Distal End Radius Fracture - Clinical Examination

Overview

Fracture Types at the Distal Radius

History

• Mechanism of injury
  • Colles': fall on an outstretched hand (FOOSH) with wrist extended - the most common mechanism
  • Smith's: fall on dorsum of the hand/wrist, or FOOSH with wrist flexed or in supination shifting to pronation
  • Barton's (dorsal): dorsiflexion and pronation force; (volar): FOOSH in supination
• Age and sex: Colles' fracture is most common in postmenopausal women (osteoporotic bone)
• Dominant vs non-dominant hand
• Pre-injury functional status
• Complaints: pain, swelling, deformity at the wrist; palmar paresthesias (median nerve compression)

Inspection

• "Dinner fork deformity" (Colles'): the wrist viewed from the side has a step-like contour due to dorsal displacement and angulation of the distal fragment, resembling the profile of a dinner fork
• "Garden spade deformity" (Smith's): volar/palmar displacement of the distal fragment creates the reverse contour
• Radial deviation of the hand: the wrist deviates toward the radial side, making the distal ulna appear prominent
• Swelling and bruising around the wrist and distal forearm
• Check for open wounds or skin tenting (rare but requires urgent management)

Palpation

• Tenderness directly over the distal radial metaphysis (within 2-2.5 cm of the articular surface)
• Prominent distal ulna: the lower end of the ulna may be unusually prominent due to radial shortening and radial deviation of the hand
• Ulnar styloid tenderness: fracture of the ulnar styloid is common, avulsed by the interarticular disc (triangular fibrocartilage complex - TFCC); this represents disruption of the distal radioulnar joint (DRUJ) and is a frequent cause of long-term morbidity
• DRUJ tenderness: ballottement of the ulnar head; instability at the DRUJ suggests concomitant TFCC injury or Galeazzi pattern
• Scaphoid tenderness in the anatomical snuffbox: exclude a concurrent scaphoid fracture, especially in younger patients

Neurovascular Examination (Critical - Must be Done BEFORE and AFTER Reduction)

Median Nerve (most commonly injured)

• Sensation: assess light touch and two-point discrimination over the palmar aspect of thumb, index, middle, and radial half of ring finger
• Motor: thumb opposition (abductor pollicis brevis) - have the patient touch thumb to little finger against resistance
• Median nerve may be compromised by:
  • Contusion
  • Traction from displacement
  • Transection from fracture fragments
  • Nerve compression after closed reduction
  • Overlying cast/splint pressure
  • Acute carpal tunnel syndrome (ACTS)
• Patients may complain of palmar paresthesias from pressure on the median nerve

Radial and Ulnar Nerves

• Check dorsal hand sensation (radial nerve - first web space) and little finger sensation (ulnar nerve)
• Motor: finger abduction (ulnar nerve intrinsics)

Vascular Assessment

• Radial pulse: compare to contralateral side
• Capillary refill in all fingers
• Assess for hand pallor or blanching

Range of Motion

• Wrist flexion, extension, radial and ulnar deviation - all typically restricted and painful
• Forearm pronation and supination - especially restricted and painful if DRUJ is disrupted
• Finger and thumb motion should be assessed (swelling may limit MCP/PIP movement)

Radiographic Examination

PA View

• Distal metaphyseal fracture of the radius
• Radial shortening (the radius should be equal to or longer than the ulna - negative ulnar variance)
• Intraarticular extension into the radiocarpal or radioulnar joints
• Amount of intraarticular step-off
• Associated ulnar styloid fracture (suggests TFCC/DRUJ injury)
• Radial deviation of the distal fragment

Lateral View

• Dorsal angulation and displacement of the distal fragment (Colles')
• Loss of the normal volar tilt of the distal radial articular surface (normal = ~10-11° volar)
• The lateral view provides the best assessment of dorsal comminution

Radiographic Indicators of Instability (Higher-risk features)

• Dorsal angulation >20 degrees
• Intra-articular involvement
• Marked comminution

• 1 cm of radial shortening

• Associated ulnar styloid fracture at its base

Additional Imaging

• CT scan: indicated when significant intra-articular extension or comminution is suspected, or DRUJ instability cannot be fully assessed on plain film
• Ultrasound: handheld US has shown sensitivity of 100% and specificity >90% for diagnosing distal radius fractures in some studies (Rockwood & Green's)

Colles' Fracture X-ray

Associated Injuries to Examine For

Documentation Checklist

• Mechanism of injury and hand dominance
• Inspection: deformity type, radial deviation, swelling, skin integrity
• Palpation: fracture site tenderness, distal ulna prominence, ulnar styloid tenderness, DRUJ assessment
• Neurovascular exam (median, radial, ulnar nerve; radial pulse; capillary refill) - documented before and after reduction/splinting
• Range of motion (wrist and forearm)
• PA and lateral X-ray findings: displacement direction, angulation degree, radial shortening, intraarticular extension, ulnar styloid, comminution
• Stability assessment (based on radiographic criteria above)
• Diagnosis: fracture type (Colles', Smith's, Barton's, Galeazzi, intra/extra-articular)

Sources

• Rosen's Emergency Medicine: Concepts and Clinical Practice - Colles Fracture, p. 612
• Tintinalli's Emergency Medicine: A Comprehensive Study - COLLES' FRACTURE, p. 1847-1848; SMITH'S FRACTURE, p. 1848
• Pye's Surgical Handicraft, 22nd Ed. - Colles' fracture, p. 189
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed. - Colles' Fracture, p. 1321
• Campbell's Operative Orthopaedics, 15th Ed. 2026 - Distal Radius Fractures
• Rockwood and Green's Fractures in Adults, 10th Ed. 2025 - Ultrasonography in fracture assessment