Distal radius fractures: Difference between revisions

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==Diagnosis==
==Background==
* Mechanism often c/w FOOSH
{{Forearm anatomy}}
* Examine for deformity
*Definition: Fracture at the metaphysis or the articulation of the distal radius
** "Dinner-fork" deformity common with Colles' fracturs
*One of the most common fractures seen in the ED (1/6th of all fractures treated)
* Examine for impaired sensation of thumb, IF
** Median nerve injury is common in displaced fractures


===Imaging===
{{Distal radius fracture DDX}}
# Is there loss of normal anatomy (e.g. fx displacement or angulation, loss of radial height)
# Is there involvement of the radiocarpal or distal radioulnar joint?
# Is there discontinuity of the articular surface or diastasis (separation) of the articular fragments?
# Are high-risk features present (severe comminution, articular step-off >2 mm, fracture-dislocation)?


# PA
==Clinical Features==
## Radial inclination (angle between line perpendicular to long axis of radius and line between radial styloid and ulnar corner of lunate fossa)
[[File:Dinner fork Deformity.jpg|thumb|Classic "dinner fork" deformity.]]
### Normal = 15-25 degrees
[[File:Distalradiusfracture.jpg|thumb|Distal radius fracture demonstrating the deformity in the wrist.]]
#### Often smaller with fx
*Commonly from a fall on an outstretched wrist that is dorsiflexed
## Radial height (Distance between distal tip of radial styloid and articular surface of the radius)
*Wrist/forearm trauma and pain
### Normal ~ 10-17mm
*Possible forearm deformity
#### Often smaller with comminuted or impacted fx 
 
## Ulnar variance (Distance between ulnar-side articular surface of radius and the ulnar carpal surface)
===Exam Pearls===
### Normally 1-2mm
*Perform full neurovascular assessment of the hand (including median, ulnar, and radial nerves
# Lateral
*Examine ipsilateral elbow, shoulder, and hand
## Palmar Tilt (angle between line perpendicular to long axis of radial shaft and line through the apices of the palmar and dorsal rims of the radius
 
###  Normally 10o-25o
==Differential Diagnosis==
#### Often smaller with fx
{{Forarm fracture DDX}}
# Oblique
 
# May reveal intra-articular involvement not seen on other views
==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
 
===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:
*#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
 
===Splinting<ref>Olive View Medical Center Upper Arm Extremity Splint Recommendations 2022</ref>===
*Reduction performed
**[[Sugar tong splint]]
*Reduction not attempted or failed
**[[Volar short arm splint]]
***If severe pain with pronation/supination, then [[sugar tong splint]]


==Fracture Types==
# Colles' Fx
## Dorsal displacement of the distal radius fragment
# Smith's Fx
## Palmar displacement of distal radius fragment
# Hutchinson's Fx
## Radial styloid avulsion +/- lunate or scapholunate dissocation
# Galeazzi Fx
## Radial shaft Fx + dislocation of the distal radioulnar joint (ulna positive variance)
# Barton's Fx-dislocation
## Palmar Barton's
### Radial avulsion + palmar displacement of radiocarpal unit
## Dorsal Barton's
### Radial avulsion + dorsal displacement of radiocarpal unit
==Treatment==
# Immediate reduction only required for neurovascular invovlement
# Nondisplaced extra-articular fx
## Relatively stable
## Sugar tong, reverse sugar tong, or double sugar tong splint
### Elbow flexed to 90o, arm in neutral position
# Displaced fx
## Splint, arrange next-day f/u; reduction by experienced clinician is appropriate, but not required
### Adequate reduction:
#### No dorsal tilt of the distal radial articular surface
#### Less than 5 mm of radial shortening
#### Less than 2 mm of displacement of fracture fragments
==Disposition==
==Disposition==
# Refer all of the following:
*Most can be treated with orthopedic follow up within 1 week
## Palmarly displaced fx
 
## Articular step-off >2mm
===Admit===
## Large ulnar styloid fx with displaced fragments at the styloid base
*[[Open fracture]]
## Fracture dislocations
*Neuro-vascular compromise
## Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries
*Risk or concern for [[compartment syndrome]]
## Fractures with significant displacement or comminution
*Patient is unable to function at home (e.g. uses walker with that arm)
# Unstable fx
 
## Greater than 20 degrees of dorsal angulation
==See Also==
## Fracture displacement in any direction greater than two-thirds the width of the radial shaft
*[[Forearm fractures]]
## Metaphyseal comminution with more than 5 mm of radial shortening
 
## Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm
==External Links==
## Intraarticular component (especially involving the DRUJ)
*https://www.orthobullets.com/trauma/1027/distal-radius-fractures
 
==Source==
==References==
UpToDate
<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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