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Basics ⬇

Author(s): Kevin B.Gebke, MD and DinaElnaggar, MD, MS

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).
    • Dorsal Barton fracture: dorsal fracture-dislocation involving displacement of carpus with distal fragment.
    • Volar Barton (also known as reverse Barton): fracture with volar displacement.
    • Hutchinson fracture (also known as chauffeur’s 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.
    • Die-punch fracture: a depressed fracture of the lunate fossa on the articular surface of the distal radius.
  • Synonym(s): Colles fracture; Smith fracture; Barton fracture; dorsal Barton; reverse Barton fracture; volar Barton; Hutchinson fracture; chauffeur’s fracture; Galeazzi fracture-dislocation; die-punch fracture

Epidemiology

  • Most common fracture of the upper extremity (1)
  • Most common fracture in children <16 yr old and most common during the metaphysical growth spurt (1)
  • Incidence also peaks in patients 60 and 69 yr of age. 60–70% of all Colles fractures occur in postmenopausal women (1).
  • Distal radius fractures represent 12.5% of fractures caused by sporting activity in one 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%

Etiology and Pathophysiology

Commonly sustained by falling onto an outstretched hand with the wrist in extension

Risk-Factors

  • In general, decreased bone mineral density and unsteady gait
  • In sports activities: 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 (3)[B]:

  • Beginner snowboarders get the most benefit from wrist guards.

Commonly Associated Conditions

  • Arthrosis secondary to poor joint approximation at radioulnar or radiocarpal joint
  • Joint stiffness or weakness
  • Median nerve dysfunction—the median nerve and flexor tendons run volar to the distal radius.
  • Triangular fibrocartilage complex (TFCC) injury

Diagnosis ⬆ ⬇

History

  • Elicit specific details regarding fall or trauma involved in high- or low-energy mechanism.
  • Comorbid conditions such as osteoporosis or malignancy

Physical Exam

  • Key is to always describe fracture location, angulation, displacement, and involvement of either radiocarpal or radioulnar joints.
  • Gross visualization of the involved extremity for bony deformity and evidence of open injury
  • Pain, swelling, and limitation of movement of distal upper extremity
  • Tenderness to the dorsal aspect of the wrist
  • Paresthesias, weakness, or coolness to touch (associated neurologic or vascular injury)
  • Neurologic evaluation, including radial, median, and ulnar nerve testing
  • Vascular evaluation, including capillary refill, radial and ulnar pulses
  • In addition to fracture, one must evaluate for associated injuries at the scapholunate joint, distal radioulnar joint, ulnar styloid, and elbow injuries.
  • Multiple classification systems have been described: Fernandez is based on mechanism of injury, Frykman is based on joint involvement, Melone divides intra-articular fractures into four types based on displacement, AO/OTA is a more comprehensive classification system, Lafontaine criteria and the McQueen equation predict secondary displacement after reduction.

Differential Diagnosis

  • Carpal fracture
  • Ulnar fracture
  • Radiocarpal sprain
  • Radioulnar sprain
  • Soft tissue/bony contusion

Diagnostic Tests & Interpretation

  • Consider obtaining bilateral x-rays to compare angulation.
  • Anteroposterior (AP)/lateral views of wrist, forearm, and elbow
  • AP view of the wrist: measures radial height (normal 13 mm, note shortening >5 mm), radial inclination (normal 22 degrees, note change >5 degrees), articular step-off (note >2 mm step-off), and ulnar variance:
    • Decreased radial height and inclination result in a hand that appears radially deviated with increased prominence of the ulnar head.
  • Lateral view of the wrist: measures lateral tilt (normal 11 degrees volar, note dorsal angulation >5 degrees or within 20 degrees of contralateral distal radius):
    • Altered lateral tilt of the articular surface may cause midcarpal instability.
  • AP and lateral view of the forearm and elbow: useful for identifying a Galeazzi fracture-dislocation (Loss of radius length producing an ulnar positive wrist increases the chance of symptomatic ulnar impaction syndrome.)
  • Computed tomography (CT) scan: important to evaluate intra-articular involvement and for surgical planning
  • Magnetic resonance imaging (MRI): useful to evaluate for soft tissue injuries such as TFCC injuries, scapholunate ligament injuries, and lunotriquetral injuries
  • In a recent study, sports ultrasound has been found to have a sensitivity of 97.1% specificity of 100%, and a positive predictive value of 100% in diagnosing distal radius fractures in the pediatric population (4)[C].

Treatment ⬆ ⬇

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 intravenous (IV) narcotics
    • For pediatric fractures, ibuprofen is equal to acetaminophen (Tylenol) with codeine (5)[A].
    • Hematoma blocks can provide pain relief for closed reductions (may be less effective than IV regional anesthesia).
  • Nondisplaced/minimally displaced fractures:
    • Can be initially immobilized in a sugar tong splint or radial gutter splint until follow-up
  • Pediatric torus fracture can be treated safely with a wrist immobilizer. Displaced fractures/unstable fractures warrant orthopedic referral.
  • 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, especially if signs of neurovascular compromise are present.
    • Finger trap reduction method is most common:
      • Finger traps are applied to thumb, index, and middle fingers with manual traction or by finger traps hanging from an IV pole with the patient’s arm at 90 degrees.
      • Reduction may be achieved by distal manual reduction methods or by a weighted stockinette.
    • More than two attempts at closed reduction in pediatric fractures involving the physis increases the risk of growth arrest (6)[B].
  • Postreduction evaluation:
    • Repeat neurovascular examination.
    • Post reduction x-rays (AP and lateral) after application of immobilizing device to assure maintenance of reduction

Medication

  • Acetaminophen is preferred for mild to moderate pain due to theoretical concern about nonsteroidal anti-inflammatory drugs (NSAIDs) inhibiting bone healing.
  • Narcotic pain medications are commonly used in the first few weeks following injury.

Issues for Referral

  • Emergent orthopedic referral:
  • Nonemergent orthopedic referral:
    • Unstable fractures
    • Intra-articular involvement
    • Comminution
    • Fractures involving the physis
    • Severe osteoporosis
    • Displacement involving >2/3 the width of the radius
    • Dorsal angulation >5 degrees or >20 degrees of contralateral distal radius
    • >5 mm radial shortening or ulnar variance >5 mm
    • Progressive loss of volar tilt and loss of radial length following closed reduction and casting

Additional Therapies

There is limited evidence to suggest a short-term benefit of physical therapy after distal radius fracture.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Vitamin C 500 mg 1 × day for 50 days decreased the incidence of complex regional pain syndrome (CRPS) (7)[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, and so forth, are used in the treatment of distal radius fractures.
  • Nonoperative management is generally preferred in the geriatric population in appropriate circumstances.
  • Operative treatment may allow athletes to return to play faster than nonoperative treatment (8)[C].
  • Depending on where the athlete is in the season, and if their performance is not substantially limited by pain or being in a cast, a displaced fracture requiring surgery may be delayed by waiting 1 to 2 wk until the end of the season (8)[C].

Ongoing Care ⬆ ⬇

Follow-up Recommendations

  • Most patients should be reexamined and x-rays repeated in 3 to 5 days for nondisplaced and 2 to 3 days for displaced fractures to ensure fracture stability.
  • Splint removed and short arm cast for 4 to 6 wk for nondisplaced fractures and long arm cast for reduced fractures for 3 to 4 wk and then a short arm cast for a total of 6 to 8 wk
  • Repeat x-rays every 2 to 3 wk for nondisplaced and every week for reduced fractures.
  • Healing time is generally 6 to 8 wk in adults and 3 to 4 wk in children.
  • Range of motion (ROM) exercises (8)[C]:
    • Immediately: without resistance for fingers, elbow, and shoulder
    • 3 wk: forearm rotation within the confines of a short arm cast
    • After removal of cast: wrist ROM
    • After resolution of tenderness: strengthening exercises
  • Step-wise return to play is recommended after at least 80% of baseline ROM and strength is regained as well as radiographic healing if use of wrist is required. If use or wrist is not required, the athlete may return to play in a cast (9)[C].

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).
  • TFCC injuries
  • Median nerve neuropathy (carpal tunnel syndrome):
    • Most frequent neurologic complication
    • 1–12% in low-energy fractures and 30% in high-energy fractures
    • Prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position).
  • Ulnar nerve neuropathy: seen with distal radioulnar joint injuries
  • Extensor pollicis longus tendon rupture (9):
    • Most common in nondisplaced or minimally displaced distal radius fractures (incidence from 0.3% to 5%)
    • Usually between 6.6 wk after distal radius fracture
  • Degenerative changes, stiffness, and pain are more common in intra-articular fractures (1).
  • Malunion and nonunion may occur. Malunion is the most common complication in pediatric patients.
  • Radial physeal arrest in pediatric fractures is relatively common (up to 7%) but generally asymptomatic (6):
    • Risk increases with more than two attempts at closed reduction.
    • Ulnocarpal impaction may also occur from continued growth of the ulna after radial arrest.
  • CRPS is an uncommon complication and may be associated with fibromyalgia (10)[B].

Additional Reading ⬆ ⬇

LaMartina J, Jawa A, Stucken C, et al. Predicting alignment after closed reduction and casting of distal radius fractures. J Hand Surg Am. 2015;40(4):934–939.

References ⬆ ⬇

  1. Wulf CA, Ackerman DB, Rizzo M. Contemporary evaluation and treatment of distal radius fractures. Hand Clin. 2007;23(2):209–226, vi.
  2. Court-Brown CM, Wood AM, Aitken S. The epidemiology of acute sports-related fractures in adults. Injury. 2008;39(12):1365–1372.
  3. 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(2):145–150.
  4. Ko C, Baird M, Close M, et al. The diagnostic accuracy of ultrasound in detecting distal radius fractures in a pediatric population [published ahead of print November 15, 2017]. Clin J Sport Med. doi:10.1097/JSM.0000000000000547.
  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;54(4):553–560.
  6. Lee BS, Esterhai JL Jr, 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.
  7. 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(7):1424–1431.
  8. Crijns TJ, van der Gronde BATD, Ring D, et al. Complex regional pain syndrome after distal radius fracture is uncommon and is often associated with fibromyalgia. Clin Orthop Relat Res. 2018;476(4):744–750.
  9. Romano N, Fischetti A, Mussetto I, et al. Extensor pollicis longus (EPL) tendon rupture as a complication of distal radius fracture: the role of ultrasound examination. Med Ultrason. 2018;1(1):114–115.
  10. Beleckas C, Calfee R. Distal radius fractures in the athlete. Curr Rev Musculoskelet Med. 2017;10(1):62–71.

Clinical Pearls ⬆

  • Swelling and pain over the physis may indicate a physeal injury even with normal radiographs.
  • Physical exam and radiographic analysis are key to determining management of distal radius fractures.