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Current Concepts in the Treatment of Distal Radial FracturesKyros Ipaktchi, MD; Meryl Livermore, MD; Christopher Lyons, MD; Rodrigo Banegas, MD

Fractures of the distal end of the radius account for

the majority of upper extremity fractures and for up to 15% of all extremity fractures seen in emergency departments.1 Apart from pediatric fractures, one must differentiate high-energy injuries in younger patients from fragility fractures seen in elderly patients.2 Given the topographic

vicinity, high-energy fractures of the distal radius can be as-sociated with concomitant in-juries to adjacent bones, joints, and ligaments (ie, carpal bones and ligaments, distal radioulnar joint, interosseous membrane), as well as neurovascular injury (Figures 1, 2). Patient treatment targets functional reconstruction of the distal forearm, restoring

anatomy and articular congru-ity. Although earlier recommen-dations suggested that outcomes are determined by residual joint incongruities,3 current evidence suggests a multifactorial in-fluence on outcomes, and the literature lacks higher-level evidence.4 In contrast with the pathophysiology of fractures in younger patients, fractures seen in elderly patients are largely based on skeletal fragility and reduced proprioceptive feed-back. Treatment must respect skeletal insufficiency and al-tered daily activity levels (Fig-ure 3).

Surgical treatment for dis-tal radial fractures has seen a significant evolution over the past decade with the advent of locking plate technologies and anatomic and low-profile plate contouring, as well as the use of novel materials. These in-novations have challenged and advanced traditional treatment concepts, including the choice of surgical approach, the use of structural bone grafting, and re-habilitation. Although techno-logical advances offer current surgeons more refined treat-

ment choices, there is a lack of evidence-supported guidance for conservative and surgical treatment of this commonly seen upper extremity fracture.5,6

Surgical anatomy and PathoPhySiology

The carpal surface of the distal radius shows 2 distinct impressions: the scaphoid and lunate facets, which articulate with the correspondingly named carpal bones. Medially, the sig-moid notch (a shallow groove accommodating the ulnar head) forms part of the distal radioul-nar joint. This joint allows rota-tional and translational motion of the forearm during pronosu-pination. It is stabilized by the dorsal and volar radioulnar liga-ments, the joint capsule, the ex-tensor carpi ulnaris, and the tri-angular fibrocartilage complex, which features a meniscoid disk suspended between the sigmoid notch and the ulnar fovea.7 Disruption of the distal radio-ulnar joint commonly leads to unrestrained dorsal translation of the ulnar head in pronation and ulnar-sided pain. Although coronal displacement of distal

The authors are from the Department of Orthopaedic Surgery (KI, ML, RB), Denver Health Medical Center, Denver; and the University of Colorado School of Medicine (CL), Aurora, Colorado.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Kyros Ipaktchi, MD, Department

of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock St, Den-ver, CO 80204 (kyros.ipaktchi@dhha.org).

doi: 10.3928/01477447-20130920-07

Abstract: Distal radial fractures are among the most commonly encountered traumatic fractures of the upper extremity. Initial trauma mechanism, fracture pattern, associated injuries, and patient age influence treatment and outcome. Although stable fractures are commonly treated conservatively, the past decade has seen changes in surgical practice and techniques. Indica-tions for surgery have been extended and refined based on new insight into the pathophysiology of the distal end of the forearm and technological advances in implant design. Despite the fre-quency of this fracture, only limited higher-level evidence exists to guide practitioners in decision making for this injury. This article highlights key concepts in the treatment of distal radial fractures and summarizes current evidence.

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radial fractures can directly af-fect rotatory distal radioulnar joint function, the longitudinal mismatch of nonreduced radial height can lead to pathologic load sharing between the car-pus and the forearm bones and to ulnocarpal impingement.

Trabecular condensations underlying the scaphoid and lu-nate fossa, as well as the thinner cortical structure of the dorsal distal radius, explain typical fragmentation patterns of the distal radius. This fracture dis-tribution forms the basis of the concept of fragment-specific fixation (Figure 4).8 The lu-nate can be seen as the center of radiocarpal rotation and constitutes a keystone in car-pal architecture. The anatomic alignment of the ulnar-sided radius and maintenance of the volar-prominent lunate facet are essential for the maintenance of wrist motion. Fragmentation of the volar ulnar and dorsoulnar corners of the lunate fossa can lead to rotational carpal sublux-ation and must be reduced and retained.9

The thick volar cortex of the distal radius is covered by the pronator quadratus, distal to which lies an exposed bony ridge known as the watershed line, where flexor tendons and the median nerve lie in the di-rect vicinity of bone. Implant-ing hardware at or beyond this region is associated with a higher rate of tendon injuries and must be avoided.10

On the dorsal surface of the radius, the extensor tendons run through 6 compartments in close contact to the thinner cortical bone of the radius. The greater depth of the distal radius

in the sagittal plane at the level of the third extensor compart-ment and the adjacent Lister’s tubercle are important for screw placement; radially or laterally to this plane, the sagittal depth of the bone decreases substan-tially, and shorter screw lengths must be chosen to prevent corti-cal transgression.11,12

radiograPhic anatomyStandard 3-way radiograph-

ic views of the uninjured dis-tal radius demonstrate distinct radiographic features, which are essential for the functional demands of wrist and forearm motion (Figure 5). The normal radioulnar alignment, as seen in standard posteroanterior views of the wrist, features a radial in-clination of 22°, radial length of 9 to 12 mm, and ulnar variance of 0 mm. In lateral joint views, the distal radius shows a volar tilt of approximately 11°.

In proper lateral views, as suggested by overprojection of the pisiform over the distal scaphoid pole, the radio-luno-

capitate axis should appear collinear, without radiocarpal or midcarpal offset and with-out volar or dorsal intercalated

segment instabilities of the lu-nate. The distal radioulnar joint should appear reduced in these views, and the scapholunate an-

Figure 2: Arthroscopic-assisted reduction and fixation of an intra-articular distal radial fracture caused by a compression mechanism with associated central die-punch fragment (A). Joystick guided elevation of depressed fragment (B) and final fixation (C). Intra-articular arthroscopic pre- (D) and postreduction (E) views of the distal radius.

2C

2D

2A 2B

2E

Figure 1: Intraoperative photograph (A) and preoperative lateral (B) and posteroanterior (C) radiographs showing a high-energy, airbag-induced open distal forearm fracture with laceration of the ulnar neurovascular bundle and com-minuted distal radius and ulnar shaft fracture with distal radioulnar joint disruption. Postoperative posteroanterior (D) and lateral (E) radiographs showing a volar distal rim plate fixation of the distal radius and adjunctive K-wires, as well as distal radioulnar joint transfixation and open reduction and internal fixation of the ulna. Microsurgical repair of the ulnar neurovascular bundle was performed.

1E1A 1B 1D1C

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gle should be between 30° and 60°. In posteroanterior views, the carpal rows should align har-moniously without interruption of curvilinear lines placed along the outlines of the proximal and distal rows (Gilula lines), and no diastasis should be found within the proximal row.13

Based on the injury mecha-nism, physicians should ac-tively rule out associated car-pal injuries and request, when indicated, additional forearm and elbow radiographs to rule

out out proximal fractures or associated elbow injuries. Axial translations of the radius, as seen in Essex-Lopresti injuries, can lead to a failure of the in-terosseous membrane and sub-sequent radial head fractures. In selected cases, postreduction computed tomography scans can aid in surgical planning (Figure 4).14

claSSificationFracture classifications aim

to facilitate therapeutic decision

making and standardize treat-ment and, ideally, should help define expected outcomes and serve as a research tool. Clas-sifications differentiate between intra- and extra-articular frac-tures, as well as stable and un-stable patterns. They should include information on distal ra-dioulnar joint injuries and trau-ma mechanism to help appreci-ate possible associated injuries.

Although traditional ep-onyms are still used (eg, Colles’, Smith’s, Barton’s, die-punch,

and Chauffeur’s fracture),15 they may incorrectly describe injury patterns and are not help-ful for treatment and outcome evaluation.

Multiple newer classifica-tions have improved orthope-dists’ understanding of fracture patterns and injury severity. Descriptive classifications, such as the Malone16 and Frykman17 classifications, provide detailed anatomic fracture pattern analy-sis. The well-established AO classification with its subgroups

Figure 4: Illustration (A) and computed tomography scan (B) of typical frag-mentation patterns. The major fragments seen in distal radial fractures are the radial styloid, the central joint fragment, and the volar and dorsoulnar corners, all of which are shown.

4A 4B

Figure 5: Illustrations showing the standard anatomic measurement of radial inclination (RI) and radial height (RH) (A), as well as radial tilt (RT) (B)

5A 5B

Figure 3: Preoperative posteroanterior (A) and lateral (B) radiographic views showing a pending distal radial mal-union with loss of radial height and inclination and increased volar tilt in an active 68-year-old woman with osteopenia due to a fragility fracture with a bending mechanism. Resulting positive ulnar variance and clinical ulnar-sided pain and deformity are shown. The patient requested corrective surgery. Postoperative posteroanterior (C) and lateral (D) radiographs showing a volar plate–instrumented, open-wedge osteotomy with restored anatomic alignment.

3C 3D3A 3B

3E

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may help improve documenta-tion. The injury mechanism–based fracture classification according to Fernandez and Ju-piter assigns fractures to bend-ing, shearing, or compressive force mechanisms.18 This may provide helpful insight into sur-gical planning, which should reverse the traumatic force direction. Although modern classification systems provide the details needed to classify fracture patterns, their low in-ter- and intraobserver reliability limits their daily clinic use.19

treatmentThe management of distal ra-

dial fractures depends on patient factors, fracture patterns, and stability criteria. The presence of associated injuries influences treatment timing and modal-ity. Initial injury radiographs provide important information on the degree of instability and trauma severity and must be compared with postreduction radiographs (Figure 1 shows the significant translation of the carpus and medial perforation of the ulna through the soft tissues).

Often, no injury radiographs are available for highly unstable injuries that were reduced first and then imaged (Figure 6). Standard emergency depart-ment management involves a reduction maneuver under he-matoma block and splinting.

Peripheral neurovascular sta-tus must be documented before proceeding with any manipula-tion. The incidence of acute car-pal tunnel syndrome has been associated with the initial degree of fracture displacement.20 This entity differs from secondary carpal tunnel syndrome seen in

healed fractures irrespective of operative or nonoperative treat-ment.21,22 Nonresolving acute carpal tunnel syndrome after re-duction, as well as clinical sus-picion of a compartment syn-drome in higher-energy injuries, are indications for urgent carpal tunnel release and fasciotomies. Small lacerations on the ulnar border of the wrist need to be searched for, and commonly represent open fractures. Open fractures, fractures with associ-ated neurovascular injuries, and nonreducible associated carpal injuries need urgent or emergent management in the operating room.23

Stability criteria as intro-duced by Lafontaine et al24 can aid in assessing the risk for sec-ondary fracture displacement. These include the degree of ini-tial deformity, dorsal angulation greater than 20°, volar displace-ment, radial shortening, amount of dorsal comminution, intra-articular involvement, associ-ated ulnar fractures, and patient

age. Recent studies have shown that one-third of fractures ini-tially deemed stable went on to displace during conservative treatment.25

Stable, reduced distal radial fractures without articular in-volvement, such as those com-monly seen in the emergency department, are amenable to conservative treatment with initial splinting and cast conver-sion in clinic. The widely used practice of sugar-tong splinting to block both wrist and elbow range of motion has been chal-lenged. A recent study showed similar rates in reduction loss comparing this form of immo-bilization with standard short-arm splinting, which is more accepted by patients.26 The ade-quacy of reduction and the abil-ity to retain the initial reduction, as well as the degree of intra-articular displacement, dictates the need for surgical fixation. Limits of accepted reduction are generally seen critically in younger patients (Table).

Guidelines from the American Academy of Orthopaedic Sur-geons (AAOS) recommend sur-gical fixation if postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10°, or intra-articular displacement or stepoff greater than 2 mm are observed.27

However, evidence shows good outcomes even in dis-placed articular fractures in el-derly patients.6 When assessing surgical indications in elderly patients, levels of activities of daily living, presence of degen-erative changes, and prior wrist pathologies must be accounted for. Although surgical fixation in high-functioning retirees may be appropriate, the presence of preexisting arthritis may limit the expected benefit of surgical fixation for elderly patients.

Unless urgent or emergent surgery is needed, as mentioned above, surgical fixation of distal radial fractures should be per-formed as soon as soft tissue conditions allow or when the

Figure 6: Preoperative posteroanterior (A) and lateral (B) radiographs of a radiocarpal fracture dislocation caused by a shear mechanism taken after a reduction attempt failed to show the extensive capsuloligamentous injury; a radial styloid avulsion and dorsal carpal subluxation are also observed. Intraoperative photograph showing avulsion of the radial styloid and scaphoid fossa with disrupted dorsal capsular attachments (C); the lunate fossa and adjacent ulnar head are also visible. Due to extensive soft tissue injury, minimal instrumentation with combined screw and K-wire fixation was chosen, along with distal radioulnar joint and radiocarpal transfixation. Posteroanterior (D) and lateral (E) radiographs 6 weeks postoperatively showing maintained alignment and a broken distal radioulnar joint K-wire.

6A 6B 6C 6D 6E

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indication for fixation arises, such as in instances of sec-ondary fracture displacement. Weekly radiographic monitor-ing of conservatively treated fractures for the first 3 weeks is recommended per AAOS guidelines.27 Early correction of pending malunions allows for faster rehabilitation and may avoid secondary joint injury.28,29

Surgical techniqueSSurgical fixation techniques

can be divided into closed, min-imally invasive, and open. Frac-ture pattern, soft tissue status, patient factors, and available resources dictate the indication for each method.

Closed Reduction and Fixation Techniques

Closed Reduction and Per-cutaneous Pinning. Percuta-neous wire fixation may be indicated for unstable extra-

articular fractures with dorsal metaphyseal comminution and injuries with noted soft tissue damage.30 This technique is still widely used for intra-articular fractures in low-resource facili-ties around the world.

Various extrafocal tech-niques (eg, Lambotte and De-palma) have been described in which K-wires serve to retain the closed reduction until union is achieved.31 This must be dif-ferentiated from intrafocal tech-niques, as introduced by Ka-pandji,32 in which direct fracture manipulation and reduction are performed by inserting percu-taneous wires into the fracture itself. Closed reduction and per-cutaneous pinning techniques have led to good outcomes when clinically indicated and per-formed with technical expertise.

External Fixation. Indi-cations for external fixation include open or highly com-

minuted fractures and wrist injuries in polytrauma patients. Joint-spanning assemblies are commonly used and rely on ligamentotaxis for reduction. Excessive long-term traction is associated with stiffness and poorer outcomes.33,34 Unilateral constructs spanning only the in-jury side of the wrist can avoid these concerns and may be used for direct fracture reduction us-ing the external fixator pins as a joystick. This form of instru-mentation is suitable for more proximal fractures with an in-tact distal radius rim.35 External fixators can be an adjunct to arthroscopic fracture reduction and serve as a neutralization device with minimal traction.36

Minimally Invasive FixationApart from direct open

visualization, arthroscopy is the only way to gain a direct overview of the joint surface

in surgical fixation of the distal radius.37 This can be of signifi-cant importance when dealing with central joint depressions (Figure 7). Several studies sug-gest improved outcomes given the precision of reduction.36,38 Arthroscopy plays an impor-tant role in searching for and addressing associated injuries seen in distal radial fractures, such as cartilage injuries, loose intra-articular bodies, and liga-ment injuries (Figure 2).

Internal Wrist-spanning Plates. These temporary im-plants are used as internal fix-ators and have shown good results in elderly patients or in selected indications, such as in severely comminuted wrist fractures.39 Using minimally invasive approaches, internal wrist-spanning plates help main-tain distal radial and radiocar-pal alignment until bony union is achieved. They are typically removed after 3 to 4 months.39 Despite the longer immobiliza-tion of the wrist with this static device, mid-term recovery of functional wrist range of motion has been observed.40 These find-ings may be seen as a challenge to the traditional paradigm of fixation and early mobilization and should be kept in mind when considering postoperative immo-bilization of complex injuries.41

Endomedullary Fixed-angle Devices. A recently introduced fixation concept allows the in-troduction of a fixed-angle in-ternal fixation device through a mini-open technique.42 Al-though evidence on outcomes using this technique is still lim-ited, a recent study suggests im-proved 1-year outcomes when compared with casting.43

Figure 7: Arthroscopic detection of occult intra-articular pathologies in distal radial fractures showing a loose osteocar-tilaginous fragment (A), a cartilage defect of the lunate (B), and a scapholunate ligament rupture (C).

7B 7C7A

Table

Limits of Acceptable Reduction in Distal Radial Fractures

Posteroanterior View Lateral View Any View

Radial inclination, .15° Dorsal tilt, ,10° Articular gap, ,2 mm

Ulnar variance, 0 mm Volar tilt, ,20° Articular stepoff, ,1 mm

Radial height, ,2 mm shorter

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Open FixationIn the past 2 decades, the

introduction of locking plate systems and an improved un-derstanding of fracture patterns and associated injuries have changed the practice of fracture fixation in distal radial frac-tures.44 Volar approaches have gained great acceptance and permit standardized fixation for many fracture patterns.

The Henry-type approach using the plane of the flexor carpi radialis is the most com-monly used access point to the volar carpus and stays clear of the median nerve and the ra-dial artery. Medial extensile volar approaches can be used to access lunate facet frag-ments. Dorsal approaches, usually elevating the third and fourth extensor compartments, are indicated when addressing dorsal fragments or irreducible depressions. Current evidence suggests that soft tissue–pro-tecting dissection techniques combined with shorter screw lengths and low-profile plates can limit extensor tendon com-plication rates.45-47

Surgical approaches must be selected individually to address key fragments and restore artic-ular congruity, radiocarpal sta-bility, and alignment as used in fragment-specific fixation.9,48,49

Since their introduction, the use of locking plates for fixation of distal radial fractures has surged in all age groups, especially in elderly patients.2 This may be explained by the initial impression of having a solid technique at the hand offering reliably good reduc-tion and retention capabilities, which was perceived as leading

to improved patient outcomes. Locking technology offers a fixed-angle support to the joint surface and strong retention, even in osteopenic bone (Figure 3). In addition to fracture reten-tion, locked plates can serve as reduction devices and are help-ful in reducing dorsal displace-ment against the shaft fragment.

Earlier locking T-plates were followed by anatomic-shaped plates and variable lock-ing-angle plates, allowing more individualized plate and screw positioning. Current evidence shows good short-term results comparing these implants with other forms of fixation, and complication rates appear to be low.34 Results appear similar when looking at mid-term out-comes comparing volar locking plates with external fixation.34 No comparative long-term re-sults are available given the recent introduction of these im-plants.

Ongoing dynamic develop-ment in plate design provides a steady inflow of new implants on the market, which may chal-lenge comparative long-term studies. Available data show that volar and dorsal tendon injuries are possible using the originally presumed safe volar approach and that fracture re-tention is not warranted using these implants. Success de-pends on the surgeon’s experi-ence and diligent planning.50

comPlicationSAlthough malunions and

associated carpal instabilities combined with stiffness and tendon ruptures rank among the more commonly seen com-plications in conservative treat-

ment, surgical therapy can ex-pose patients to various added risks. Of the many factors in-fluencing potential adverse re-sults, few are preventable, such as a loss of reduction and ten-don injuries due to suboptimal pate and screw positioning.10,51 Proper training can minimize the learning curve when using newer implants. Exact intraop-erative radiographic visualiza-tion of reduction and hardware placement is mandatory.

outcomeSAlthough ample literature

supports good short-term out-comes, higher-level evidence examining the outcomes of surgical fixation in distal radial fractures stresses the impor-tance of age and socioeconomic status.52,53 No evidence supports one surgical technique over the other in younger patients, and no consensus exists regard-ing the best treatment for these fractures in elderly patients.51 The call for prospective, multi-center outcomes studies in dis-tal radial fractures remains the same as it was years ago.

concluSionDistal radial fractures are the

most commonly seen upper-ex-tremity fractures. With the epi-demiologic growth of the el-derly population, a continued increase will be seen in the inci-dence of this fracture. Despite the growing trend of operative treatment in the past decade, no Level I evidence indicates whether operative treatment leads to improved outcomes in elderly patients. The enthusias-tic reception of locking plate systems needs long-term out-

come data to support its exten-sive current use.

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