Distal radius fractures: Difference between revisions

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==Types==
==Background==
{{Forearm anatomy}}
*Definition: Fracture at the metaphysis or the articulation of the distal radius
*One of the most common fractures seen in the ED (1/6th of all fractures treated)


==Differential Diagnosis==
{{Distal radius fracture DDX}}
{{Forarm fracture DDX}}


==[[Colles fracture]]==
==Clinical Features==
===Background===
[[File:Dinner fork Deformity.jpg|thumb|Classic "dinner fork" deformity.]]
*Distal radial metaphysis fx that is dorsally displaced and angulated
[[File:Distalradiusfracture.jpg|thumb|Distal radius fracture demonstrating the deformity in the wrist.]]
**Fracture line may extend into radioulnar or radiocarpal joint ("die-punch" fx)
*Commonly from a fall on an outstretched wrist that is dorsiflexed
*Occurs due to FOOSH
*Wrist/forearm trauma and pain
*Ulnar styloid fx is often present and suggests injury to TFCC
*Possible forearm deformity


===Clinical Features===
===Exam Pearls===
*Characteristic dorsiflexion or "dinner-fork" deformity
*Perform full neurovascular assessment of the hand (including median, ulnar, and radial nerves
*Palmar paresthesias (pressure on median nerve)
*Examine ipsilateral elbow, shoulder, and hand


===Imaging===
==Differential Diagnosis==
*PA
{{Forarm fracture DDX}}
**Distal metaphyseal fx that often appears shortened from angulation or comminution
*Lateral
**Provides best view of dorsal angulation and comminution


[[File:Colles fracture.JPG|thumb|Colles fracture]]
==Evaluation==
[[File:Collesfracture.jpg|thumb|[[Colles' fracture]], one type of distal radius fracture.]]
[[File:Radiograph_of_Barton's_fracture.jpg|thumb|Volar [[Barton's fracture]], one type of distal radius fracture.]]
[[File:Displaced distal radius fracture.jpg|thumb|Displaced, intra-articular distal radius fracture.]]
===Workup===
*Forearm x-ray AP and lateral


===Management===
===Diagnosis===
*Assess for instability:
*Typically from plain forearm x-rays
**>20 degrees angulation
**Intra-articular involvement
**Marked comminution
**>1cm shortening
*Stable Fracture
**Compression dressing and sugar tong splint
**Closed reduction may be attempted
*Unstable Fracture
**Immediate ortho referral


==[[Smith fracture]]==
==Management==
===Background===
{{General Fracture Management}}
*Volar angulated fx ("reverse Colles fracture" or "garden-spade deformity")
*Occurs due to fall or direct blow to dorsum of hand/wrist


===Imaging===
===Acute Reduction===
*Similar but opposite to Colles fracture
*Indications:
**Most angulated and/or displaced distal radius requires closed reduction and placement of a sugar-tong splint
**Consider even if operative management is expected (to reduce pain and swelling)
*Steps:
*#Adequate analgesia (e.g. [[morphine]] and/or [[hematoma block]])
*#highly consider [[procedural sedation]]
*#Axial traction: Manual or finger traps with hanging weights, if available
*#Recreate, then reverse, mechanism of injury
*#*Although recreating the injury briefly exaggerates the existing deformity, this maneuver "unlocks" any periosteal sleeve folded into the fracture site (which can be critical in achieving reduction)
*#*Continue to maintain axial traction throughout manuver
*#*For example with a fracture with dorsally angulated fragments, establish axial traction, then slightly bending the dorsal fragment even more dorsally while maintain traction, then reverse pressure to reduce the distal fragment volarly and back out to length, all while maintaining traction.
*#[[Splint]]
*#Re-image
*Goal:
**Always target optimal (anatomic) fracture reduction
**Operative fixation is recommended for fractures with post-reduction<ref>AAOS OrthoGuidelines. Treatment of Distal Radius Fractures. http://www.orthoguidelines.org/topic?id=1003</ref>:
***Radial shortening > 3mm
***Dorsal tilt > 10°, or
***Intra-articular displacement or step-off > 2mm


===Management===
===Splinting<ref>Olive View Medical Center Upper Arm Extremity Splint Recommendations 2022</ref>===
*Similar to Colles fracture
*Reduction performed
**[[Sugar tong splint]]
*Reduction not attempted or failed
**[[Volar short arm splint]]
***If severe pain with pronation/supination, then [[sugar tong splint]]


==[[Barton fracture]]==
==Disposition==
===Background===
*Most can be treated with orthopedic follow up within 1 week
*Dorsal or volar rim fx
*Often is fx-dislocation or subluxation because carpus is displaced in direction of the fx


===Imaging===
===Admit===
*PA
*[[Open fracture]]
**Communiuted fx of distal radial metaphysis
*Neuro-vascular compromise
*Lateral
*Risk or concern for [[compartment syndrome]]
**Intra-articular fx of volar or dorsal rim of radius
*Patient is unable to function at home (e.g. uses walker with that arm)
 
===Management===
*Minimally displaced: sugar tong splint and ortho referral
*Unstable requires ORIF
**>50% of radial articular surface
**Accompanying carpal subluxation
 
==[[Radial styloid fracture]]==
===Background===
*Often accompanied by lunate dislocation
*Often assoc w/ carpal instability (carpal ligaments insert on the radial styloid)
 
===Management===
*Short arm splint; position wrist in mild flexion and ulnar deviation
 
==Distal Radioulnar Joint Disruption==
===Background===
*Seen w/ intra-articular or distal radial shaft fractures or both bone fracture
 
===Imaging===
*PA
**Narrowing and overlap of distal radioulnar joint
*Lateral
**Volar or dorsal displacement of ulna (which is usually centered/overlapping the radius)
**Requires a true lateral to avoid a false positive result
 
===Management===
*Dorsal dislocation
**Immobilize wrist in supination
*Volar dislocation
**Immobilize wrist in pronation


==See Also==
==See Also==
*[[Forearm fractures]]
*[[Forearm fractures]]


==Source==
==External Links==
*Tintinalli
*https://www.orthobullets.com/trauma/1027/distal-radius-fractures
 
==References==
<references/>


[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 20:46, 26 April 2022

Background

Left arm, anterior view of radius and ulna.
Left arm, posterior view of radius and ulna.
  • Definition: Fracture at the metaphysis or the articulation of the distal radius
  • One of the most common fractures seen in the ED (1/6th of all fractures treated)

Distal radius fractures

Distal radius fracture eponyms

Eponyms Description
Barton's Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip)
Chauffer's Fracture of radial styloid
Colles' Dorsally displaced, extra-articular fracture
Die-punch Depressed fracture of the lunate fossa (articular surface)
Smith's Volar displaced, extra-articular fracture

Clinical Features

Classic "dinner fork" deformity.
Distal radius fracture demonstrating the deformity in the wrist.
  • Commonly from a fall on an outstretched wrist that is dorsiflexed
  • Wrist/forearm trauma and pain
  • Possible forearm deformity

Exam Pearls

  • Perform full neurovascular assessment of the hand (including median, ulnar, and radial nerves
  • Examine ipsilateral elbow, shoulder, and hand

Differential Diagnosis

Forearm Fracture Types

Evaluation

Colles' fracture, one type of distal radius fracture.
Volar Barton's fracture, one type of distal radius fracture.
Displaced, intra-articular distal radius fracture.

Workup

  • Forearm x-ray AP and lateral

Diagnosis

  • Typically from plain forearm x-rays

Management

General Fracture Management

Acute Reduction

  • Indications:
    • Most angulated and/or displaced distal radius requires closed reduction and placement of a sugar-tong splint
    • Consider even if operative management is expected (to reduce pain and swelling)
  • Steps:
    1. Adequate analgesia (e.g. morphine and/or hematoma block)
    2. highly consider procedural sedation
    3. Axial traction: Manual or finger traps with hanging weights, if available
    4. Recreate, then reverse, mechanism of injury
      • Although recreating the injury briefly exaggerates the existing deformity, this maneuver "unlocks" any periosteal sleeve folded into the fracture site (which can be critical in achieving reduction)
      • Continue to maintain axial traction throughout manuver
      • For example with a fracture with dorsally angulated fragments, establish axial traction, then slightly bending the dorsal fragment even more dorsally while maintain traction, then reverse pressure to reduce the distal fragment volarly and back out to length, all while maintaining traction.
    5. Splint
    6. Re-image
  • Goal:
    • Always target optimal (anatomic) fracture reduction
    • Operative fixation is recommended for fractures with post-reduction[1]:
      • Radial shortening > 3mm
      • Dorsal tilt > 10°, or
      • Intra-articular displacement or step-off > 2mm

Splinting[2]

Disposition

  • Most can be treated with orthopedic follow up within 1 week

Admit

See Also

External Links

References

  1. ↑ AAOS OrthoGuidelines. Treatment of Distal Radius Fractures. http://www.orthoguidelines.org/topic?id=1003
  2. ↑ Olive View Medical Center Upper Arm Extremity Splint Recommendations 2022
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