Wrist Distal Radius Fracture/A distal radius fracture, commonly known as a wrist fracture, is defined by the involvement of the metaphysis of the distal radius. The fracture may or may not involve the radiocarpal joint, distal radioulnar joint, and/or the distal ulna. This injury is commonly associated with high-energy mechanisms in younger patients and lower energy mechanisms or falls in older patients. The fracture results in acute wrist pain and swelling, and if left untreated, it can result in significant morbidity. Treatment can involve both non-operative and operative management and ultimately depends on multiple factors.

Causes of Wrist Distal Radius Fracture

High-energy injuries may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

Common mechanisms in younger individuals

  • Falls from height
  • Motor vehicle accident
  • Injuries sustained during athletic participation
  • Simple falls from standing height
  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of a broken distal radius.
  • Sports injuries – Many distal radius fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Wrist Distal Radius Fracture

  • Swelling, pain, and stiffness in the wrist
  • Clicking or clunking in the wrist
  • The weakening of grip strength
  • Tenderness directly over the lunate bone
  • Difficulty or pain when turning the hand upward
  • Wrist pain
  • Tenderness directly over the lunate bone
  • Decreased motion or stiffness of the wrist
  • Swelling

Staging/ Classification of Wrist Distal Radius Fracture

Multiple Classification Systems of Distal Radius Fractures

Frykman Classification 

Based on the pattern of intraarticular involvement

  • Extraarticular distal radius fracture
  • 1 + distal ulna fracture
  • Intraarticular distal radius fracture involving radiocarpal joint
  • 3 + distal ulna fracture
  • Intraarticular distal radius fracture involving distal radioulnar joint
  • 5 + distal ulnar fracture
  • Intraarticular distal radius fracture involving radiocarpal and distal radioulnar joint
  • 7 + distal ulna fracture

Fernandez Classification

Based on the mechanism of injury

  • Metaphyseal bending fracture with the inherent problems of loss of volar tilt and radial shortening relative to the ulna
  • Shearing fracture requiring reduction and often buttressing of the articular segment
  • Compression of the articular surface without the characteristic fragmentation; also the potential for significant interosseous ligament injury
  • Avulsion fracture or radiocarpal fracture-dislocation
  • Combined injury with significant soft tissue involvement owing to high-energy injury

Common Eponyms for Distal Radius Fractures

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Colles fracture

  • Low energy, intraarticular and extraarticular distal radius fracture demonstrating dorsal angulation, dorsal displacement, and radial shortening
  • Clinically, described as a “dinner fork” deformity

Smith fracture

  • Low energy, extraarticular distal radius fracture demonstrating volar angulation

Barton fracture

  • Fracture-dislocation or subluxation of the wrist. The dorsal or volar rim of the distal radius gets displaced with the hand and carpus
  • Volar involvement is more common

Chauffeur’s fracture

  • Avulsion fracture of the radial styloid

Die-punch fracture

  • A depressed fracture of the lunate fossa of the articular surface of the distal radius

Diagnosis of Wrist Distal Radius Fracture

History and Physical

Patients will typically present with variable wrist deformity and displacement of the hand relative to the wrist. The wrist usually swells, with ecchymosis, tenderness, and painful range of motion. The mechanism of injury should be investigated to assist in assessing the energy and level of destruction. It is essential to establish the patient’s functional status before the injury as well as occupational demands as these may aid in determining treatment direction. Document co-existing medical conditions that may affect healing such as osteoporosis, diabetes, and/or tobacco use.

The physical examination should include careful attention to the following

  • Condition of the surrounding skin and soft tissue
  • Quality of vascular perfusion and pulses
  • The integrity of nerve function
  • Sensory 2-point discrimination
  • Motor function of intrinsic, thenar, and hypothenar muscles of the hand
  • Careful attention to median nerve function as acute carpal tunnel syndrome can occur up to 20% of the time
  • The integrity of the median nerve requires assessment and documentation

Associated injuries include

  • Ipsilateral elbow
  • Ipsilateral shoulder
  • Distal radial ulnar joint
  • Radial styloid fracture
  • Triangular fibrocartilage complex
  • Scapholunate ligament
  • Lunotriquetral ligament

Magnetic Resonance Imaging –  Diffuse decrease in lunate bone marrow signal on T1-weighted images is a hallmark of the disease. Signal changes on T2-weighted images or short-TI inversion recovery (STIR, which nullifies signal from fat) images vary with progression and extent of osteonecrosis. MRI also assesses the integrity of the articular cartilage.

Radiography – Normal early in the disease. Findings, when present, depend on the morphological stage and include diffuse lunate sclerosis, cystic changes, articular surface collapse, carpal collapse, mid-carpal and/or radio-carpal secondary arthrosis. Coronal fractures may occur in lunates with a type I morphology.

Computed Tomography – Is useful for surgical planning. It is also more sensitive than radiography for detecting subtle subchondral fractures, coronal lunate fractures, fragmentation, carpal instability, and the degree of trabecular disruption. Patients are frequently re-staged after CT imaging.

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Nuclear Scintigraphy – Findings are non-specific. It previously found use as an adjunct for diagnosing early-stage disease. It has fallen out of favor since introducing MRI.

Differential Diagnosis

Radiographs confirm the diagnosis; however, the following must merit consideration:

  • Associated and contributory injuries should always be in the differential
  • Pathologic fracture
  • Associated injuries to the carpus

Treatment of Wrist Distal Radius Fracture

Nonoperative management

Fractures that are non-displaced and within the distal third of the bone can be managed non-operatively with immobilization in a cast. There is active debate as to whether a long or short arm cast is optimal and whether a thumb spica should be included to immobilize the thumb, but there is no evidence currently to suggest one option is better than the other.

The cast usually needs to remain on for six weeks with repeat radiographs taken at this time to assess for the union. Time to union varies depending on the location of the fracture. The distal-third would be expected to heal within 6-8 weeks, middle-third within 8-12 weeks and proximal third within 12-24 weeks.  The relative increase in time to healing while moving from distal to proximal is secondary to the tenuous blood supply and retrograde arterial flow.

Medication

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Surgical Fixation

Indications for operative management include:

  • Displacement greater than 1mm
  • An intrascaphoid angle greater than 35 degrees (humpback deformity)
  • A radiolunate angle of more than 15 degrees
  • Transcaphoid perilunate dislocation
  • Proximal pole fractures
  • Comminuted fractures
  • Non displaced waist fractures in individuals that need to return quickly to work/sport
  • Nonunion or avascular necrosis

Surgical fixation involves the insertion of a single or multiple screws and can be done percutaneously or via an open procedure. The latter is preferable for non-unions and those fractures that exhibit gross displacement with the former for acute, minimally displaced fractures.

Technique

The positioning of the screw is crucial and should be in the middle third of the central axis of the scaphoid; this provides the most stability, reduces time to union, and improves alignment.

Access to the scaphoid can be via a dorsal or volar approach. The decision is made based on surgeon preference and the location of the fracture. The volar approach uses the interval between flexor carpi radialis and the radial artery and is the optimal approach for waist and distal pole fractures. It has the benefits of allowing exposure of the entire scaphoid and radioscapholunate ligament and is least damaging to the vascular supply. The dorsal approach is preferred for proximal pole fractures but places the vascular supply at greater risk of injury.

Nonunion

Treatment of scaphoid non-union is approachable in a variety of ways. Early on in its course, open reduction and internal fixation with bone grafting can is an option.  Bone graft can be sourced from the distal radius or the iliac crest.

Complications

Median Nerve Neuropathy (Carpal Tunnel Syndrome)

  • Most frequent neurologic complication
  • One percent to 12% of low-energy fractures and up to 30% of high-energy fractures
  • Treat with acute carpal tunnel release in progressive paresthesias, weakness in thumb opposition if symptoms do not respond to closed reduction, and if they last greater than 24 to 48 hours

Extensor Pollicus Longus Tendon Rupture

  • Nondisplaced distal radius fractures have a higher rate of spontaneous rupture of the extensor pollicus longus tendon

Radiocarpal Arthrosis

  • The reported incidence of up to 30%
  • Ninety percent of young adults will develop symptomatic arthrosis if articular step-off is greater than 1 to 2 mm
  • May also be asymptomatic
  • Malunion and nonunion
  • Compartment Syndrome
  • Complex Regional Pain Syndrome

References

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