Distal radius fractures

Distal radius fracture is a common fracture of the arm, occurring most frequently in individuals 10–30 years of age and in those older than 65. The injury can be caused by low-energy trauma (common in women with osteoporosis) or high-energy trauma (e.g., sports injuries or motor vehicle accidents). Clinical features include wrist pain and tenderness, soft tissue swelling, visible deformity, and decreased range of motion at the wrist joint. Diagnosis is confirmed by x-ray. Nondisplaced stable fractures are typically managed with closed reduction and immobilization. Fractures that are open, unstable, comminuted, and/or accompanied by neurovascular injury are usually managed surgically.

• Total incidence: 2.5% of all emergency department (ED) visits ^[1]
• Bimodal peak incidence ^[1]
  • 10–30 years of age; most commonly due to high-energy trauma in male individuals
  • > 65 years of age; most commonly due to low-energy trauma in women with osteoporosis

Distal radius fractures are the second most common type of fracture in older adults presenting to the ED. ^[2]

Epidemiological data refers to the US, unless otherwise specified.

• Mechanism of injury ^[2][3]
  • Fall onto an outstretched hand (most common)
    • Dorsiflexed wrist (a typical protective action used to break one's fall) → extension fracture (Colles fracture)
    • Palmar-flexed wrist → flexion fracture (Smith fracture)
  • High-energy trauma, e.g., MVC, contact sports
• Risk factors
  • Osteoporosis
  • See “Etiology of fractures.”

This section lists common types of distal radial fractures and their mechanisms of injury. See “Fracture classification” for general principles of fracture description. ^[4]

• Colles fracture
  • Result of a fall on an extended wrist
  • The distal fragment is usually radially angulated and dorsally displaced.
  • Intraarticular extension is possible.
• Smith fracture
  • Result of a fall onto a flexed wrist or direct injury to the back of the wrist
  • The distal fragment is volarly angulated and volarly displaced.
  • Intraarticular extension, neurovascular compromise, and/or instability are more likely than in Colles fractures.
• Barton fracture
  • Result of a fall on an extended wrist.
  • Intraarticular fracture and dislocation
  • The radiocarpal segment is avulsed and dorsally displaced.
• Reverse Barton fracture
  • Result of a fall on a flexed wrist
  • An intraarticular fracture and dislocation
  • The radiocarpal segment is avulsed and volarly displaced.
• Hutchinson fracture (Chauffeur fracture)
  • Result of a direct blow to the radial portion of the wrist
  • The radial styloid is intraarticularly avulsed.
• Die-punch fracture ^[5]
  • Result of an axial or transverse load through the lunate into the radius
  • Intraarticular depression fracture of the lunate fossa of the distal radius

• Pain, tenderness, and soft tissue swelling
• Reduced range of motion at the wrist joint
• Wrist deformities based on the type of fracture
  • Colles fracture: dorsally displaced and dorsally angulated fracture (bayonet or dinner fork deformity)
  • Smith fracture: garden spade deformity
• See “Fracture signs.”

Clinical evaluation ^[3]

• Neurovascular exam
  • Assess radial and ulnar artery pulses and capillary refill time.
  • Evaluate for median nerve injury , radial nerve injury , and ulnar nerve injury. ^[3]
  • Repeat the exam after reduction and again after immobilization.
• Skin exam: Evaluate for laceration, tearing, and tenting.

Repeat the neurovascular exam after reduction and again after immobilization of the radial fracture. ^[4]

Imaging ^[3][6][7]

• X-ray: anterior-posterior, lateral, and oblique views of the wrist (including the carpal bones)
  • Assess angulation, rotational deformity, shortening, joint alignment, and comminution.
  • Radial inclination: Inclination ≥ 10–15° indicates acceptable fracture reduction. ^[2][6]
    • Normal range: 15–25° ^[8]
    • On posterior-anterior view, measure the angle between:
      • A line from the radial styloid to the ulnar border of distal radius
      • A line across the articular surface perpendicular to the long axis of the radius
  • Volar inclination: Inclination > 20° indicates a potentially unstable fracture. ^[6]
    • Normal range: 10–25° ^[8]
    • On lateral view, measure the angle between:
      • A line along the dorsal to palmar articular surface of radius
      • A line across the articular surface perpendicular to the long axis of the radius
  • See “Radiographic signs of a fracture.”
• CT wrist: may be required for preoperative planning ^[2][3]

Obtain a second set of x-rays after reduction and immobilization of the fracture.

See also “Types of distal radius fractures.”

• Ligamentous injury
• Triangular fibrocartilage complex sprain
• Galeazzi fracture: associated with DRUJ instability
• Ulnar styloid fracture
• Carpal bone fractures, e.g., scaphoid fracture ,lunate fracture
• Carpal bone subluxation and/or dislocation
  • Lunate dislocation
  • Perilunate dislocation
  • Dorsal intercalated segment instability (DISI)
  • Volar intercalated segment instability (VISI)
• See also “Overview of radius and ulna fractures.”

The differential diagnoses listed here are not exhaustive.

Overview ^[2][9][10]

Nonoperative management ^[2][3][4]

Nondisplaced and stable fractures are typically managed with closed reduction and immobilization. ^[2]

• Closed reduction while applying longitudinal traction through the fingers either manually or using a finger trap
• Initial immobilization in sugar tong splint
• Short arm cast when edema resolves
• Postreduction x-rays and serial exams to evaluate for subsequent displacement
• Cast removal after 6 weeks
• See also “Conservative management of fractures.”

The radius should be realigned to its normal position after fracture reduction.

Operative management ^[2][3]

Indications ^[4][9]

Operative fixation in patients ≥ 65 years of age does not improve long-term functional outcomes. ^[9][10]

• Open, significantly displaced, intraarticular, and/or unstable fractures
• Neurovascular injury
• Any of the following post-reduction radiographic signs of instability:
  • > 3 mm radial shortening
  • ≥ 10° dorsal tilt
  • Intraarticular step-off > 2 mm
• Concurrent ulnar fracture
• Fracture-dislocation

Common techniques

All procedures require postoperative immobilization of the forearm and wrist.

• Open reduction internal fixation: Fixed-angle volar plates are used for displaced, unstable, and/or involve osteoporotic bone.
• K-wire fixation: typically limited to patients with minimal fracture comminution and healthy bone
• External fixation: typically used in patients with severe soft tissue injury and/or polytrauma

• General complications of fractures
• Traumatic acute carpal tunnel syndrome ^[2][3]
• Tendinopathy (e.g., extensor pollicis longus) ^[13]

We list the most important complications. The selection is not exhaustive.