Distal radius fracture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Distal radius fractures are one of the most common injuries encountered in orthopedic practice. They make up 8%−15% of all bony injuries in adults. Abraham Colles is credited with description of the most common fracture pattern affecting distal end radius in 1814, and is classically named after him. Colles’ fracture specifically is defined as metaphyseal injury of cortico-cancellous junction (within 2−3 cm of articular surface) of the distal radius with characteristic dorsal tilt, dorsal shift, radial tilt, radial shift, supination and impaction. Smith’s fractures, also referred to as reverse Colles’ fracture, have palmar tilt of the distal fragment. Barton’s fracture is the displaced intra-articular coronal plane fracture-subluxation of dorsal lip of the distal radius with displacement of carpus with the fragment. Reverse Barton’s occurs with wrist in palmar-flexion and involves the volar lip. Chauffer’s fracture was described as originally occurring due to backfire of the car starter handles in older models. It involves an intra-articular fracture of radial styloid of variable size.Intra-articular component in distal radius fractures usually signifies high-energy trauma occurring in young adults. High-energy injuries frequently cause shear and impacted fractures of the articular surface of the distal aspect of the radius with displacement of the fracture fragments. The fracture pattern most commonly observed in geriatric age group is extra-articular while the high-energy intra-articular type is most frequent in young adult patients.There are multiple classifications available for distal radius fractures. The most common classification systems for distal radius fractures include Frykman, Melone, Fernández, Universal, and AO classification. Many Distal radius fractures can be treated nonoperatively. Those that are undisplaced or minimally displaced can be treated in a cast for 6 weeks. Mainly type I and type IIA Melone’s fracture can be managed conservatively. In elderly, cast immobilization provided functional outcomes similar to those achieved with surgical treatments. Surgical management of distal radius fracture can present many challenges, particularly in patients with multiple fracture fragments, extensive articular comminution, or metadiaphyseal bone loss. Understanding the column model of distal radius fractures and the goals of reconstruction can be extremely beneficial in preoperative planning and intraoperative decision making. Successful surgical management of complex distal radius fracture requires versatility in surgical approaches and techniques in addition to familiarity with a variety of fixation methods such as volar locking plate, dorsal locking plate, distraction bridge plate and external fixation.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

In 3000 B.C., ancient Egyptian case reports within the Edwin Smith Papyrus described about the distal radius fracture. In 1814, Abraham Colles published his landmark treatise on distal radius fracture that led to his eponymous reward. In the 1850s, plaster of Paris gained popularity in Europe as the solidifying agent in casting techniques. The first case of using x-rays for clinical diagnosis of distal radius fracture was published in Lancet in 1896. In 1908, Lister described the use of a percutaneously placed wire through the radial styloid to maintain reduction. The first two case reports using internal fixation in the distal radius were published in the literature in 1958. In the 1970s, Kapandji introduced the concept of intrafocal pinning of the fracture site as a means to buttress the distal segment.

• In 3000 B.C., ancient Egyptian case reports within the Edwin Smith Papyrus described about the distal radius fracture.^[1]
• In 490 BC, Hippocrates described distal radius fracture and its mechanism of injury for the first time.^[2]
• In 1814, Abraham Colles published his landmark treatise on distal radius fracture that led to his eponymous reward.^[3]
• In the 1850s, plaster of Paris gained popularity in Europe as the solidifying agent in casting techniques.^[4]
• In 1895, Wilhelm Röntgen published his work on x-rays and questioned the conservative management of distal radius fracture.^[5]

• In 3000 B.C., ancient Egyptian case reports within the Edwin Smith Papyrus described management of distal radius fracture by splinting using wood and rolls of linen, which were subsequently hardened with grease and honey to maintain their position.^[6]
• In 490 BC, Hippocrates described distal radius fracture and its mechanism of injury for the first time.^[7]
• In 18th century, Petit and Pouteau first theorized that Hippocrates had failed to fully conceptualize the injury he was describing and treating.^[8]
• In 1814, Abraham Colles described how to reduce the injury and suggested the importance of immobilization with a wooden splint to prevent the wrist from falling into dorsal displacement.^[3]
• In the 1850s, plaster of Paris gained popularity in Europe as the solidifying agent in casting techniques.^[9]
• In 1896, the first case of using x-rays for clinical diagnosis of distal radius fracture was published in Lancet.^[10]
• In 1908, Lister described the use of a percutaneously placed wire through the radial styloid to maintain reduction.^[11][12]
• In 20th century, Lorenz Böhler introduced the use of pins with plaster to treat distal radius fracture.^[13]
• In 20th century, Donald Murray described the use of an adhesive traction device to maintain radial length during the consolidation phase of bony union.^[14]
• In 1944, Anderson and O’Neil’s introduced their initial design of external fixator for management for distal radius fracture.^[15]
• In 1958, the first two case reports using internal fixation in the distal radius were published in the literature.^[16][17]
• In the 1970s, Kapandji introduced the concept of intrafocal pinning of the fracture site as a means to buttress the distal segment.^[18][19]
• In the 1990s, Pi and Forte plates which were dorsally applied became popular, but fell quickly out of favor due to the frequent tendon irritations.^[20][21]
• Over the last decade, volar locking plates have taken hold as the implant of choice, and operative fixation of distal radius fracture to an all time high.^[22][23][24]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

There are multiple classifications available for distal radius fractures. The most common classification systems for distal radius fractures include Frykman, Melone, Fernández, Universal, and AO classification.

There are multiple classifications available for distal radius fractures. The most common classification systems for distal radius fractures include Frykman (1967), Melone (1984), Fernández (2001), Universal (Cooney 1993), and AO classification (Marsh et al. 2007).

• Frykman classified distal radius fracture based on location.^[1]

• Melone classified distal radius fracture based on location.^[2][3]

• Fernández classified distal radius fracture based on trauma mechanism.^[4]

• Cooney classified distal radius fracture based on location and stability.^[5]

• AO/ASIF classification is the widely accepted classification.
• Radius is given the number 21 based on the classification.^[6]
• It is further subdivided as:

• Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip)

• Fracture of radial styloid

• Dorsally displaced, extra-articular fracture

• Depressed fracture of the lunate fossa (articular surface)

• Volar displaced, extra-articular fracture

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The pattern of fracture and degree of comminution are the resultant of several factors or variables such as the nature of the fall, the bone quality, the age and weight of the patient, the energy involved, and the position of the hand and wrist at the time of impact. Various combinations of these variables lead to a variety of different fracture patterns.

• The fracture pattern and severity of comminution depends on multiple factors including:
  • Nature of the fall
  • Bone quality
  • Age of the patient
  • Weight of the patient
  • Energy involved
  • Position of the hand and wrist at the time of impact
• Decrease in bone mass density involves following process:^[1]
  • Autophagy is the mechanism through which osteocytes evade oxidative stress.
  • The capability of autophagy in cells decreases as they age, a major factor of aging.
  • As osteocytes grow, viability of cells decrease thereby decreasing the bone mass density.

• Mechanism of fracture may be described as follows:^{[2][3][4][5][6][7][8][9]}
  • The majority of the distal radius fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion.
  • The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist depends on the position of the wrist at the moment of hitting the ground.
  • The width of the angle influences the localization of the fracture.
  • Pronation, supination, and abduction determine the direction of the force and the compression of carpus and different appearances of ligamentary injuries.
  • The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution.
  • As the deformation of the wrist continues, the ulnar styloid may also fracture due to the attachment of the triangular fibrocartilage complex to its base and the distal radius.
  • In elderly osteoporotic patients, the distal ulna may fracture through the metaphysis.
  • Cancellous impaction of the metaphysis further compromises dorsal stability.
  • Additional shearing forces influence the injury pattern, resulting in articular surface involvement.
  • Distal radius fractures typically occur with the wrist bent back from 60 to 90 degrees.
  • Radial styloid fracture would occur if the wrist is ulnar deviated and vice versa.
  • If the wrist is less dorsifelxed, then proximal forearm fracture would occur, but if the dorsiflexion is more, then the carpal bones would fracture.

• The articular surface of the distal aspect of the radius tilts 21 degrees in the antero-posterior plane and 5 to 11 degrees in the lateral plane.^[3][4]
• The dorsal cortical surface of radius thickens to form the Lister tubercle as well as osseous prominences that support the extensors of the wrist in second dorsal compartment.
• A central ridge divides the articular surface of the radius into a scaphoid facet and a lunate facet.
• The triangular fibrocartilage extends from the rim of the sigmoid notch of the radius to the ulnar styloid process.
• Only the brachioradialis tendon inserts onto the distal aspect of the radius; the other tendons of the wrist pass across the distal aspect of the radius to insert onto the carpal bones or the bases of the metacarpals.
• In addition to the extrinsic ligaments of the wrist, the scapholunate interosseous and lunotriquetral interosseous ligaments maintain the scaphoid, lunate, and triquetrum in a smooth articular unit that comes into contact with the distal aspect of the radius and the triangular fibrocartilage complex.
• Because of the different areas of bone thickness and density, the fracture patterns tend to propagate between the scaphoid and lunate facets of the distal aspect of the radius.
• The degree, direction, and extent of the applied load may cause coronal or sagittal splits within the lunate or scaphoid facet.

Conditions associated with poor bone quality leading to distal radius fracture include:^[4]

• Osteoporosis
• Osteopenia
• chronic stroke
• Diabetes
• Rheumatoid arthritis
• Chronic kidney disease
• Hyperparathyroidism
• Hypophosphatemic rickets
• Immobility
• Menopause
• Multiple myeloma
• Mixed connective tissue disease
• Paget’s disease of bone
• Primary hypoparathyroidism
• Short stature
• Chronic corticosteroid use

On gross pathology, decreased bone density and small pores in diaphysis of bones are characteristic findings of osteoporosis, leading to distal radius fracture.^[4]

• On microscopy, characteristic findings of bone with osteoporosis is increased number of osteoclasts and decreased number of osteoblasts under the microscope.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The most common cause of distal radius fracture is fall on an outstretched hand.

The most common cause of distal radius fracture is fall on an outstretched hand (FOOSH).^[1][2][3]

• There are no life-threatening causes of distal radius fracture, however complications resulting from distal radius fracture is common.

Common causes of distal radius fracture may include:

• Trauma (Fall on an outstretched hand)

Less common causes of distal radius fracture include conditions that predisposes to fracture:

• Osteoporosis
• Osteopenia

List the causes of the disease in alphabetical order:

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Distal radius fracture must be differentiated from wrist strain, ligamentous carpal injury such as scapholunate ligament and triangular fibrocartilage complex (TFCC) tear.

• Distal radius fracture must be differentiated from other diseases that wrist pain, restriction of movements, and deformity, such as wrist strain, ligamentous carpal injury such as scapholunate ligament and triangular fibrocartilage complex (TFCC) tear.^[1][2][3][4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Distal radius fracture is a common wrist injury and the radius was the most common long bone to fracture. The incidence distal radius fracture is approximately 162 per 100,000 individuals worldwide. Patients of all age groups may develop distal radius fracture. Extremes of ages are at the highest risk for distal radius fractures. Distal radius fracture usually affects individuals of Caucasian race more than any other race. The female to male ratio is higher in elderly, whereas there is an equal gender predilection for young adults.

Distal radius fracture (DRF) is a common wrist injury and the radius was the most common long bone to fracture. Epidemiology and demographics of distal radius fracture is as follows:^{[1][2][3][4][5]}

• The incidence distal radius fracture is approximately 162 per 100,000 individuals worldwide.^[1]

• Patients of all age groups may develop distal radius fracture.
• Children and adolescents are at a particularly high risk for distal radius fractures, in part due to a rapidly developing skeletal structure.
• The incidence distal radius fracture in children and adolescents is approximately 301.8 per 100,000 individuals in United States of America.
• The incidence of distal radius fractures in the adult population is significantly lower than in other age groups.^[3]
• On the other hand, the incidence distal radius fracture in elderly >65 years is approximately 254.2 per 100,000 individuals.

• Distal radius fracture usually affects individuals of the Caucasian race more than African-American, Hispanics and Asians.^[4][5]

• Women have higher rates of distal radius fractures in individuals above the age of 65 years.
• The ratio of male to female is approximately the same in younger adults.

• The majority of distal radius fracture cases are reported in North Europe.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Common risk factors in the development of distal radius fracture include age, female gender, and health conditions.

Many distal radius fractures in people over 60 are due to osteoporosis if the fall was relatively minor such as a fall from a standing position. They can happen even in healthy bones if the trauma was severe enough such as a car accident or a fall off a bike.^[1][2][3][4]

• The incidence of distal radius fracture has a bimodal distribution during the life span.
• The incidence is high in the pediatric population, drops during young to middle adulthood, and increases again in older adults.

• Gender distribution curves for distal radius fracture incidence in the pediatric group indicate that boys have a higher risk of distal radius fracture than girls.
• This gender difference continues during young to middle adulthood with men aged 19-49 years having more distal radius fracture than women of the same age.
• Beyond that age, the rate of distal radius fracture increases markedly such that women older than 50 years have a 15% lifetime risk, whereas the incidence in men remains low until they reach the age of 80 years.
• Globally, injury rates remain significantly higher in elderly women as compared with elderly men.

• Distal radius fracture appears to occur less often in individuals with significant dementia.^[5][6]
• Health conditions resulting in poor bone quality include:^[7][8]
  • Osteoporosis
  • chronic stroke
  • Diabetes
  • Rheumatoid arthritis
  • Chronic kidney disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

The risk of distal radius fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. The 10-year risk for osteoporosis-related distal radius fracture in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women ≥ 65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones and quantitative ultrasonography of the calcaneus are two major methods suggested for screening osteoporosis.

The risk of distal radius fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. Osteoporosis usually affects the Caucasian population. The rate of osteoporosis is higher in the elderly. The 10-year risk for osteoporosis-related distal radius fracture in a 65-year-old white woman with no other risk factor is 9.3%. .

The US Preventive Services Task Force (USPSTF) divides the population into three groups, categorizing them on the basis of their need to be screened for osteoporosis. They include:

• Women of age ≥ 65 year, without any fracture history or pathological reason for osteoporosis
• Women of age <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)
• Men with no history of osteoporosis

According to the guidelines of USPSTF, the first two groups (women) are the target of screening for osteoporosis. There is no recommendation to screen the third group (men) for the disease.^[1]

The USPSTF recommendations from 2002 included:

• All women of 65 and older should be screened by bone marrow densitometry.^[2]
• Women aged 60-64 years old, who are at increased risk of fracture. The most significant risk factor for indicating an increased probability of having osteoporosis is low body weight (< 70 kg).
• Clinical prediction rules are available to guide the selection of women for screening.
• The Osteoporosis Risk Assessment Instrument (ORAI) is the most sensitive strategy.^[3]
• Regarding the screening process for men, a cost-analysis study suggests that screening may be “cost-effective for men with a self-reported prior fracture beginning at age 65 years, and for men 80 years and older with no prior fracture“.^[4]

There are two major methods, that are suggested to be used for screening for osteoporosis:

• Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones
• Quantitative ultrasonography of the calcaneus

Advantages of ultrasonography over DXA scan:

Although quantitative ultrasonography has numerous advantages when compared to DXA but still current diagnostic and treatment criteria rely on DXA of the hip and lumbar spine. The advantages include:

• Lower cost
• More portable
• Lower ionizing radiation exposure

After an initial screening is done for bone mineral density (BMD), optimal intervals to repeat the tests include:

• 15 years for women with normal bone density or mild osteopenia: T-score of greater than −1.50
• 5 years for women with moderate osteopenia: T-score of −1.50 to −1.99
• 1 year for women with advanced osteopenia: T-score of −2.00 to −2.49^[5]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

If left untreated, majority of patients with distal radius fracture may progress to develop malunion and loss of range of motion of the wrist and forearm. Common complications of distal radius fracture include upper extremity stiffness, malunion, carpal tunnel syndrome or median nerve involvement, and radiocarpal arthritis. Prognosis is generally good, with most patients can resume their previous level of activity, including competitive sports.

• If left untreated, majority of patients with distal radius fracture may progress to develop malunion and loss of range of motion of the wrist and forearm.^[1][2]

• Common complications of distal radius fracture include:^{[3][4][5][6][7][8]}
  • Upper extremity stiffness
  • Carpal tunnel syndrome or median nerve involvement
  • Malunion
  • Injury to the radial artery
  • Carpal instability
  • Distal Radio-Ulnar Joint (DRUJ) dysfunction
  • Dupuytren’s disease
  • Radiocarpal arthritis
  • Tendon injuries
  • Ligament injuries
  • Post-traumatic osteoarthritis
  • Compartment syndrome
  • Infection mostly by open fractures or after fracture fixation
  • Complex regional pain syndrome

• Prognosis is generally good, with most patients can resume their previous level of activity, including competitive sports.^[9][10]
• Most patients will likely lose a few degrees of final flexion and extension, and possibly supination as well; however, these limitations generally do not prevent full function.
• Some patients are unable to resume their prior level of functioning.
• All treatment approaches have a percentage of poor results, with decreased supination, prominent ulnar heads, ligamentous problems, distal radioulnar instability, and degenerative joint disease.

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