Fracture of the Distal radius

Orthopedic Surgery

Fracture of the Distal radius
5th Stage Lec. 1

Fracture of the Distal radius

Colle’s fracture
Most common fracture in orthopedic practice.
Usual victim is elderly women (osteoporosis).
It is extraarticular fracture of distal radius.

Mechanism: Fall on the out stretched hand, fracture is at the corticocacellous junction.

Transverse fracture 2.5 cm from radius displaced &tilted dorsally, also displaced radially.

Clinical features:

Typical dinner fork deformity; broad wrist, local tenderness.
painful wrist movement. look for other injury.
Examine for: neurovascular injury- median nerve injury (common)


X-ray:
 PA, Lateral & oblique view
 Transverse fracture; the distal fragment is shifted & tilted dorsally, also shifted radially.
 Sometimes impacted or comminuted.
 Often associated with fracture ulnar styloid.

Treatment

 Undisplaced fracture: plaster slab for 4-6 wks .
 Displaced fracture:
1. Reduction: under G.A, or sedation, dis-impaction by traction on the hand, the wrist in palmar flexion, ulnar deviation, the forearm pronated, digital pressure on the distal fragment toward palmar side to correct the deformity.
Reduction is confirmed by x-ray.
2. Immobilization: below elbow dorsal slab up to metacarpal neck with the wrist fixed in slight palmar flexion& ulnar deviation.

3. After care:

Elevation to watch for swelling (examine the fingers for swelling or cyanosis)
complete pop done once subsided
follow the patient weekly, by x-ray
redispalacement is not uncommon, if it occurs, repeat closed reduction.
if alignment is satisfactory, change the cast after 3 weeks &apply a new cast for further 3 wks.
Encourage shoulder, elbow &finger exercises as early as possible.


4. Surgery: by internal fixation or external fixation in unstable or severely comminuted fracture

Complications:

Early:
1. circulatory embarrassment due to tight plaster.
2. Nerve injury: median nerve compression, carpal tunnel syndrome (rare).
3. Reflex sympathetic dystrophy (sudek atrophy)

Late:

1. Malunion: common
2. Delayed union or nonunion of ulnar styloid
3. Joint stiffness: of wrist & shoulder is common.
4. Tendon rupture: of extensor pollicis longus tendon.

Smith fracture (Reversed Colles)

Uncommon, the distal fragment is displaced anteriorly,
Cause: Fall on the dorsum of the hand

Clinical features: Typical deformity; Garden spade deformity

X-ray: PA, Lateral & oblique
(PA) view: Transverse fracture of the distal radius.
Lateral view: the distal fragment is displaced & tilted volarly.

Treatment:

 Displaced fractures (stable):

1. Reduction: Under G.A, sedation, or L.A traction, supination &extension of the wrist.
2. immobilzation: above elbow POP, forearm supinated & wrist dorsiflexed for 6 weeks.

 Displaced unstable:

1. closed reduction with percutaneous pinning
2. open reduction &fixation by a plate &screws.

Fracture of the distal radius in children

Fall on the outstretched hand with the wrist in extension.
The distal fragment is displaced dorsally,
The fracture is through the distal radial physis or in the metaphysis of one or both bones.
Metaphyseal fracture is often incomplete or green stick.


Clinical features:
pain, swelling of the wrist, sometimes there is typical dinner fork deformity.

X-ray: accurate diagnosis is made on the x-ray appearance:

Physeal fractures (juvenile colle’s): according to Salter –Harris classification usually type 1 or 2. Type 5 is unusual.

2. Metaphyseal fractures:

Appear as buckling of the cortex

Or as angulated greenstick fracture

Or as complete # with displacement 7

Treatment

Physeal fractures:
reduction under G.A, or sedation, immobilized in above elbow cast, with elbow in 90 D flexion, wrist slightly flexed &ulnar deviated.
Cast retained for 4 weeks.

Buckle fracture:
2 Weeks in POP, then 2 weeks of restricted activity.


Greenstick fractures:

closed reduction (easy).
Children < 10 years up to 30D angulation
Children > 10 years up to 15 D angulation is accepted.
Above elbow POP, for 2 weeks, then re x-ray
if re-dis-placement, repeat manipulation.
Cast removed after 6 weeks.


Complete fractures:



 Difficult to reduce especially if the ulna is intact,

Closed reduction done as Colles #, full length cast applied with wrist neutral & forearm supinated. reduction is checked by x-ray, which is repeated after 2 weeks, cast retained for 6 weeks. If # slips, then do closed reduction &percutaneous K wire fixation

Complications:

Early: forearm swelling threatened compartmental syndrome.
Late:
Malunion:
Radio-ulnar discrepancy (physeal fracture, especially type 5)

Radio-carpal fractures:

Fracture radial styloid (chauffer fracture):

forced radial deviation of the wrist after a fall, or when starting handle kick-back.

X-ray: transverse fracture line,

Treatment : closed reduction, wrist held in ulnar deviation by plaster slab, if failed, the fragment is fixed by percutaneous k-wire or screw.

Fracture- subluxation (Barton fracture)

Types: Volar & Dorsal Barton.

A. Volar Barton (anterior marginal fracture):

oblique fracture through the wrist joint, the distal fragment from anterior articular surface, displaced anteriorly carrying the carpus with it.

Treatment : unstable fracture, usually redisplace after closed reduction, so open reduction& internal fixation by small ant. Plate is recommended 9.


B. Dorsal Barton (posterior marginal fracture):

Oblique fracture through distal radius, the fracture line pass through the wrist joint.

Distal fragment from dorsal articular lip, displaced upward &backward carrying the carpus with it.

Treatment :

1. try closed reduction & cast for 6 weeks,
2. IF failed; do closed reduction & percutaneous
pinning, or open reduction and internal fixation by plate & screws.

Comminuted intra articular fractures (young adults)

High energy injury, poor outcome will result unless joint congruity, fracture alignment & length are restored, and movement started early.

Treatment:

1. Reduction seldom possible, fracture is unstable & it is difficult to hold the reduction
2. Try closed reduction &above elbow cast, take serial x-ray for follow-up.
3. If failure: ORIF, or by External fixation(ligamentotaxis)+bone graft .

Complications of radiocarpal fractures

1. Associated injuries to the carpus
2. Re-dis-placement
3. Carpal instability
4. Secondary osteoarthritis