acute management of distal radius fractures. If significant nerve injury (eg,

paralysis, severe weakness) or vascular compromise is present, immediate reduction of the displaced fracture, with

analgesia, is necessary to attempt to alleviate these symptoms. Persistent symptoms despite reduction mandate emergent

consultation with the appropriate surgical specialist. Compartment syndrome is an emergency requiring immediate surgical

release. (See 'Early complications' below.)

Should no emergent conditions exist, immediate reduction is not required, and appropriate treatment depends upon the type

of fracture.

Nondisplaced extra-articular fractures (Frykman types I/II) — These fractures are relatively stable and can be treated

with a well-molded sugar tong, reverse sugar tong, or double sugar tong splint [26]. (See "Splinting of musculoskeletal

injuries", section on 'Sugar tong splints'.) The application of a circumferential cast in the acute setting increases the risk of

distal ischemia and carpal tunnel syndrome, and it should not be performed [19].

Proper positioning within the splint has the elbow flexed to 90 degrees and the arm in neutral position (ie, without forearm

supination or pronation, and without wrist flexion or extension). During the first several days following injury, the patient

should elevate the arm, apply ice to the fracture frequently (while keeping the splint dry), begin active range of motion of the

shoulder and fingers, and use analgesics as needed [3]. Opioids may be necessary; a short course of nonsteroidal anti-

inflammatory drugs (NSAIDs) may also be used.

Displaced fractures (Frykman types I-VIII) — Displaced fractures with neurovascular compromise warrant an immediate

attempt at closed reduction (see 'Early complications' below). Immediate closed reduction by an experienced clinician is

appropriate, but not required, for displaced fractures without neurovascular compromise or radiographic evidence of instability

[1]. (See 'Radiographic findings' above.) If a clinician capable of performing a reduction is unavailable, the provider may

immobilize the fracture, provide appropriate analgesia, and discharge the patient, provided follow-up the next day for

reduction by an orthopedist has been arranged.

Criteria for adequate reduction in a patient with high functional demands include (see 'Classification' above):

Fracture dislocations (ie, Barton's or Hutchinson's) (see 'Fracture dislocations' above)●

Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries [18,19] (Radial styloid

fractures are often associated with scapholunate injuries and such fractures are generally referred to an orthopedic

surgeon)

●

Fractures with significant displacement or comminution; these are unstable and likely to lose position even if initial

reduction is near-anatomic

●

Fractures likely to be unstable and unamenable to conservative treatment●

Greater than 20 degrees of dorsal angulation●

Fracture displacement in any direction greater than two-thirds the width of the radial shaft●

Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)●

Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)●

Intraarticular component (especially involving the DRUJ)●

Advanced osteoporosis●


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Substantial soft tissue swelling often accompanies displaced fractures, so splinting is recommended for postreduction

immobilization (see "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'). The application of a

circumferential cast in the acute setting increases the risk of distal ischemia and carpal tunnel syndrome, and it should not

be performed [19].

During the first several days following injury, the patient should elevate the arm, apply ice to the fracture frequently (while

keeping the splint dry), begin active range of motion of the shoulder and fingers, and use analgesics as needed [3]. Opioids

may be necessary; a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used.

FRACTURE REDUCTION BASICS — In cases of neurologic or vascular compromise, immediate closed reduction of any

displaced fracture should be performed. Persistent deficits despite reduction mandate emergent referral to an appropriate

surgeon, or transfer if such care is unavailable (see 'Indications for orthopedic consultation or referral' above). Should no

emergent conditions exist, immediate reduction is not required. Adequate anesthesia must be obtained prior to reduction.

Hematoma block — A hematoma block, with or without systemic opioids, provides adequate analgesia for reduction of

most displaced distal radius fractures. Hematoma blocks are safe and easy to perform.

First, the skin over and around the fracture site is prepared with an antiseptic solution (eg, chlorhexidine). Sterile technique

should be maintained throughout the procedure. Next, a 10 mL syringe is filled with 5 to 8 mL of one percent lidocaine

without epinephrine. A 22-gauge needle is attached to this syringe. The clinician then gently palpates the dorsum of the

wrist to locate the fracture step-off with one hand, and inserts the needle, also on the dorsal aspect of the wrist, with the

other. The needle is advanced directly into the fracture site. The clinician draws back continuously on the syringe while

advancing the needle. Aspiration is maintained until a flashback of blood confirms placement of the needle tip in the fracture

hematoma. The mixture of blood and lidocaine is then injected directly into the fracture site. Some clinicians perform

repeated aspirations and reinjections to disperse the anesthetic more completely before removing the needle.

Reduction techniques — Traction/counter-traction is critical to reduction. This can be achieved with or without finger traps

(figure 4). The two approaches do not differ in the ultimate alignment attained or in the rate of failure to maintain reduction

[27].

Regardless of the method used to reduce the fracture, finger traps are a useful adjunct before the procedure is attempted.

Traction is applied by attaching the finger traps to the thumb, index, and middle fingers, while keeping the elbow flexed at 90

degrees and the forearm in neutral rotation. Five to 10 pounds (two to five kilograms) of downward traction is placed on the

distal humerus for at least five minutes before any reduction is attempted. This enables muscular relaxation and helps

distract the fracture fragments, bringing the radius closer to normal length.

Active reduction can be performed with the patient still in the finger traps. For Colles' type fractures, the examiner's thumbs

are placed on the dorsal aspect of the distal fracture fragment, while the fingers are placed on the palmar forearm just

proximal to the fracture line. While applying downward axial traction to the proximal fragment, the distal fragment is pushed

distally, palmarly, and ulnarly to eliminate the dorsal displacement and radial shortening.

A sugar tong, reverse-sugar tong, or double sugar tong splint is then applied and molded with the patient still in the finger

traps [2]. (See "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'.) A three-point contact molding

technique is used to help hold the reduction [28]. For Colles' type fractures, ideal immobilization for the first two weeks

consists of 15 degrees of palmar flexion, 10 to 15 degrees of ulnar deviation, and slight pronation [29].

Manual reduction can also be performed without finger traps, with the help of an assistant. The assistant provides counter-

traction by holding the elbow. The clinician then supinates the patient's forearm with one hand while applying longitudinal

traction to the distal fragment with the other hand and thumb. Next, the fracture is disimpacted by applying dorsal angulation

(ie, accentuating the fracture pattern). Finally, the reduction is completed by pronating the forearm and wrist, followed by the

application of some ulnar deviation, to correct the radial and dorsal angulation. The fracture is held in this position while a

splint is applied and molded in the fashion described immediately above.

FOLLOW-UP CARE — Treatment of distal radius fractures varies according to the patient's health, functional needs, and the

injury sustained. Active patients with high functional needs require anatomic reductions, and they often need surgical

No dorsal tilt of the distal radial articular surface●

Less than 5 mm of radial shortening●

Less than 2 mm of displacement of fracture fragments●




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fixation.

The most fundamental decision is whether to treat conservatively or surgically. Clinicians should consider such medical

factors as bone quality, comorbidities, and functional demand. Fracture characteristics, associated injuries, risk of

complications, and clinician experience with fracture management are also relevant. As an example, a 16-year-old

skateboarder with a comminuted, displaced, intraarticular fracture requires surgical repair to achieve anatomic alignment; a

sedentary 80-year-old with an identical injury needs immobilization and occupational rehabilitation (see 'Geriatric

management' below). Finally, clinicians should inquire about patient preferences and social circumstances.

Conservative management with closed reduction and immobilization is appropriate for fractures that are reducible by closed

manipulation and will remain stable thereafter [29]. A systematic review found insufficient evidence to determine which

conservative treatments are most appropriate for common adult distal radius fractures [30]. Our recommendations below are

based upon the limited literature assessing treatment of these fractures and our clinical experience.

Nondisplaced extra-articular (Frykman types I/II) — Patients are seen three to five days following injury to allow swelling

to subside. The clinician should remove the splint, assess neurovascular status, and obtain radiographs of the arm out of the

splint to confirm there is no loss of position.

If the fracture remains nondisplaced or minimally displaced, the clinician applies a short arm cast. The cast should extend

from the distal palmar crease to within 5 cm of the antecubital fossa, with the wrist in neutral position. Patients should be

seen in follow-up every two to three weeks thereafter until healing is complete. Radiographs are taken at the initial

postcasting visit, at two weeks, and then sometime between four and six weeks after injury to confirm proper alignment [2].

The patient's wrist and forearm should remain immobilized until there is evidence of radiographic healing or the fracture site

is nontender, generally four to six weeks postinjury. At this point, the patient can use a wrist brace in lieu of a cast.

Complete healing usually requires six to eight weeks.

For patients over 60 years of age, the period of immobilization should be kept to a minimum to avoid post-immobilization

stiffness. Early transition to a wrist splint may be helpful depending on fracture stability. In one randomized trial, patients

treated with a wrist splint were more satisfied and regained function sooner than patients immobilized in a cast [31].

Evidence guiding the appropriate period of fracture immobilization in the geriatric population is lacking. Nevertheless, we

think that older patients who meet the following criteria can be removed from their cast and placed in a wrist splint as early

as two to three weeks following injury:

Displaced (Frykman types I-VIII) — Once reduction is achieved, we suggest patients remain in the initial sugar tong splint

for the following two to three weeks. The U-shaped part of the splint wraps around the elbow, thereby minimizing forearm

rotation and maintaining the desired pronation or supination, according to the fracture type. The sugar tong splint also

immobilizes the distal radioulnar joint (DRUJ), and splinted patients experience less pain than patients immobilized in a

short arm cast [29].

Radiographs are taken in the sugar tong splint on the third, seventh, and twelfth days following reduction. This enables the

clinician to detect quickly any loss of position and to assess the acceptability of any postreduction movement or residual

deformity. During the first two weeks, the initial splint should be adapted and molded as soft tissue swelling decreases. This

is achieved by wrapping the splint tighter with elastic bandages at each follow-up visit. Adequate tightness and molding

throughout the early postreduction period reduces the risk of secondary displacement [29].

At two to three weeks, the splint is changed to a short arm cast. Wrist immobilization continues in the cast for another three

to four weeks. The clinician must take care to maintain three point contact, and to avoid inadequate or excessively bulky

padding [29]. At each visit, the clinician should assess fracture site tenderness, swelling, elbow and hand motion, and

median nerve function. Radiographs should be obtained every two weeks and studied for signs of dorsal displacement,

palmar angulation, and radial shortening [2].

Extraarticular fracture of the distal radius●

Minimal comminution present●

Reduction was NOT necessary●

Functional demands are few●

Risk of fall or reinjury is low●











Patients should be immobilized six to eight weeks, until there is evidence of radiographic healing and the fracture site is

nontender. At this point, the clinician can remove the cast and place the patient in a wrist brace. Complete healing generally

occurs within 8 to 12 weeks. The shortest possible period of immobilization is preferred for older patients; prolonged

immobilization can cause joint stiffness and significant loss of function [2].

Once the cast is removed, patients should begin active range-of-motion exercises. Physical therapy may be needed to

achieve acceptable motion, but most patients require only a single session of instruction [32]. Older patients and those with

more complicated fractures requiring prolonged immobilization may require more extensive rehabilitation.

Styloid fractures — As described above, large ulnar styloid fractures (ie, most or all of the styloid is involved) with

displaced fragments at the styloid base should be referred to an orthopedic or hand surgeon, as they are associated with an

increased risk of distal radioulnar joint (DRUJ) instability [16,17,33,34]. Fractures of the tip of the ulnar styloid, distal to the

DRUJ, are generally considered stable and can be managed conservatively. Radial styloid fractures are often associated

with scapholunate injuries and such fractures are generally referred to an orthopedic or hand surgeon for possible surgical

management. (See 'Indications for orthopedic consultation or referral' above.)

Isolated nondisplaced fractures of the ulnar styloid that do not involve the DRUJ and are not associated with DRUJ instability

are uncommon, but can be managed conservatively in a short arm cast, as is done for nondisplaced radial fractures

generally. (See 'Nondisplaced extra-articular (Frykman types I/II)' above.)

Geriatric management

Fracture management — Vigorous elderly patients with distal radius fractures should be referred for surgical treatment

as indicated. However, many older patients are best served by conservative fracture management and rehabilitation designed

to maximize function, despite the presence of significant deformity. One study of patients older than 70 years of age who

declined operative repair of their intraarticular distal radius fractures found 89 percent had a good or excellent functional

outcome, despite 26 percent having only a fair or poor anatomic result [35].

Another study of elderly patients with moderately displaced Colles' fractures randomized to reduction under Bier block and

immobilization or to immobilization alone found no functional difference between the two groups [36]. On average, two-thirds

of the dorsal angulation corrected by manipulation was lost by five weeks. The authors concluded that up to 30 degrees of

dorsal angulation and 5 mm of radial shortening may be accepted in selected elderly patients.

The limited utility of fracture reduction among low-functioning geriatric patients was confirmed in another study of 59 patients

with a mean age of 82 years. Of 60 fractures treated by closed reduction, 53 ultimately healed with significant deformity. Of

44 dorsally displaced fractures, reduction failed in seven cases initially, and 37 lost reduction during the following weeks of

immobilization. The authors concluded that reduction of fractures of the distal radius is of minimal value in old and frail,

dependent, or demented patients [37].

Osteoporosis also complicates management of older patients with fractures. Optimal clinical results of distal radius fractures

have been shown to correlate more closely with bone mineral density than with radiographic parameters [38]. Osteoporosis

contributes to fracture instability. We suggest patients with displaced fractures in osteoporotic bone be referred to an

experienced orthopedist. (See 'Indications for orthopedic consultation or referral' above.)

Regardless of management strategy, clinicians should minimize the length of time geriatric patients are immobilized

because of the risk of joint stiffness and consequent disability. (See "Frozen shoulder (adhesive capsulitis)".)

Osteoporosis evaluation — Fracture in an elderly individual warrants an evaluation for osteoporosis. A history of a

fracture is an important risk factor for a subsequent fracture. Unfortunately, the majority of patients with vertebral, hip, and

distal radius fractures do not receive evaluation and treatment for underlying osteoporosis. As a result, these patients

frequently suffer additional fractures. Elderly patients with a history of fracture constitute a high-risk group that requires

additional evaluation and treatment. (See "Overview of the management of osteoporosis in postmenopausal women", section

on 'Medical intervention after fracture'.)

COMPLICATIONS

Early complications — Median nerve injury, compartment syndrome, and vascular compromise (although the last two

rarely occur) are the most important early complications of distal radius fractures.

Acute carpal tunnel syndrome (ACTS) is found more frequently with severely comminuted or displaced fractures, patients



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treated with multiple reductions, and those splinted in extreme wrist flexion (>15 degrees) [39]. The clinician must perform a

careful neurologic examination looking for signs of ACTS at the initial and first follow-up visits, and initial visits following any

remanipulation. Weakness or loss of thumb or index finger flexion is the most important finding. Carpal tunnel release is

indicated if symptoms progress, with or without reduction, or if surgical fixation is planned. Results are best if release is

performed urgently [39-41]. (See "Clinical manifestations and diagnosis of carpal tunnel syndrome".) A mild sensory deficit

consistent with median nerve contusion is often observed and generally is not caused by ACTS.

The interval from injury to development of compartment syndrome may range from 12 to 54 hours [42,43]. Increasing or

constant severe pain and pain elicited by passive extension of the fingers are important findings, but measurement of

elevated compartment pressures provides a definitive diagnosis. Emergent fasciotomy is required. A more detailed

discussion is found elsewhere. (See 'Complications of closed reduction and cast treatment' below.)

Vascular injuries are rare in closed fractures, but injury to the radial or ulnar artery has been reported in high-energy injuries

with significant fracture displacement. Perfusion often improves with reduction, but emergent vascular surgery evaluation is

necessary for any persistent impairment [44].

Injuries to carpal bones and carpal ligaments occasionally accompany distal radius fractures, and they should be suspected

in patients with persistent wrist pain despite acceptable alignment. A case series of 565 Colles' fractures revealed scaphoid

fractures were initially missed in 0.7 percent of cases and intercarpal ligament injuries in 0.9 percent [45]. Scaphoid

fractures in association with distal radius fractures should be treated with internal fixation [18]. Failure to identify and treat

scapholunate ligament injuries with acute pinning has been shown to adversely affect outcome [19]. Fracture lines that

involve the radial articular surface near the scapholunate ligament should raise suspicion of scapholunate ligament injury

(image 10). If initial radiographs show normal scapholunate distance but suspicion is high, we suggest placing a thumb

spica, in addition to appropriate wrist immobilization. (See "Scaphoid fractures".)

Complications of closed reduction and cast treatment — Skin tearing can occur with over-vigorous manual reduction

and also with the use of older, metal finger traps. Skin rarely tears with the newer, cloth finger traps. If metal skin traps are

used, cloth tape can be placed over the fingers before they are hung to reduce skin injury [10].

Closed extremity fractures place patients at risk for compartment syndrome, although it is an uncommon complication of

distal radius fractures [45,46]. Patients with compartment syndrome complain of increasing or constant severe pain and

paresthesias. One potential warning sign may be increasing analgesic use. The clinician generally can palpate a firm, tense

forearm, and can elicit pain by passive extension of the fingers, thereby stretching the flexor tendons within the forearm

compartment. Measurement of elevated compartment pressures enables more accurate diagnosis. Normal pressure is less

than 5 mmHg; pressure exceeding 30 mmHg generally warrants emergent fasciotomy. Alterations in capillary refill, distal

pulses, and skin color are NOT reliable findings. Clinicians should warn patients about the symptoms of compartment

syndrome and consider it in patients who complain of severe pain in the days immediately following fracture reduction.

Reports exist of compartment syndrome following closed reduction under local hematoma block [47], but it is a rare

complication, and the role of the hematoma block has not been demonstrated [10]. Staphylococcus aureus osteomyelitis

following hematoma block has also been reported [48]. Attention to sterile technique and to the amount of local anesthetic

injected should minimize these complications.

Splinting the wrist in palmar flexion greater than 15 degrees increases the risk of ACTS [49] and complex regional pain

syndrome [50]. Careful splinting that allows full flexion and extension of the metacarpal phalangeal (MCP) joints is important

to prevent MCP joint contractures and proximal tendon adhesions [10].

Persistent sensory neuropathy following distal radius fracture can occur due to median nerve contusion at the time of injury

or reduction, but it correlates closely with fracture malunion [51]. Surgical treatment with osteotomy [52] and/or release of

the median nerve is indicated for persistent symptoms [53].

Tendon inflammation and rupture can occur with closed cast treatment. Rupture of the extensor pollicis longus (EPL) tendon

is most common, with an incidence of 0.3 percent [54] to 3 percent [55,56], and it occurs between two weeks and 11

months (average seven weeks) after injury [55]. Diagnosis is usually made after rupture, and treatment is surgical. EPL

rupture is more common with minimally displaced fractures. Tendonitis of the first dorsal compartment and of the extensor

carpi ulnaris can also be seen after distal radius fracture. This is usually responsive to steroid injection, but it must be

differentiated from triangular fibrocartilage tear or other ulnocarpal ligamentous injury [10].

Long-term outcomes/complications — A number of variables related to patient characteristics, fracture type, and


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radiographic findings predispose patients to the development of osteoarthritis and disability. Major complications are

discussed below. The incidence of complex regional pain syndrome, another potential complication, may be reduced by

prophylactic vitamin C, and is discussed elsewhere. (See "Prevention and management of complex regional pain syndrome

in adults", section on 'Prevention'.)

Osteoarthritis — Extraarticular fractures that are reduced to acceptable alignment rarely cause radiocarpal

osteoarthritis. For fractures with intraarticular extension, there is a significant association between residual displacement of

articular fragments at the time of bony union and the development of radiocarpal osteoarthritis [57]. In one case series, 100

percent of fractures with articular step-off of 2 mm or more developed radiographic evidence of osteoarthritis, compared with

only 11 percent of those that healed with a congruous joint [58]. A second series found that a step-off of only 1 mm

predisposed patients to radiocarpal osteoarthritis [59].

Residual disability — Long-term disability has been correlated with a number of radiographic parameters and fracture

characteristics. One series found a close correlation between the degree of postinjury radial shortening and disability: 4

percent of patients with normal height had poor function, whereas 25 percent of patients with 3 to 5 mm of radial shortening

and 31 percent of patients with more than 5 mm of radial shortening had poor function [60]. (See 'Classification' above.)

Dorsal angulation alone influenced early but not 10-year function [61], but dorsal angulation of greater than 15 degrees

combined with more than 2 mm radial shortening compromised outcomes [62,63]. More than 10 degrees of dorsal tilt leads

to a dorsal carpal shift with compressive forces, causing pain and insecurity with gripping, even during everyday activities

[64]. Grip strength correlates inversely with the degree of osteoarthrosis [65]. (See 'Classification' above.)

Incongruency of the distal radioulnar joint (DRUJ) from residual dorsal angulation [66] or positive ulnar variance [67] has been

associated with wrist pain. Triangular fibrocartilage complex (TFCC) tears occur not infrequently with distal radius fractures

[68], and greater radial shortening and dorsal angulation is found in patients with TFCC tears (figure 5) [69]. A TFCC tear has

occurred if the distal radius is shortened by more than 2.7 mm. TFCC tears are described separately. (See "Evaluation of

the adult with subacute or chronic wrist pain", section on 'Triangular fibrocartilage complex injury'.)

The extent of fracture comminution and articular involvement correlates with loss of motion [64]. Range of motion loss after

immobilization should be treated with aggressive physical therapy, unless it is caused by bony malalignment, in which case

prolonged therapy is of no benefit [10].

Distal radius fractures frequently occur at work or under circumstances that allow for financial compensation. Injury

compensation was shown in one study to be the best predictor of pain and disability at six months [70]. Another author

found that patients with work-related injuries were more than four times less likely to return to work than those injured while

away from work [59]. Patients receiving compensation for their injuries are likely to have poorer outcomes regardless of the

anatomic result [10].

One important message to be gleaned from these data is that, with the exception of a subset of low-functioning geriatric

patients, clinicians should aggressively seek to achieve congruent joint reduction and to prevent excessive loss of radial

length or abnormal tilt of the radial articular surface.

Patient satisfaction — The factors most responsible for patient satisfaction remain unclear. Some claim patient

satisfaction depends more on hand dominance and residual wrist pain than range of motion [71]. Others have found grip

power [72] and return of wrist function [73] most significant. A study of operative patients found satisfaction correlated better

with pain relief and grip strength than postoperative radiographic parameters [74].

RETURN TO SPORT OR WORK — Return to work is determined by the severity of injury and the tasks involved. Patients

with sedentary jobs may return immediately; physical laborers may return to full duty only after they have regained near-

normal wrist motion and strength. It is reasonable for participants in contact sports also to delay return to play until they

have achieved near-normal motion and strength, and to wear a protective palmar splint during the first few weeks of play.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the

Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they

answer the four or five key questions a patient might have about a given condition. These articles are best for patients who

want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are

longer, more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best

for patients who want in-depth information and are comfortable with some medical jargon.

th th

th th

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to

your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the

keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

Basics topics (see "Patient information: Cast and splint care (The Basics)" and "Patient information: Common wrist

injuries (The Basics)")

●

Beyond the Basics topic (see "Patient information: Cast and splint care (Beyond the Basics)")●

Distal radius fractures are extremely common. Fractures in younger patients are the result of high-energy trauma, often

during sports. Fractures in older patients are frequently the result of low-energy trauma to osteoporotic bone. The

typical mechanism for distal radius fracture is a Fall Onto an Out-Stretched Hand (FOOSH). (See 'Epidemiology and

risk factors' above and 'Mechanism of injury' above.)

●

Examination at the time of injury should include inspection for open fractures and deformity, assessment of wrist

motion (if possible), and evaluation for associated injuries, such as scaphoid fracture or scapholunate ligament injury.

The wrist may appear normal despite the presence of a fracture. In the days following injury or fracture manipulation,

clinicians should pay close attention to neurovascular status (particularly median nerve function) and beware of acute

compartment syndrome. (See 'Clinical presentation and physical examination' above.)

●

Diagnosis is typically made by x-ray. Clinicians should study the standard plain radiographs of the wrist, including

anterior-posterior (AP), lateral, and oblique views, looking for any loss of normal anatomy, the presence and degree of

joint involvement (including both radiocarpal and distal radioulnar joints), and the presence of any high-risk features (eg,

comminution, articular step-off >2 mm). Abnormal measurements of radial inclination, radial height, palmar tilt, or ulnar

variance suggest significant injury. (See 'Radiographic findings' above.)

●

Emergent orthopedic referral is required for the following conditions (see 'Indications for orthopedic consultation or

referral' above):

●

Open fractures•

Acute compression neuropathy or compartment syndrome•

Vascular compromise despite reduction (emergent vascular surgery referral may also be required in this

circumstance)

•

Unstable fractures and those at high risk for complications should be referred to an orthopedic surgeon. We

recommend that fractures associated with the following conditions be referred to a knowledgeable orthopedist (Grade

1B) (see 'Indications for orthopedic consultation or referral' above):

●

Palmar displacement•

Radial articular step-off greater than 2 mm, or involvement of the articular surface of the distal radial ulnar joint•

Large ulnar styloid fractures with displaced fragments at the styloid base•

Greater than 20 degrees of dorsal angulation•

Displacement in any direction greater than two-thirds the width of the radial shaft•

Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)•

Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)•

Associated scaphoid fractures or scapholunate ligament injuries•

Fracture-dislocations (see 'Fracture dislocations' above)•

Advanced osteoporosis•

Nondisplaced extraarticular fractures are relatively stable, and treatment is straightforward. We suggest the following

approach for acute management (Grade 2C) (see 'Initial treatment' above):

●

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Place the arm in a well-molded sugar tong, reverse sugar tong, or double sugar tong splint (NOT a circumferential

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extension). (See "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)

•

Elevate the arm.•

Apply ice to the fracture frequently (while keeping the splint dry).•

Begin active range of motion of the shoulder and fingers.•

Use analgesics as needed. Opioids may be necessary; a short course of nonsteroidal anti-inflammatory drugs

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•

Displaced fractures with neurovascular compromise warrant an immediate attempt at closed reduction. Immediate

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●

If a clinician capable of performing a reduction is unavailable and there is no neurovascular compromise, the provider

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●

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●

No dorsal tilt of the distal radial articular surface•

Less than 5 mm of radial shortening•

Less than 2 mm of displacement of fracture fragments•

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●

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●

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●

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•

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•

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Topic 219 Version 13.0





















GRAPHICS


Colles' fracture

Due to the dorsal displacement of the distal fragment, Colles' type fractures are

often said to have a "dinner fork" appearance.

Graphic 78559 Version 1.0




Distal radius measurements: AP view

Three important measurements can be determined, using the AP view,

to assess the distal radius. Radial inclination is the angle between one

line drawn perpendicular to the long axis of the radius and a second

line from the tip of the radial styloid to the central reference point

(CRP). Radial height is the distance between two lines drawn

perpendicular to the long axis of the radius: one through the distal tip

of the radial styloid, the second through the CRP. Ulnar variance is

the distance between this second line through the CRP and a line

through the distal articular surface of the ulnar head. Measurements

are often abnormal when a fracture of the distal radius is present.

Courtesy of Erik L Schroeder, MD.





Distal radius anatomy, antero-posterior (AP) view

Measurements performed on the AP view include radial inclination, radial height, and

ulnar variance. Abnormal measurements are often found in the setting of distal

radius fracture.




Distal radius central reference point

The central reference point (CRP) lies midway between the palmar

ulnar corner and the dorsal ulnar corner of the distal radius. Use of

the CRP provides more accurate measurements of radial inclination,

radial height, and ulnar variance.





Distal radius measurements: Lateral view

In a true lateral projection, the radius and ulna should be

superimposed, and the pisiform projected over the distal pole of the

scaphoid (white arrow). Normally, the lunate is seated within the

fossa of the distal radius, and the curvature of their articular surfaces

should correspond. Palmar migration is a sign of radiocarpal instability.

Palmar tilt is the angle formed by the intersection of one line

perpendicular to the longitudinal axis of the radial shaft and a second

line drawn through the apices of the palmar and the dorsal rims of the

radius. AP distance can also be measured.





Distal radius anatomy, lateral view

Measurements performed on lateral radiographs include volar tilt and AP distance.

Note the normal linear alignment of the capitate, lunate, and radius. Also, note how

the curvature of the articular surfaces of these bones corresponds.




Frykman I radius fracture AP view

This x-ray, taken of a 23-year-old snowboarder after she fell back

onto her outstretched left hand, shows a Frykman I distal radius

fracture. The x-ray shows several abnormalities including a significant

loss of radial height, decreased radial inclination, and positive ulnar

variance. Also, several fracture lines are present (black arrows),

indicating comminution.





Frykman I radius fracture lateral view

On the lateral x-ray of the same fracture, the dorsal angulation of the

distal fragment is apparent. Such fractures are often referred to by

the eponym Colles'. Note this is not a true lateral: the images of the

radius and ulna are not superimposed, and the pisiform (black arrow)

is seen dorsal to the distal pole of the scaphoid.





Frykman I radius fracture oblique view

The oblique view of the same fracture highlights the loss of radial

height.





Frykman IV radius fracture AP view

This fracture occurred in a 73-year-old osteoporotic woman following

a low-energy fall onto her outstretched right hand. Due to the

extension of the fracture into the radiocarpal joint and the distal ulnar

injury (white arrow), this fracture is categorized as a Frykman IV.

Most notable on this image is the displacement of the distal radial

fragment (red arrow) and the loss of radial height. Other injuries are

present, most notably a scaphoid fracture (black arrow).





Frykman IV radius fracture lateral view

The lateral x-ray of the same injury demonstrates significant dorsal

displacement and angulation of the distal radial fragment.





X-ray of Frykman Type VI fracture of distal

radioulnar joint and ulnar styloid

This anteroposterior plain radiograph of the left wrist shows a distal

radial fracture involving the distal radioulnar joint (arrowhead) and a

transverse ulnar styloid fracture (arrow).

A-P: anteroposterior.




Xray of Frykman Type VII radioulnar and

radiocarpal fracture

This anteroposterior plain radiograph of the wrist shows a radioulnar

fracture (arrow), and a fracture into the radiocarpal joint

(arrowhead).

A-P: anteroposterior.




Plain x-ray of Barton’s fracture dislocation of wrist

The patient is a 40-year-old man who presented with wrist pain following a fall on an

outstretched hand, and found to have a Barton's fracture/dislocation. Image A is an AP

radiograph of the right wrist demonstrating an intraarticular fracture of the distal radius

(arrow). Image B is a lateral radiograph demonstrating an intraarticular radial fracture with

dorsally-displaced radial bone fragments (arrow) and dorsal dislocation of the carpal bones

with respect to the radius (arrowhead), consistent with a Barton's fracture/dislocation.

AP: anteroposterior.

Courtesy of Aaron Harman, MD.




X-ray of Hutchinson's radiocarpal fracture

This anteroposterior plain x-ray of the right hand shows an intra-

articular fracture through the radial styloid process (arrow) with

minimal displacement.




Palpation of the scaphoid in anatomic snuffbox

A good method for evaluating the body of the scaphoid is to gently

bring the patient’s wrist into ulnar deviation and slight volar flexion,

and then, palpate the anatomic snuffbox. The snuffbox lies between

the extensor pollicis longus tendon medially and extensor pollicis brevis

and abductor pollicis longus tendons laterally.

Courtesy of Kevin Burroughs, MD.




Finger trap fixture

Regardless of whether they are used in reduction, finger traps are a

useful adjunct before the procedure. Traction is applied by attaching

the finger traps to the thumb, index, and middle fingers, while keeping

the elbow flexed at 90 degrees and the forearm in neutral rotation.

Downward traction, using weights, is placed on the distal humerus for

at least five minutes before any reduction attempt. This enables

muscular relaxation and helps distract the fracture fragments, bringing

the radius closer to normal length.




Scapholunate dissociation

This anteroposterior radiograph of the wrist shows a >3 mm

separation (black arrow) between the scaphoid and lunate (Terry

Thomas sign) that indicates a scapholunate dissociation (tear). This

patient also had a distal radius fracture.

Courtesy of Kevin E Burroughs, MD.




Triangular fibrocartilage complex

Reproduced with permission from: Nagle DJ. Arthroscopically assisted triangular

fibrocartilage complex débridement and ulnar shortening. In: Operative Techniques in

Orthopaedic Surgery, Wiesel SW (Ed), Philadelphia: Lippincott Williams & Wilkins, 2010.

Copyright © 2010 Lippincott Williams & Wilkins.

http://www.lww.com


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Disclosures: David J Petron, MD Nothing to disclose. Patrice Eiff, MD Nothing to disclose. Jonathan Grayzel, MD, FAAEM Employeeof UpToDate, Inc.

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Distal Radius Fractures in Adults