Right shoulder and arm, posterior view
Distal Radius Fractures
Upper Limb Anatomy
Medial aspect of right forearm
Left Brachial plexus
Nerves Posterior to Elbow Joint
Posterior view of right elbow
Blood supply around the elbow joint
Blood supply and anastomosis around the right elbow. Anterior view
Elbow joint structural stability structures
Left Arm
Distal Humerus Biomechanics
The triangular structure of distal humerus at elbow joint provides structural strength.
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 Fracture
- 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)
Injury mechanism
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.
Frykman Classification for Distal Radius Fracture
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.
Chauffers’ Fracture
- Radius styloid fracture
- Exclude scapholunate associated injury
Radial styloid fracture. Assess and exclude potential scapholunate disruption
AO classification for Distal Radius Fracture
Acceptable Malunion for Distal Radius Fracture
Management
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
Conservative distal radius fracture management
using cast /Plaster of Paris
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)
Factors associated with instability following closed reduction of distal radius fractures:
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
Surgery
Plate and screw fixation
Closed distal complex radius fracture with wrist spanning external fixator
Surgery Technique
Anterior (Henry approach) to forearm
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.
Surgery technique principles for distal radius ORIF
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 fractures
Open distal radius complex fracture
Open distal radius fracture with external wrist spanning external fixator with wound vacuum suction dressing
Surgical technique
- 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
Post Operative Rehabilitation
- Rigid fixation: arm sling for 7-10 days then elbow range of motion, non-weight bearing
- Suboptimal fixation may require extended splintage
- Strengthening exercises after fracture union
Arm sling
Hand grip exercises with arm in splint
Forearm strength exercise
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
References
- A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
- Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
- A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
- Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
- Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
- Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
- Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
- Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
- A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
- Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
- Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
- Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
