Comminuted Articular Distal Radius Fractures

Importance of the Problem

Comminuted, intraarticular distal radial fractures present a substantial management challenge. Typically, the result of higher energy injuries they can also occur during fractures in osteopenic bone. Although frequently the focus of our efforts is directed at the bony injury, the surgeon must consider associated bon and soft-tissue injuries and their impact on the patients overall clinical picture. While all injuries have the potential for ongoing disability and functional impairment, overall fracture severity of the distal radius has been shown to be correlated with inferior health-related quality of life and radiographic outcomes. During the assessment of these injuries, radiography remains the mainstay of initial management. Radiographic examination alone, however, may inaccurately predict the amount and location of intraarticular pathology and thus additional cross-sectional imaging modalities may provide valuable information to guide management. Computer tomographic (CT) evaluation improves assessment of the articular involvement and provides a more reliable, reproducible assessment of the fracture pattern ( Fig. 1 ).

Once diagnosed treatment goals are to restore the wrist to as near anatomic as possible. Ultimately radiographic parameters for reconstruction focus on :

• Radial tilt between 20 degrees volar and 15 degrees dorsal

• Restoration of radial inclination > 15 degrees

• Minimized radial shortening < 5 mm

• Minimized radiocarpal articular step-off or gap < 2 mm

• Minimized sigmoid notch articular congruency < 2 mm

In the setting of complex articular fracture pattern, a number of approaches and techniques have been described. Regardless of treatment modality, surgical goals remain the restoration of alignment, length, and re-establishing articular congruency. Additionally, the congruity and stability of the articular component of the lunate facet fragment and sigmoid notch generate a stable central column for reconstruction. The lunate facet serves as the central component for force transmission and fulcrum of motion for the wrist. In this role, the re-establishment of stability and alignment of the intermediate column plays a critical role in eventual outcome. Despite a variety of available surgical techniques to aid in the management of these complex intraarticular distal radius fractures, strong evidence to support the superiority of any one technique remains limited, however. Each technique brings with it specific advantages and complications. Despite a lack of scientific consensus, volar plating has become the mainstay of conventional treatment for distal radius fractures. However, highly comminuted articular fractures may present specific challenges for this technique. This is particularly the case when complex articular comminution, and shear patterns are present where higher rates of complications and poorer radiographic outcomes have been reports.

Interestingly, despite evidence to support improved radiological restoration of articular congruency using many of these techniques, inferior functional outcomes regardless of reduction are common in these complex injuries. This finding likely represents the inherent chondral injury present despite radiographic osseous reduction. Further complicating the issue is the lack of clear a relationship between radiographic outcome and functional/clinical outcomes, particularly in the elderly.

Main Question

How are comminuted articular DRF most effectively treated?

Current Opinion

Comminuted intraarticular fractures can be successfully managed with a number of techniques each with specific advantages and disadvantages. While no single technique has documented superiority, an understanding of the merits of each technique allows the surgeon to select the most appropriate strategy for a particular fracture pattern and patient.

Finding the Evidence

• Cochrane Database search: Comminuted intraarticular Distal Radius fracture

• PUBMED: (“Complex intra-articular distal radius” [Mesh] OR “Distal radius articular fracture”)

• Bibliography of eligible articles

• Foreign language articles not written in English were excluded from review

• Nonscientific review manuscripts were excluded

Quality of the Evidence

Level I:

• Metaanalysis/Systematic Reviews: 3

Level II:

• Randomized trials with methodological limitations: 6

Level III:

• Retrospective/Cohort studies: 66

Level IV:

• Consecutive case series/Bio-mechanical studies: 35