Distal radius fracture in orthopedic
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"distal radius fracture" AND treatment
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distal radius fracture classification radiograph volar plate ORIF
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I now have comprehensive content from Rockwood & Green and Miller's Review. Here is the complete clinical overview:
Distal Radius Fracture — Orthopedic Overview
Epidemiology
Distal radius fractures are the most common fracture of the upper extremity, accounting for at least one-sixth of fractures seen in the emergency department. Annual prevalence in the US exceeds 600,000 cases. There is a bimodal distribution:
- Young men: high-energy mechanisms (MVAs, falls from height, industrial injuries)
- Elderly women: low-energy falls; incidence in females is 2–3× that of males; second most common fracture in the elderly
— Rockwood and Green's Fractures in Adults, 10th ed., p. 1823
Mechanism of Injury
| Fracture Type | Wrist Position at Impact |
|---|---|
| Dorsally displaced (Colles) | Outstretched hand in 40–90° dorsiflexion |
| Volarly displaced (Smith) | Wrist in volar flexion |
| Volar shear (Barton) | High-energy axial/shear load |
Poor bone quality (low DXA T-scores) correlates with greater fracture severity and risk of early instability.
Applied Anatomy
Key anatomic facts relevant to fracture management:
- Volar surface: concave and smooth → ideal for volar plate application; covered by pronator quadratus (PQ)
- Dorsal surface: convex with extensor tendon grooves; Lister tubercle forms pulley for EPL
- Sigmoid notch: ulnar border of radius; articulates with distal ulna at DRUJ
- Articular surface: two concave facets — scaphoid facet (radial) and lunate facet (ulnar)
- Lunate facet: projects ~3 mm volarly; prone to shear forces; difficult to repair
- Brachioradialis: only tendinous insertion on distal radius; acts as deforming force in fractures
- TFCC: primary soft tissue stabilizer of the DRUJ
— Rockwood and Green's, p. 1826
Normal Radiographic Parameters ("11:11:22 Rule")
| Parameter | Normal Value | Acceptable Postreduction Limit |
|---|---|---|
| Radial height | ~11 mm | < 5 mm shortening |
| Volar tilt | ~11° | < 10° dorsal angulation |
| Radial inclination | ~22° | < 5° change |
| Intra-articular step-off | 0 mm | < 2 mm |
Ulnar variance (neutral, positive, or negative) should be assessed with forearm in neutral rotation compared to the contralateral side.
— Miller's Review of Orthopaedics, 9th ed., p. 650
Associated Injuries
| Injury | Frequency / Notes |
|---|---|
| TFCC injury | 39–82%; most are peripheral avulsions with ulnar styloid fractures |
| Scapholunate ligament | 4.7–46% (arthroscopic studies); true clinical significance debated |
| Lunotriquetral ligament | 12–34% |
| Acute carpal tunnel syndrome | Less common; characterized by progressive pain and neurologic deficit → urgent release |
| Chondral injuries | Present in comminuted/articular patterns |
The carpal stretch test (traction to accentuate Gilula lines) has ~78% sensitivity and ~72% specificity for grade 3–4 interosseous ligament tears.
Classification
Eponyms (pre-radiographic; still widely used)
| Eponym | Pattern |
|---|---|
| Colles | Dorsally angulated, apex volar extra-articular metaphyseal fracture |
| Smith | Volarly angulated, apex dorsal metaphyseal fracture ("reverse Colles") |
| Barton | Intra-articular fracture with dorsal cortex involvement + radiocarpal subluxation/dislocation |
| Reverse (Volar) Barton | Intra-articular fracture with volar extension + volar subluxation |
| Chauffeur's (Hutchinson) | Isolated intra-articular radial styloid fracture |
AO/OTA Classification (most widely used)
| Group | Description |
|---|---|
| A | Extra-articular |
| B | Partial articular (one cortex remains intact) |
| C | Complete articular (articular surface fully separated from diaphysis) |
Each group has 3 subgroups with 3 further subtypes = 27 total patterns.
Historical systems (rarely used clinically)
- Gartland & Werley: 3 groups based on articular involvement and comminution
- Frykman: Based on articular involvement ± ulna fracture
- Melone: Emphasizes "medial complex" (dorsomedial + palmar medial fragments) and lunate facet impaction
None of the existing systems reliably predict treatment or prognosis. — Rockwood and Green's, p. 1828
Instability Predictors
Lafontaine Criteria (≥3 of 5 = high risk of secondary displacement)
- Dorsal angulation > 20°
- Dorsal comminution
- Intra-articular radiocarpal fracture
- Associated ulnar fracture
- Age > 60 years
Note: A larger study (MacKenney ~4,000 fractures) found that age, ulnar variance, and metaphyseal comminution were the most consistent predictors; dorsal angulation alone was not significant. Risk of displacement increases linearly with age.
Treatment
Goals
- Maintain reduction until union
- Restore function
- Prevent symptomatic post-traumatic radiocarpal arthritis
Nonoperative Treatment
Indications: Extra-articular minimally displaced fractures; low-demand patients
Technique of closed reduction:
- Dorsal hematoma block with local anesthetic; finger traps for traction
- Volar translation of lunate with traction and ulnar deviation
- Re-create deformity → manipulate distal fragment
- Sugar-tong plaster splint with three-point mold (hook volar cortex)
- MCP and IP joints must be kept free
Immobilization: 6–8 weeks
Post-reduction benchmarks (AAOS guideline):
- Radial shortening < 5 mm
- Dorsal articular tilt < 5–10°
- Intra-articular step-off < 2 mm
Operative Treatment
| Method | Indications / Key Points |
|---|---|
| CRPP (Closed reduction, percutaneous pinning) | Extra-articular fractures in younger patients without osteoporosis; Kapandji intrafocal or arthroscopically assisted technique; less used since volar plating advent |
| External fixation | Unstable fractures with soft tissue compromise; combination with CRPP; articular alignment difficult; overdistraction → risk of CRPS |
| ORIF — Volar locking plate | Most commonly performed; stable fixation for most dorsally displaced fractures; plate must be proximal to watershed line to avoid flexor tendon irritation |
| ORIF — Dorsal plate | Used for dorsal shearing, die-punch, and severely comminuted articular fractures; concurrent SL ligament injuries; higher tendon irritation rate |
| Bridge/distraction plate | Alternative to external fixation in highly comminuted unstable fractures or severe osteoporosis; allows weight-bearing through the extremity |
| Fragment-specific fixation | Best for certain intra-articular patterns including volar-ulnar ("critical corner") fragment; hook plate for volar-ulnar fragment |
AAOS 2020 CPG: Appropriate to treat isolated, low-energy AO/OTA type A fractures in high-functioning, healthy patients with ORIF.
Post-operative Radiographs: Volar Locking Plate
AP view — post ORIF volar locking plate (left wrist):
Lateral view — post ORIF volar locking plate (right wrist):
Complications
| Complication | Key Details |
|---|---|
| Acute CTS | Progressive paresthesias + disproportionate pain → emergent carpal tunnel release. Mild non-progressive sensory dysfunction is NOT acute CTS. |
| EPL tendon rupture | Most common tendon rupture, both operative and non-operative; late complication (hematoma, attrition at Lister tubercle); treat with EIP transfer |
| FPL rupture | After volar plating; occurs when plate is distal to the watershed line; most common flexor tendon injured |
| Extensor tendon irritation (EPL) | From volar plate dorsal screw too long; check on fluoroscopy |
| Malunion | Common in elderly managed nonoperatively; treatment should target symptomatic patients |
| Ulnar nerve palsy | After high-energy displaced fractures; most often neuropraxia |
| CRPS | Risk increased with overdistraction via external fixation |
| Hardware removal | Complication rate up to 13% with locking plates |
Malunion Criteria
- Radial inclination < 10°
- Volar tilt > 20° or dorsal tilt > 20°
- Radial height < 10 mm
- Ulnar variance > +2 mm
- Intra-articular incongruity > 2 mm
Distal Ulna Fractures (Associated)
- Ulnar styloid fracture: Concurrent treatment is not routinely necessary — no additional clinical benefit if DRUJ is stable after radial fixation
- DRUJ instability/painful nonunion occurs in < 10% of cases after radial reduction
- Unstable DRUJ: indicated for fixation; options include tension band construct or mini-fragment T-plate
Controversies & Special Topics
- Arthroscopy: Aids articular reduction and confirms screws do not penetrate radiocarpal joint
- Bone grafting: Used for structural defects from impaction; calcium phosphate or coralline hydroxyapatite
- Post-operative motion: Evidence does not support early over late motion recovery
- Osteoporosis: Should prompt evaluation and treatment in low-energy fractures (DXA screening)
- Rehabilitation: Recent 2024 systematic review (Mehta et al., JOSPT, PMID 39213418) provides evidence-based rehabilitation guidelines
Recent Evidence (2024)
| Study | Key Finding |
|---|---|
| Mehta et al. 2024 (Syst. Review) [PMID 39213418] | Evidence-based rehabilitation guidelines for distal radius fractures |
| Gruisen et al. 2024 (Syst. Review) [PMID 38849773] | Patient-reported outcomes after surgical salvage for post-traumatic radiocarpal OA |
| Lister et al. 2024 (Syst. Review) [PMID 37269124] | Spontaneous EPL rupture — relevant complication after distal radius fixation |
Sources: Rockwood and Green's Fractures in Adults, 10th ed. (2025); Miller's Review of Orthopaedics, 9th ed.
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