Christopher Doumas and David J. Bozentka
DEFINITION
Distal radius fractures occur at the distal end of the bone, originating in the metaphyseal region and often extending to the radiocarpal and distal radioulnar joints.
Distal radius fractures can be classified as stable or unstable and extra- or intra-articular to assist in treatment decisions.
Fractures may angulate dorsal or volar and may have significant comminution, depending on the energy of the injury and the quality of the bone.
Percutaneous pins or K-wires, typically 0.062 or 0.045 inch, can be used for unstable intra-articular or extra-articular fractures with mild comminution and no osteoporosis.
Percutaneous pins can aid reduction and stabilize the fragments in a minimally invasive manner.
Percutaneous pins can support the subchondral area of the distal radius and maintain the articular reduction in highly comminuted fractures, which is useful in combined fixation methods.
Smooth percutaneous pins may also be placed across the physis to maintain a reduction in children without causing a growth arrest.
Highly comminuted fractures are more difficult to fix rigidly and often require internal and external fixation to maintain alignment during healing.
External fixators can be hinged or static, and may or may not bridge the wrist joint.
ANATOMY
The distal radius consists of three articular surfaces: the scaphoid fossa, the lunate fossa, and the sigmoid notch.
Ligamentotaxis aids in the reduction of intra-articular and comminuted fractures.
Volar ligamentous attachments include the radioscaphocapitate, long radiolunate, and short radiolunate ligaments.
Dorsal ligamentous attachments include the dorsal intercarpal and radiocarpal ligaments.
Dorsal and radial to the second metacarpal lie the first dorsal interosseous muscle and the terminal branches of the radial sensory nerve.
The distal radial sensory nerve branches lie superficial to the distal radius and should be protected during dissection and pin placement.
The radial sensory nerve emerges between the brachioradialis and the extensor carpi radialis longus (ECRL) muscle bellies (FIG 1).
The terminal branches of the lateral antebrachial cutaneous nerve lie superficial to the forearm fascia at the radial wrist.
There is a bare spot of bone between the first and second dorsal compartments in the region of the radial styloid.
The brachioradialis tendon inserts onto the radial styloid adjacent to the first dorsal compartment.
The extensor carpi radialis longus and the extensor carpi radialis brevis lie dorsal to the brachioradialis in the second dorsal compartment.
Lister's tubercle is dorsal, with the extensor pollicis longus (EPL) tendon on its ulnar side, in the third dorsal compartment.
The extensor digitorum communis tendons lie over the dorsal ulnar half of the distal radius in the fourth dorsal compartment.
The extensor digiti minimi lies over the distal radioulnar joint (DRUJ) in the fifth dorsal compartment.
PATHOGENESIS
Distal radius fractures are the most common fractures of the upper extremity in adults, representing about 20% of all fractures seen in the emergency room.17
Mechanism of injury typically is a fall on an outstretched hand with axial loading, but other common histories include motor vehicle accidents or pathologic fractures.
Higher-energy injuries cause increased comminution, angulation, and displacement.
Osteoporosis, tumors, and metabolic bone diseases are risk factors for sustaining pathologic distal radius fractures.
In children, fractures typically occur along the physis due to its relative weakness compared to the surrounding ligaments.
NATURAL HISTORY
Distal radius fractures needing no reduction and those that are stable after reduction typically recover functional range of motion with minimal long-term sequelae.
FIG 1 • Anatomy surrounding the radial sensory nerve branch in the forearm.
Three parameters that affect outcome include articular congruity, angulation, and shortening.16,20
1 to 2 mm of articular surface incongruity of the distal radius can lead to degenerative changes, pain, and stiffness.
Dorsal angulation can lead to decreased range of motion and increased load transfer to the ulna.
Radial shortening can lead to decreased range of motion, pain, and ulnar impaction of the carpus.
PATIENT HISTORY AND PHYSICAL FINDINGS
The history of a fall on an outstretched hand is the most common presentation for a patient with a distal radius fracture.
Motor vehicle or motorcycle accidents and osteoporosis account for most comminuted fractures.
It may be clinically indicated to implement a workup for osteoporosis.
Pain, tenderness, swelling, crepitus, deformity, ecchymosis, and decreased range of motion at the wrist are typical symptoms and warrant radiographic evaluation.
Physical examination should include the following:
Inspection: Evaluate the integrity of the skin, cascade of the digits, direction of displacement, and presence of any swelling.
Identify points of maximal tenderness to differentiate between distal radius injuries and carpal or ligamentous injuries.
Touch or press specific areas of the wrist and hand to differentiate distal intra-articular, DRUJ, and carpal injuries.
Two-point discrimination: Higher than normal (5 mm) results in the form of progressive neurologic deficit may signify an acute carpal tunnel syndrome or ulnar neuropathy.
Passive finger stretch test to assist with diagnosis of compartment syndrome.
EPL tendon function should be evaluated.
EPL assessment: Assess the resting position of the thumb interphalangeal joint and the patient's ability to lift the thumb off of a flat surface to determine the continuity of the EPL tendon.
Palpation of forearm and elbow to assess for concomitant injury proximally.
The DRUJ must be assessed for displacement.
The bony anatomy must be carefully evaluated to avoid missing minimally displaced fractures, which may displace without treatment.
Skin should be assessed to avoid missing an open fracture.
Swelling should be monitored to allow for early diagnosis of compartment syndrome.
Sensory examination should be monitored for progressive changes, which may represent acute carpal tunnel syndrome.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Radiographic evaluation should include posteroanterior (PA), lateral, and oblique views to assess displacement, angulation, comminution, and intra-articular involvement, and allow for radiologic measurements.14,17
Lateral articular (volar) tilt is the angle between the radial shaft and a tangential line parallel to the articular margin as seen on the lateral view (FIG 2A). The normal angle is 11 degrees.
Radial inclination, measured on the PA view (FIG 2B), is the angle between a line perpendicular to the shaft of the radius at the ulnar articular margin and the tangential line along the radial styloid to the ulnar articular margin. The normal angle is 22 degrees.
Ulnar variance, also measured on the PA view (see Fig 2B), is the distance between the radial and ulnar articular surfaces. Ulnar variance is compared to the contralateral side.
Traction radiographs help assess intra-articular involvement, intercarpal ligamentous injury, and potential fracture reduction through ligamentotaxis.
CT scans are useful in fully elucidating the anatomy of the fracture, including impaction, comminution, and size of the fragments.
CT scans often significantly alter the original treatment plan.11
MRI is rarely performed acutely but can diagnose concomitant ligamentous injuries, triangular fibrocartilage complex injuries, and occult carpal fractures.
DIFFERENTIAL DIAGNOSIS
Bony contusion
Radiocarpal dislocation
Scaphoid or other carpal fracture
Perilunate or lunate fracture dislocation
Distal ulna fracture
Wrist ligament or triangular fibrocartilage complex injury
DRUJ injury
NONOPERATIVE MANAGEMENT
Conservative treatment consists of splinting or casting for stable fracture patterns using a three-point mold.
Fractures amenable to nonoperative treatment include fractures that are stable after reduction with minimal metaphyseal comminution, shortening, angulation, and displacement.
FIG 2 • A. Lateral radiograph of the wrist demonstrating volar tilt (black lines). B. PA radiograph demonstrating radial inclination (black lines), ulnar variance (red bracket), and radial height (white bracket).
Evaluation for secondary displacement weekly for 2 to 3 weeks is critical as the swelling subsides.
Unstable patterns will displace if not surgically stabilized.
There is little role for nonoperative treatment in highly comminuted fractures.
The physiologic age, medical comorbidities, and functional level of the patient should be considered in determining the need for surgical treatment.
Early range of motion of the nonimmobilized joints is essential in the nonoperative treatment of all fractures near the wrist to prevent contracture.
The cast or splint must not extend past the metacarpophalangeal joints so as to allow digital motion.
SURGICAL MANAGEMENT
Surgical treatments are indicated to prevent malunion and improve pain control, function, and range of motion.
Surgery is reserved for unstable fractures, including displaced, intra-articular, comminuted, or severely angulated injuries and fractures that displace following attempted closed management.
Percutaneous pinning can assist in obtaining and maintaining reduction of displaced fractures with limited comminution in a minimally invasive manner.
External fixators maintain radius length but cannot always control angulation and displacement; therefore, supplementation with percutaneous pins is typically performed.2
Conversely, external fixators may augment percutaneous pins and plate fixation when extensive comminution is present.
Supplemental external fixation should be considered for fractures with comminution of over 50% of the diameter of the radius on a lateral view.
External fixation may be used as a neutralization device, because the distraction forces decrease soon after fracture reduction.
External fixators also are useful for “damage control orthopaedics” to temporarily stabilize wrist fractures, especially for complex, combined, open injuries.
For nonbridging external fixation, there must be at least 1 cm of volar cortex intact and adequate fragment sizes to allow proper pin placement.
A relative contraindication to pin fixation with or without external fixation is a volar shear injury, which should be reduced and stabilized using a volar plate and screws.
Preoperative Planning
All radiographs should be reviewed before surgery and brought into the operating room.
Analysis of the pattern and presumed stability of the fracture fragments determines whether percutaneous fixation, with or without external fixation, is suitable.
For intra-articular fractures, the specific fragments to be reduced and fixed must be identified preoperatively to avoid incomplete reduction of the joint surface.
The surgeon must be prepared to change his or her management decision intraoperatively if the fracture behavior is different than anticipated. A variety of fixation devices should be available in the operating room.
Positioning
The patient is positioned supine on the operating table with a radiolucent arm board.
A tourniquet is applied near the axilla with the splint still in place (FIG 3).
Fluoroscopy should be used for reduction confirmation and fixation throughout the procedure.
There must be enough range of motion of the shoulder and elbow to allow standard AP, lateral, and oblique images.
FIG 3 • Positioning of patient supine on the hand table with tourniquet in place.
Approach
Various approaches can be used in the application of external fixators and the insertion of percutaneous pins.
Distal external fixator half-pins may be placed directly into the second metacarpal or into other carpal bones (for injuries including the second metacarpal). Wires and half-pins, which are non-bridging fixators, may be placed in the distal radius itself.
Percutaneous pins can be inserted through the radial styloid between the first and second dorsal compartments, through Lister's tubercle, through the interval between the fourth and fifth dorsal compartments, and across the DRUJ (FIG 4).
Caution is taken to avoid skewering tendons and nerves and to avoid penetrating the articular surface.
FIG 4 • Areas for K-wire insertion at the distal radius.
TECHNIQUES
CLOSED REDUCTION OF A DISTAL RADIUS FRACTURE
Closed reduction should be performed before fixation using distraction and palmar translation of the distal radius fragment and carpus.1
Use of a padded bump or towel roll will aid in the reduction (TECH FIG 1).
Overdistraction will cause increased dorsal angulation due to the intact short, stout volar ligaments.1
Excessive palmar flexion of the wrist can restore volar tilt but leads to an increased incidence of stiffness and carpal tunnel syndrome.7
Overdistraction can be assessed by measuring the carpal height index, measuring the radioscaphoid and midcarpal joint spaces, checking full finger flexion into the palm, or evaluating index finger extrinsic extensor tightness.8
TECH FIG 1 • Closed reduction over a towel bump using traction and palmar translation.
KAPANDJI TECHNIQUE FOR PERCUTANEOUS PINNING
Closed reduction is obtained using a bump, and the reduction is confirmed using fluoroscopy.
This technique should be employed in patients younger than 55 years of age with minimal comminution. It should not be used in osteoporotic, elderly patients or those with comminution secondary to a higher loss of reduction. External fixation should be used to supplement pinning in these populations.21
A stab incision is made radially, and a 0.062-inch pin is manually inserted into the fracture site, taking care to protect the sensory nerve branches and the first dorsal compartment tendons (TECH FIG 2A).
The pin is angled distal, levering the bone back into its normal position and restoring the radial inclination (TECH FIG 2B). The pin is advanced through the far cortex using power, acting as a buttress to prevent loss of radial inclination (TECH FIG 2C).
TECH FIG 2 • A. An incision is made over the radial styloid and a K-wire is manually inserted into the fracture site. B. The wire is levered distally to correct the radial inclination. C. The wire is advanced proximally, using power, into cortical bone. D. An incision is made over Lister's tubercle, and a wire is inserted into the fracture site. E,F. The wire is levered distally to correct the dorsal angulation and advanced proximally using power into cortical bone.
A second stab incision is placed dorsally, and a second pin is manually inserted into the fracture (TECH FIG 2D).
The pin is angled distal, levering the bone back into its normal position and restoring the volar tilt (TECH FIG 2E). The pin is advanced through the volar cortex using power, acting as a buttress to prevent loss of volar tilt (TECH FIG 2F).
Using the modified technique, a third pin is placed retrograde using power, starting at the radial styloid and proceeding into the ulnar cortex of the radius proximal to the fracture line.
The pins are buried and cut just below the skin, and the skin is sutured.
Alternatively, the pins may be bent using two needle drivers and left outside the skin.
The pins are then cut and covered with pin caps or antibiotic gauze.
A sterile dressing is applied, followed by a splint.
AUTHOR'S PREFERRED TECHNIQUE FOR PERCUTANEOUS PINNING
Closed reduction is obtained using a bump, and the reduction is confirmed using fluoroscopy (TECH FIG 3A,B).
A small incision is placed over the bare spot on the radial styloid between the first and second dorsal compartments (TECH FIG 3C).
Two 0.062-inch smooth K-wires are placed retrograde from the radial styloid across the reduced fracture, engaging the opposite cortex in a divergent fashion (TECH FIG 3D,E).
A small incision is placed over the interval between the fourth and fifth dorsal compartments.
One or two K-wires are placed retrograde from the dorsal ulnar corner of the distal radius across the reduced fracture, engaging the opposite cortex in a divergent fashion (TECH FIG 3F–H).
The pins are cut just beneath the skin, which is closed with a 5-0 nylon suture.
Alternatively, the pins are bent and cut and left outside the skin (TECH FIG 3I).
A dressing and splint are then applied.
TECH FIG 3 • A,B. PA and lateral views demonstrating reduction of distal radius fracture. C. The incision is made over the radial styloid. D. A pin is inserted retrograde into the radial styloid. E. PA radiograph demonstrating the course of the radial styloid wire. F. Two radial styloid wires and two dorsoulnar wires are in place. (continued)
TECH FIG 3 • (continued) G. PA view showing fixation and the path of the wires. H. Lateral view showing fixation and path of wires. I. Pins are bent, cut, and covered above the skin.
BRIDGING EXTERNAL FIXATOR APPLICATION
Distal Pin Placement
A 3-cm incision is made over the dorsal index metacarpal, exposing the proximal two thirds.
The distal sensory nerve branches are retracted, and the first dorsal interosseous muscle is elevated from the metacarpal to identify the insertion of the ECRL (TECH FIG 4A).
The index metacarpophalangeal joint is flexed to protect the sagittal band and first dorsal interosseous aponeurosis.
The metacarpal drill guide is placed on the radial base of the index metacarpal at the flare of the metaphysis. Partially threaded 3- to 4-mm pins are used, with or without predrilling.
TECH FIG 4 • A. An incision is made over the second metacarpal base, with reflection of the first dorsal interosseous muscle and radial sensory nerve terminal branches. (The thumb is at the top of the photograph.) B.Diagram showing placement of fixator pins in the shaft of the index and the base of the index and long metacarpals. C. Parallel placement of two metacarpal pins.
A long threaded pin is placed through the index and long metacarpal bases, obtaining three cortices of fixation.
Care is taken not to enter the carpometacarpal joint.
The double drill guide is then placed over the first pin, and the distal short threaded pin is placed through both cortices of the index metacarpal shaft (TECH FIG 4B,C).
Fluoroscopy confirms placement and length of the pins.
Proximal Pin Placement and Frame Construction
A 4to 5-cm incision is made over the radial forearm, proximal to the first dorsal compartment musculature, through skin and subcutaneous tissue, avoiding the lateral antebrachial cutaneous nerve branches.
The fascia overlying the interval between the brachioradialis and the ECRL is divided, and the radial sensory nerve is identified and retracted (TECH FIG 5A).
The interval between the ECRL and ECRB also may be used to avoid the radial sensory branch.
The double drill guide is placed onto the diaphysis of the radius between the brachioradialis and the radial wrist extensors or between the ECRL and ECRB (TECH FIG 5B).
Threaded 3- to 4-mm pins are placed, with or without predrilling.
The fracture should be reduced, and the pins placed parallel to the metacarpal pins to facilitate alignment of the fracture.
The proximal pin should be placed bicortically, just distal to the tendon of the pronator teres.
The distal pin is then drilled bicortically through the double drill guide.
Pin placement is confirmed using fluoroscopy.
The incisions are closed using nylon suture, ensuring no tension is on the skin at the pin sites.
Clamps and rods or adjustable fixators may then be applied to the pins to achieve and maintain final reduction (TECH FIG 5C).
Supplementary K-wire fixation is added before or after external fixation (TECH FIG 5D).
TECH FIG 5 • A. Incision over the radial forearm demonstrating the radial sensory nerve branch deep to the fascia. (The hand is to the right.) B. The double drill guide is placed onto the radius. C. Final reduction is maintained by the addition of clamps and rods. D. K-wires are used for supplemental fixation when necessary.
NONBRIDGING EXTERNAL FIXATOR APPLICATION
Fracture reduction can be performed after insertion of the distal pins, allowing direct control of the distal fragment.
The wrist is placed for a lateral fluoroscopic view, and a marker is used to determine the level of incision halfway between the radiocarpal joint and the fracture. A short transverse skin incision is made just proximal to the radiocarpal joint.
A longitudinal incision is then made through the retinaculum on either side of Lister's tubercle, and the EPL is protected.
The first distal pin is drilled using power, parallel to the radiocarpal joint on the lateral view, halfway between the fracture and the joint surface (TECH FIG 6A).
TECH FIG 6 • A. Distal pin placement. B. Final reduction with nonbridged external fixator in place.
The second distal pin is placed between the second and third dorsal compartments, between the radial wrist extensors and the EPL tendon.
This pin should be placed parallel to the first pin in both planes, with the starting point halfway between the radiocarpal joint and the fracture.
The two proximal radius pins are placed using the technique described for placement of a bridging external fixator.
The incisions are closed, after which the clamps are applied but not tightened.
Reduction is achieved by manipulation of the distal pins and clamps.
Pushing the pins in the dorsal/volar plane corrects dorsal tilt.
Adjusting the pin clamp can correct radial inclination.
Reduction is confirmed using fluoroscopy, and the clamps are tightened (TECH FIG 6B).
POSTOPERATIVE CARE
After fixation with percutaneous pins, alone the wrist is immobilized in a short-arm splint to allow for swelling but provide stability. A cast is applied after the swelling goes down.
Isolated radial styloid fractures fixed with pins can be placed in a volar wrist splint.
External fixation devices typically require no additional immobilization, although a volar forearm–based Orthoplast (Johnson & Johnson, Langhorne, PA) splint may be used for support and patient comfort.
The splint or cast is continued for 4 to 8 weeks, until healing occurs and the pins are removed.
K-wires and half pins should be inspected and cleaned regularly using either soap and water or half-strength hydrogen peroxide and water.
Finger, elbow, and shoulder range of motion are begun immediately, and wrist range of motion is begun as the fracture heals.
OUTCOMES
A prospective randomized trial comparing percutaneous pinning and casting versus external fixation with augmentation (eg, pins, screws, bone graft) found no difference in clinical outcomes for fractures with minimal articular displacement.9
In patients over 60 years of age, percutaneous pinning has been shown to provide only marginal radiographic improvement over cast immobilization alone, with no correlation with clinical outcome.4
Ebraheim et al5 reported excellent outcomes for restoration of radiographic parameters and functional outcomes with intrafocal pinning and trans-styloid augmentation.
An evaluation of percutaneous pinning outcomes found the best results for metaphyseal fractures. Good results were found for intra-articular fractures. The worst results were seen in fractures with associated ulnar styloid fractures and fractures in elderly persons.15
A retrospective review of radiographic and clinical outcomes of open reduction internal fixation (volar and dorsal) versus external fixation revealed no significant differences, except that palmar tilt was more effectively restored with dorsal plating.22
A meta-analysis found no evidence for the use of internal fixation over external fixation for unstable distal radius fractures.12
Women over 55 years of age with unstable intra-articular distal radius fractures treated with external fixation have a high rate of secondary displacement but can have acceptable functional outcomes.10
Patients over the age of 55 years have better results with external fixation and pinning than with pinning alone. Younger patients with two or more sides having comminution also have better results with supplemental external fixation.21
Nonbridging external fixation has been shown to maintain volar tilt and carpal alignment better than bridging external fixation while having significantly better function during the first year.13
Nonbridging external fixation was shown to have no clinical advantage in patients over 60 years of age with moderately or severely displaced distal radius fractures.3
A prospective, randomized comparison of bridging versus nonbridging external fixation revealed more complications in the nonbridging fixators and better outcomes in the bridged fixator group.18
A prospective study compared unrepaired ulnar styloid fractures to those without ulnar styloid fractures and found no significant differences in clinical outcome. However, DRUJ instability was not evaluated.19
COMPLICATIONS
Infection (pin tract or deep). Pin tract infections occur in 10% to 30% of patients.8,9
Injury to tendons, vessels, and nerves due to percutaneous technique. Stiffness may result if tendons are inadvertently skewered, and the radial sensory branch can be injured.
Loss of range of motion
Posttraumatic arthritis
Weakness in grip or pinch
Tenosynovitis and tendon rupture
Malunion or nonunion
Compartment syndrome
Carpal tunnel syndrome
Hardware failure
Nonunion (associated with overdistraction with an external fixator)
Complex regional pain syndrome type I (associated with overdistraction with an external fixator)
REFERENCES
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3. Atroshi I, Brogren E, Larsson GU, et al. Wrist-bridging versus nonbridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. Acta Orthop 2006;77:445–453.
4. Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br 2005;87B:837–840.
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