Medial aspect of right forearm

Left Brachial plexus

Anterior view right distal humerus bone

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Extensor muscles

Flexor muscles

Haversion bone system

• Distal radius fractures a common orthopaedic injury
• The mechanism usually a fall to the outstretch arm
• More common in females

Risk factors:

• Osteoporosis

Presentation:

• Pain
• Swelling
• Deformity

Clinically:

• Bone tenderness

Investigations:

• X-ray
• CT: for intra-articular fracture evaluation and surgical planning
• MRI: useful to evaluate soft tissue injuries that include the carpal ligaments (scapholunate, lunotriquetral or TFCC associated injuries)

Wrist/forearm position while falling producing either a Colles’ fracture or Smith fracture. When there is a partial dorsal or volar fragment extending to the wrist joint in the sagittal plane then the fracture is termed a dorsal or volar Barton fracture respectively.

Wrist/forearm position while falling producing either a Colles’ fracture or Smith fracture. When there is a partial dorsal or volar fragment extending to the wrist joint in the sagittal plane then the fracture is termed a dorsal or volar Barton fracture respectively.

Radial styloid fracture. Assess and exclude potential scapholunate disruption

Non surgical with immobilization in a splint/cast for closed fractures that are:

• Extra-articular
• < 5mm radial shortening
• Dorsal angulation < 5° or within 20° of contralateral side

Surgery:

• For fractures not compliant with conservative criteria
• Unstable fractures including (articular margin), dorsal and volar Bartons’ fractures,/li>
• Comminuted and displaced extra-articular fractures (Smiths’ fracture)
• Associated volar/dorsal comminution
• Associated ulnar fracture
• Articular incongruency > 2mm
• Die-punch fractures
• Open fractures

Options:

• Plate and screw fixation
• External fixator for open fractures, complex intraarticular fractures

Principles of fracture reduction and immobilization in cast/Plaster of Paris (POP).

Avoid extreme wrist flexion and ulnar deviation when positioning and molding a Colles’ fracture in POP, thereby preventing carpal tunnel syndrome (Cotton-Loder Position)

Injury factors:

• More than 5 mm shortening
• Dorsal tilt > 20°
• Articular displacement > 2mm
• Displacement > 2/3 shaft width in any direction
• Dorsal metaphyseal comminution
• Associated Ulnar fracture

Patient Factors:

• Osteoporosis

Plate and screw fixation

Closed distal complex radius fracture with wrist spanning external fixator

Superficial skin anatomy landmarks:

• Proximal: biceps tendon, medial to brachioradialis
• Distal: radial styloid process

Superficial: Brachioradialis & flexor carpi radialis. Radial artery lies deep to brachioradialis in middle forearm and distally between brachioradialis and flexor carpi radialis. Superficial Radial nerve lies under brachioradialis.

Deep dissection: Middle third lateral border of pronator teres. Distal third lies flexor pollicis longus & pronator quadratus. Classic Henry approach is between brachioradialis and radial artery or modified Henry approach between radial artery and flexor carpi radialis. The radial artery is retracted laterally while flexor carpi radialis is retracted medially. With flexor pollicis longus also retracted medially pronator quadratus is exposed.

Anterior (Henry) approach to distal radius shaft. Release Brachioradialis at radius styloid process and make radial incision over pronator quadratus.

Plate & screw fixation radius

Open distal radius complex fracture

Open distal radius fracture with external wrist spanning external fixator with wound vacuum suction dressing

• Open wound debridement and curettage
• Apply vacuum suction dressing after debridement
• Application of external fixator: 2 Doral distal radius pin insertion with 2 pins inserted to the dorsal aspect of 2nd metatarsal

Arm sling

Hand grip exercises with arm in splint

Forearm strength exercise