Distal Radial Fracture
Types and Classification
The most important types: [Ref]
| Distal radial fracture type | Mechanism of injury | Description |
|---|---|---|
| Colles’ fracture – most common | FOOSH onto an extended wrist | An extra-articular fracture with dorsal angulation of the distal fragment
This may produce the typical “dinner fork” deformity |
| Smith’s fracture | FOOSH onto a flexed wrist | An extra-articular fracture with volar angulation of the distal fragment
This may produce the typical “garden spade” deformity |
Note: These fracture patterns are named according to the direction of displacement of the distal fragment (i.e. the fracture fragment closer to the hand/fingers)
Other fracture patterns: [Ref]
| Distal radial fracture type | Description |
|---|---|
| Barton fracture | An intra-articular fracture of the distal radius
It can be classified as dorsal Barton or volar Barton, depending on the direction of displacement. |
| Chauffeur’s fracture | An intra-articular fracture of the distal radius involving the radial styloid process |
| Galeazzi fracture-dislocation | A radial shaft fracture + distal radioulnar joint dislocation
Monteggia fracture-dislocation is often mentioned together with Galeazzi, which is a proximal ulnar fracture + proximal radial head dislocation |
Causes and Risk Factors
Distal radius fractures can occur after any trauma to the wrist, but the most common mechanism is fall on outstretched hand (FOOSH) [Ref]
Distal radial fracture has a bimodal age distribution: [Ref]
- 1st peak at <18 y/o
- Usually due to higher-energy trauma, e.g. sports injuries or falls
- More common in males
- 2nd peak at >50 y/o
- Usually due to low-energy trauma, e.g. a simple fall from standing height
- More common in females
- Osteoporosis is an important risk factor
- Distal radial fracture is the 2nd most common fracture in the elderly, after hip fractures
Clinical Features
Patients typically present after a FOOSH with:
- Acute wrist pain (→ reduced wrist movement)
- Reduced grip strength or difficulty using the hand
- Swelling around the wrist / distal radius
- Tenderness over the distal radius
- Bruising around the wrist or forearm
Visible deformities may be seen, such as:
- “Dinner fork” deformity in Colles’ fracture
- “Garden spade” deformity in Smith’s fracture
Visible deformity is not always present or obvious. Therefore, before imaging is performed, it may be difficult to determine the specific type of distal radius fracture clinically.
Investigation and Diagnosis
Clinical assessment should include:
- Assess skin integrity (to check for open fractures)
- Distal neurovascular assessment
- Assess the ulna
- Assess the joints above and below
1st line investigation: X-ray of the wrist (lateral and posteroanterior views)
- Colles’ fracture = extra-articular fracture with dorsal angulation of the distal segment
- Smith’s fracture = extra-articular fracture with volar angulation of the distal segment
Management
Important: If there is any disruption to skin integrity, the fracture should be treated as an open fracture and managed differently.
An open fracture is an orthopaedic emergency due to the high risk of infection. It requires immediate empirical IV antibiotics, urgent orthopaedic assessment, and surgical debridement with fracture stabilisation where indicated.
Initial Management
Perform closed reduction under regional anaesthesia
- The reduction technique depends on the type of radial fracture
- The 3-step disimpaction, traction and manipulation is typically used to reduce Colles’ fracture (see the YouTube link for more information)
Definitive Management
Management of Colles’ fracture (or other dorsally displaced fractures):
- Conservative management should be offered to≥65 y/o if there are no other indications for operative management (see below)
- Conservative management typically involves
- Closed reduction (manipulation), followed by
- Casting the wrist in neutral flexion (usually with a below-elbow cast)
- Mobilisation should begin 4 weeks after the injury
- Rationale: in geriatric patients, operative management does NOT improve long-term patient-reported outcome compared to non-operative management [Ref]
Indications for operative management:
| Universal indications for surgery (regardless of age and type of fracture) | ANY of the following:
|
| Threshold for surgery is lower in non-geriatric patients (<65 y/o) | ANY of the following: [Ref]
|
Choice of surgical management:
- Dorsally displaced fractures (e.g. Colles’ fracture) → K-wire fixation (if there is no fracture of the articular surface of the radial carpal joint, or the displacement can be successfully reduced by closed reduction)
- If closed reduction of the displacement is not possible → open reduction and plate fixation)
- Volarly displaced fractures (e.g. Smith’s fracture) → open reduction and plate fixation
Management in Children (Skeletally Immature)
In children (skeletally immature) with dorsally displaced distal radius fractures (including fractures involving a growth plate) who have undergone manipulation, consider:
- Below-elbow plaster cast, or
- K-wire fixation if the fracture is completely displaced