High Yield Topics

Fracture, Distal Radius

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Fracture, Distal Radius
Kevin B. Gebke
Vijay Jotwani
Basics
Description
  • Classically, the fractured distal portion will be dorsally displaced and angulated (“silver-fork deformity”); commonly referred to as Colles fracture
  • Other variations include:
    • Smith fracture (volar displacement and angulation)
    • Barton fracture (dorsal fracture-dislocation involving displacement of carpus with distal fragment)
    • Reverse Barton (Barton fracture with volar displacement)
    • Hutchinson fracture (lateral-oriented fracture through radial styloid process extending into radiocarpal articulation)
    • Galeazzi fracture-dislocation (fracture of distal third of radius with associated dislocation of distal radioulnar joint)
  • Key is to always describe fracture location, angulation, displacement, and involvement of either radiocarpal or radioulnar joints
  • Synonym(s): Colles fracture; Smith fracture; Barton fracture; Reverse Barton fracture; Hutchinson fracture; Galeazzi fracture-dislocation
Epidemiology
  • General (1):
    • Most common fracture of the upper extremity
    • Seen in all age groups, with peaks between 6 and 10 yrs of age and 60 and 69 yrs of age
    • Female predominance in the general population, but male predominance in sports (1,2)
  • Sports:
    • True incidence in sports is unknown:
      • Distal radius fractures represent 12.5% of fractures caused by sporting activity in 1 study (2): Percentages of total fractures by sport that were distal radius: Snowboarding 34.8%, ice skating 36.4, soccer 19.1%, rugby 14.7%, mountain biking 14%
      • Distal radius fractures represent 14.5% of injuries in snowboarders (3).
Risk Factors
  • General:
    • Decreased bone mineral density
    • Unsteady gait
  • Sports:
    • Activities with high risk of falls and impact: Snowboarding, football, ice skating, etc.
General Prevention
Wrist guards can decrease the rates of wrist injury, including distal radius fractures in snowboarders (4)[B]:
  • 50 snowboarders have to wear wrist guards to prevent 1 wrist injury.
  • Beginner snowboarders get the most benefit from wrist guards.
  • Unclear if these results can be generalized to other sports
Etiology
Commonly sustained by falling onto an outstretched hand with the wrist in extension
Commonly Associated Conditions
  • Vascular injury
  • Compartment syndrome
  • Nonunion
  • Arthrosis secondary to poor joint approximation at radioulnar or radiocarpal joint
  • Joint stiffness or weakness
  • Median nerve dysfunction
  • Reflex sympathetic dystrophy
Diagnosis
Pre Hospital
  • If a distal radial fracture is suspected during event coverage, splinting should be applied after careful neurovascular assessment.
  • Transport for radiographic evaluation
History
  • Elicit specific details regarding fall or trauma involved:
    • High- or low-energy mechanism
  • Comorbid conditions such as osteoporosis or malignancy
Physical Exam
  • Pain, swelling, and limitation of movement of distal upper extremity
  • Paresthesias, weakness, or coolness to touch:
    • Associated neurologic or vascular injury
  • Gross visualization of the involved extremity for bony deformity and evidence of open injury
  • Neurologic evaluation, including radial, median, and ulnar nerve testing
  • Vascular evaluation, including radial and ulnar pulses
Diagnostic Tests & Interpretation
Multiple classification systems have been described, Frykman, Melone, A-O, etc., but none have been found to be reliable and reproducible, nor do they add prognostic value to treatment or outcomes (1).
Imaging
  • Posteroanterior (PA) view: Useful for identifying Colles and Hutchinson fractures and Galeazzi fracture-dislocation
  • Lateral view: Useful for identifying Colles, Smith, Barton, and reverse Barton fractures and Galeazzi fracture-dislocation
  • Ancillary imaging techniques, including CT, arthrography, bone scan or MRI: May be necessary in subtle or complex cases for further evaluation:
    • CT can be useful for evaluation of the articular surface in fractures that have an intra-articular component.
  • PA and lateral views should be obtained after reduction to evaluate correction of radial length and angulation of distal articular surface.
Differential Diagnosis
  • Carpal fracture
  • Ulnar fracture
  • Radiocarpal sprain
  • Radioulnar sprain
  • Soft tissue/bony contusion
Treatment
  • General:
    • Most studies that compare conservative vs surgical management do not involve younger patients. This makes it difficult to determine the best treatment option in many cases.
    • Treatment of the fractures may vary significantly based on the type of fracture, patient demands, and physician experience.
  • Analgesia:
    • Adequate pain relief using oral and/or IV narcotics
    • For pediatric fractures, ibuprofen is equal to Tylenol with codeine (5)[A].
    • Hematoma blocks can provide pain relief for closed reductions:
      • May be less effective than IV regional anesthesia (6)[B]
  • Nondisplaced fractures:
    • Nondisplaced fractures can be immobilized in a sugar tong splint or radial gutter splint (7)[B].
    • Pediatric torus fracture can be treated safely with a wrist immobilizer (8)[B].
  • Displaced fractures/unstable fractures:
    • No defined criteria for displacement, but it is generally accepted as (1)[C]:
      • >20° dorsal angulation
      • >5 mm of radial shortening
      • >2 mm of articular displacement
    • No defined criteria for unstable fractures, but risk fractures for instability may include (1):
      • Dorsal angulation >20°
      • Comminution
      • Intra-articular involvement
      • Age >60
    • It is unclear which fractures may benefit from closed reduction vs surgical techniques.
    • There are multiple surgical techniques, percutaneous pinning, external fixation, volar or dorsal plating, etc.:
      • No clear superiority of one technique over the other
    • The decision for surgery and the choice of surgical technique is based on multiple factors and the individual patient.
  • Reduction techniques:
    • Goal is to achieve anatomical alignment to allow proper healing of the fragments and eventual restoration of normal function.
    • Reduction should always be accomplished in a timely manner before soft tissue inflammatory changes progress.
    • Reduction should be attempted urgently for signs of neurovascular compromise.

      • P.193


    • Closed reduction of displaced distal radial fractures frequently can be accomplished using manual traction of the extremity in combination with manipulative maneuvers to restore alignment.
      • No evidence to suggest superiority of any one method of closed reduction (9): Manual vs finger traps, etc.
    • More than 2 attempts at closed reduction in pediatric fractures involving the physis increases the risk of growth arrest (10)[B].
    • Pinning, external fixation, and open reduction and internal fixation are frequently used when there is concern of loss of reduction or instability, especially for intra-articular fracture requiring maintenance of anatomic alignment (1)[C].
  • Postreduction evaluation:
    • Repeat neurovascular examination.
    • Postreduction x-rays (PA and lateral) after application of immobilizing device to assure maintenance of reduction
Medication
  • Acetaminophen and NSAIDs can be used for mild-to-moderate pain:
    • Although there is some theoretical concern about NSAIDs inhibiting bone healing, there are no clinical studies addressing this question.
  • Narcotic pain medications are commonly used in the first few weeks following injury.
Additional Treatment
Referral
  • Referral patterns will vary on treating physician experience level.
  • Orthopedic referral for:
    • Open fractures
    • Unstable fractures
    • Intra-articular involvement
    • Significant comminution
    • Neurovascular compromise
    • Fractures involving the physis
Additional Therapies
Overall there is unclear benefit of rehabilitation of distal radius fractures in adults (11):
  • Limited evidence to suggest a short-term benefit of physical therapy after distal radius fracture (<3 mos) (11)[B]:
    • May be more important in athletes in terms of functional recovery and faster return to play, but no studies address this specifically
  • A single visit with a physical therapist for instruction may be as effective as multiple visits (11)[B].
  • Home-based exercise program is effective after volar plating for distal radius fractures (12)[B].
Complementary and Alternative Medicine
Vitamin C 500 mg 1 × day for 50 days decreased the incidence of complex regional pain syndrome (13)[A].
Surgery/Other Procedures
  • Surgery is indicated for unstable and significantly displaced fractures (1)[C].
  • Multiple surgical techniques, percutaneous pinning, external fixation, volar or dorsal plating, etc., are used in the treatment of distal radius fractures:
    • The choice of techniques is based on many factors and the individual patient.
    • No evidence exists to suggest one technique is superior in the management of these fractures (14).
Ongoing Care
Follow-Up Recommendations
  • Most patients should be re-examined and x-rays repeated in 7–10 days to ensure fracture stability:
    • Pediatric torus fractures do not require repeat radiographs in most cases (15)[B]:
      • Consider repeat x-rays for pain >3–4 wks
  • Splint removed and cast applied at 7–10 days:
    • There appears to be no benefit of long arm casting vs short arm (16)
  • Final radiographs are generally done at 6–8 wks.
  • Healing time is generally:
    • 6–8 wks adults
    • 3–4 wks children
  • Some athletes may be able to return to sports with protection as soon as pain allows:
    • This will depend on the type of fracture, intervention, athlete, and the sport.
Prognosis
Generally good, with most patients regaining full function and motion at the wrist
Complications
  • Severe acute complications, such as neurovascular injuries and compartment syndrome, are associated with high-energy trauma and are, fortunately, rare (1).
  • Degenerative changes, stiffness, and pain are more common in intra-articular fractures (1).
  • Complex regional pain syndrome (CRPS) is relatively common after distal radius fractures (13):
    • 24% of patients with Colle's fracture in a cohort study met all clinical criteria for CRPS at 2 wks post fracture
    • Vitamin C 500 mg 1 × day for 50 days reduces the incidence of CRPS (13)[A]:
      • Number needed to treat = 13
  • Growth arrest in pediatric fractures is relatively common (up to 7%), but generally asymptomatic (10,17):
    • Risk increases with more than 2 attempts at closed reduction.
References
1. Wulf CA, Ackerman DB, Rizzo M. Contemporary evaluation and treatment of distal radius fractures. Hand Clin. 2007;23:209–226, vi.
2. Court-Brown CM, Wood AM, Aitken S. The epidemiology of acute sports-related fractures in adults. Injury. 2008.
3. Matsumoto K, Sumi H, Sumi Y, et al. Wrist fractures from snowboarding: a prospective study for 3 seasons from 1998 to 2001. Clin J Sport Med. 2004;14:64–71.
4. Russell K, Hagel B, Francescutti LH. The effect of wrist guards on wrist and arm injuries among snowboarders: a systematic review. Clin J Sport Med. 2007;17:145–150.
5. Drendel AL, Gorelick MH, Weisman SJ, et al. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med. 2009.
6. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002:CD003320.
7. Bong MR, Egol KA, Leibman M, et al. A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal radius: a prospective randomized study of long-arm versus short-arm splinting. J Hand Surg [Am]. 2006;31:766–770.
8. Firmin F, Crouch R. Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review. Int Emerg Nurs. 2009;17:173–178.
9. Handoll HH, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003:CD003763.
10. Lee BS, Esterhai JL, Das M. Fracture of the distal radial epiphysis. Characteristics and surgical treatment of premature, post-traumatic epiphyseal closure. Clin Orthop Relat Res. 1984;185:90–96.
11. Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev. 2006;3:CD003324.
12. Krischak GD, Krasteva A, Schneider F, et al. Physiotherapy after volar plating of wrist fractures is effective using a home exercise program. Arch Phys Med Rehabil. 2009;90:537–544.
13. Zollinger PE, Tuinebreijer WE, Breederveld RS, et al. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89:1424–1431.
14. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003:CD003209.
15. Farbman KS, Vinci RJ, Cranley WR, et al. The role of serial radiographs in the management of pediatric torus fractures. Arch Pediatr Adolesc Med. 1999;153:923–925.
16. Handoll HH, Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003:CD000314.
17. Cannata G, De Maio F, Mancini F, et al. Physeal fractures of the distal radius and ulna: long-term prognosis. J Orthop Trauma. 2003;17:172–179; discussion 179–180.
Codes
ICD9
  • 813.40 Closed fracture of lower end of forearm, unspecified
  • 813.41 Colles' fracture, closed
  • 813.42 Other closed fractures of distal end of radius (alone)
Clinical Pearls
  • Swelling and pain over the physis may indicate a physeal injury even with normal radiographs.
  • Complex regional pain syndrome is relatively common after distal radius fractures, and vitamin C can help prevent this complication.


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