Distal radius fractures in adults

Distal radius fractures are very common. The injury is usually caused by falling on the wrist. Patients usually refer to this type of injury simply as "wrist fracture."

Glossary

The radius is one of the 2 forearm bones that span the distance from the elbow to the wrist. The distal radius is the part of the radius just above the wrist.

Treatment recommendations depend on fracture pattern, patient preferences, as well on surgeon's expertise, biases, etc.

Fracture pattern

Distal radius fractures differ from each other based on

  1. Amount of comminution
  2. The extent of initial displacement and instability
  3. Intraarticular involvement
  4. Bone quality
  5. Extent of involvement of the DRUJ (distal radioulnar joint)

Patient's preferences

Which treatment option is chosen depends on the preferences of both the patient and the treating surgeon.

Large amounts of fracture displacement can be tolerated very well by patients with lower functional demands.

Surgeon's preferences

The same fracture can be treated successfully with different surgical methods. The options include:

  1. Casting
  2. External fixation with percutaneous pins
  3. Application of a spanning external fixator
  4. Open reduction internal fixation with plate + screws

What I am saying is this: among orthopedic surgeons there is no consensus regarding the best treatment method.

In my practice, I follow the 2009 AAOS guidelines. I recommend surgical treatment for distal radius closed fractures with

  1. Radial shortening of 4mm or more
  2. Dorsal tilt of 10 degrees or more
  3. 2 mm of displacement for intraarticular fractures

How is this surgery done?

It depends on the exact treatment chosen. Percutaneous pinning, without an incision, can be sufficient in simpler fracture patterns.

For comminuted fractures, either closed reduction with the application of an external fixator, or formal open reduction with plate+screw fixation are options. Randomized controlled studies have not shown any advantage in outcomes of one method vs the other.

What is a reasonable course of treatment?

For patients who wish to avoid surgery, a reasonable course of treatment is as follows

  1. Closed reduction + casting. This can be done with local or general anesthesia
  2. Follow up xrays every week until the fracture is healed
  3. If the xrays show loss of reduction, surgical treatment can be carried out 2-4 weeks after the injury if necessary.
  4. If this course of "close follow-up" is chosen, the patient must be prepared to go to surgery on short notice.

What are the advantages of surgical treatment?

  1. Typically a cast is not necessary after surgery
  2. Alignment of the fracture is more reliably maintained

Downsides of surgery

  1. Risk of infection is 1% or less, but not zero.
  2. Risk of general anesthesia complications (stroke, heart attack, etc., including death)
  3. Cost
  4. Even with orthopedic hardware, some risk of loss of reduction remains

A couple of examples to illustrate the above points follow.

Case 1: distal radius fracture with acute carpal tunnel syndrome

The decision making in this case was fairly simple.

The fracture was acute, displaced, and the patient had acute deep numbness and severe pain and tingling in the palm of the hand. These symptoms suggested compression of the median nerve from the fracture, so called acute carpal tunnel syndrome.

Here are the xrays:

I recommended surgical treatment strongly.

Median nerve was explored, it was found to be bruised, but otherwise intact.

Fracture was stabilized with the plate I usually use (the old "Hand innovations").

Here is the appearance after surgery:

Splint is applied temporarily for the first week after surgery. Splint is removed, and physical therapy is started within 1 week.

At 2 weeks the wrist is almost pain free and the alignment of the fracture is excellent.

At 6 months the fracture is fully healed, and patient is pain free.

Case 2

The decision to recommend surgery for this injury was straightforward as well.

Here are the injury films:

If you have not noticed it already, in addition to the comminuted distal radius, xrays show a scaphoid fracture as well. This is an ipsilateral distal radius and scaphoid fracture, a potentially devastating wrist injury.

I did the surgery on Saturday morning at Memorial Medical Center, Woodstock, IL, in the early days of my orthopedic career. There were actually two separate incisions: one for the distal radius in front of the wrist, and one in the back of the wrist for the scaphoid.

Inclination, tilt, and length of radius have been restored and the comminution has been "bridged". The scaphoid looks good as well.

At 10 days after surgery, dressings and the temporary plaster splint were all removed. Early motion was started. Here's a picture of the xrays, taken with my cell phone.

This fracture healed uneventfully, the patient fully satisfied.

Here's the xray at 3 months. The patient's range of motion at this time was lacking 5 degrees in flexion only.

Case Study 3

This case illustrates some of dilemmas in the treatment of distal radius fractures.

This was a 52 year old active female who fell on slippery Chicago ice.

I was on call that night, and I carried out closed reduction with hematoma block. As you can see in the following xrays, reduction is excellent.

Based on the fracture pattern, the amount of dorsal comminution, I anticipated loss of reduction, and I offered the option of early surgical treatment to the patient. She declined. Patient then went home from the ER.

Xrays were then repeated 1, and 2 weeks later. Xrays continued to look good 2 weeks after the closed reduction. At 2 weeks, the splint felt loose because the swelling had decreased. A new cast was placed. The following xray is done after cast application at 2 weeks.

Just past the 3 week point, patient called and complained of increasing pain. She was asked to come in the clinic to be seen. Xrays indicated some loss of alignment.

At this point and with this xray appearance, it would not have been unreasonable to "double down," wait a full 6 weeks and see how the patient felt at that time.

We did not wait 6 weeks however.

Anticipating possible further loss of alignment, taking into account her high functional demands, and taking into account the increase in pain as well, we decided to proceed with surgical stabilization.

She underwent surgery with plate and screws at the 5 week point. Postoperative splint was removed and physical therapy was started 2 weeks after surgery.

Fracture was fully healed at 3 months after the initial injury.

This patient did very well ultimately. She was involved in her care and the treatment I provided was technically perfect each time. Nevertheless, every thing we did can be argued.

Take the initial "closed reduction". There are surgeons who would insist that the best thing to do is to not try closed reduction at all, but to set up surgery ASAP. The downside of this strategy is that many more patients will undergo surgery than necessary.

Or the decision to proceed with ORIF: there are plenty of surgeons who would look at the xrays of this patient after closed reduction and insist that surgery was not necessary.

Or take the surgery itself: there is controversy as to whether treatment with plate+screws is better than a spanning external fixator. A spanning external fixator is more easily applied and arguably is a simpler treatment method. So why use plate+screws? (Perhaps because a spanning fixator is more difficult to care for after surgery.)

In summary, the same distal radius fracture can be properly treated with several different methods. Nobody really knows the answer as to what is "the best treatment." In the end, as a surgeon I have to try to find out what is important to the patient, and then come up with a recommendation.

Such is the state of art in the field of distal radius fractures.