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Distal Ulnar Fractures Concomitant With Distal Radius Fractures

Key Points Database studies and case series suggest most ulnar fractures associated with distal radius fracture do not benefit from specific treatment. In particular, there is no advantage to fixation of the ulna if it lines up reasonably after the radius fracture is satisfactorily aligned and stabilized. In the absence of data, and in our opinion, fractures of the ulnar styloid base, head, neck, or shaft…

Acute Distal Radioulnar Joint Instability

Key Points All fractures of the distal radius should be evaluated with a physical exam to test for concurrent instability at the distal radioulnar joint. Radiographs that show excessive radial shortening, widening at the distal radioulnar joint, or a large ulnar styloid fracture should raise suspicion for instability. Most cases of instability can be managed with immobilization of the forearm in the position of stability. Cases…

Diagnosis and Treatment of an Essex-Lopresti Injury

Key Points Essex-Lopresti injuries are frequently missed, therefore every proximal radius fracture requires at least a clinical and radiological examination of the elbow, forearm and wrist. In case of a clinical suspect Essex-Lopresti injury the recommended diagnostic tools to find or rule out an intraosseous membrane (IOM) rupture are either MRI or ultrasound (US). During proximal radius fracture surgery, forearm stability should always be examined by…

Galeazzi Fracture Dislocations

Key Points Recognition of a Galeazzi pattern of injury is essential, as failure to recognize the distal radioulnar joint (DRUJ) injury can lead to permanent impairment. The primary goal of management is to obtain anatomic restoration of the radius and subsequent alignment/stability of the DRUJ. Surgical reduction is indicated except in patients with comorbidities/conditions that preclude surgery. After open reduction and internal fixation of the radius…

Simultaneous Fractures of the Distal Radius and Scaphoid

Key Points Simultaneous distal radius and scaphoid fractures are rare. If diagnosed, rule out or confirm if they are part of a trans-styloid, trans-scaphoid perilunate fracture dislocation (greater arc) with CT or MRI. These injuries are most often caused by high-energy trauma, sometimes as part of polytrauma which will affect how to manage the fractures. There is low-grade evidence that they should be treated, operatively. Panel…

Arthroscopic-Assisted Treatment of Distal Radius Fractures

Key Points Arthroscopic assistance allows direct visualization and correction of the reduction of intraarticular distal articular radius fractures A high percentage of concomitant scapholunate interosseous ligament (SLIL) and triangular fibrocartilage complex (TFCC) lesions are diagnosed with this technique Arthroscopy allows same-stage treatment of SLIL and TFCC injuries after fracture fixation, although its clinical relevance remains debated due to the favorable natural course of the vast majority…

Bone Graft (Substitutes) in Distal Radius Fractures

Key Points The use of bone grafts or bone graft substitutes for treatment of comminuted distal radius fractures is dictated by tradition, training, and personal experience. The use of bone grafts (substitutes) for treatment of comminuted distal radius fractures does not improve outcome in elderly patients. The use of autologous bone graft is characterized by a significant number of complications related to the procedure of harvesting.…

Extra-Articular Distal Radius Fractures With Metaphyseal Comminution

Key Points The mainstay treatment for displaced extra-articular distal radius fractures with limited metaphyseal comminution is closed reduction and plaster immobilization. However, not all patients benefit. Carpal alignment and coronal plane translation are less familiar parameters to surgeons but important reduction criteria for these extra-articular distal radius fractures. Patients aged 18–75 years benefit from early open reduction and volar plate fixation, notably in more comminuted fractures.…

Comminuted Articular Distal Radius Fractures

Key Points A number of treatment strategies exist for successful management of complex intraarticular distal radius fractures including: immobilization, external fixation, open reduction, and volar or fragment-specific plating as well as dorsal bridging plating. No well-controlled, methodologically strong studies have compared all treatment modalities and thus there is a paucity of evidence to support the use of one treatment modality over another. Careful diagnosis, an appropriate…

Volar, Dorsal, and/or Radial Plating

Key Points Volar plating is the workhorse of internal fixation for unstable distal radius fractures (DRFs) Dorsal plate technology has improved, decreasing associated hardware-related complications Combination plating is a viable option for highly unstable fracture patterns Fixation strategy should ultimately be chosen based on fracture pattern and stability Panel 1: Case Scenario A 27-year-old right hand dominant male fell on his outstretched hand and sustained a…

Minimally Invasive Plate Osteosynthesis of Distal Radius Fractures

Key Points The minimally invasive approach of the flexor carpi radialis can be used for volar plate fixation of distal radius fractures. The upsides of this technique are the preservation of the ligamentotaxis to facilitate the reduction of the fracture and the small size of the incision to improve the cosmetic results of the procedure. The incision can always be extended in case of difficulties of…

Predictors of Instability and Secondary Displacement After Conservatively Managed Distal Radius Fractures

Key Points Up to two-thirds of distal radius fractures re-displace after initial reduction or from a minimally displaced position at presentation. Increasing age and the presence of comminution, particularly dorsal, are the most commonly significant predictors of secondary displacement. Other factors proposed to increase displacement risk are female gender, as well as dorsal tilt > 5 degrees, ulnar variance > 0 mm, loss of radial inclination,…

Surgical Versus Conservative Interventions for Displaced Distal Radius Fractures

Key Points Treatment is based on radiographical fracture pattern, bone quality, and functional demand. Evidence suggests that functional recovery may be faster in volar locking plating compared to conservative treatment, whereas there is not enough study of external fixation and percutaneous pinning compared to conservative treatment regarding patient-reported outcome. Evidence suggests that regarding the complication rate, which needed secondary surgery, there is no statistical difference in…

Closed Reduction and Immobilization of Displaced Distal Radius Fractures

Key Points Despite the popularity of surgical treatment, most displaced distal radius fractures (DRFs) are initially managed with closed reduction and immobilization. Radiological outcomes were not significantly different between mechanical reduction using finger-trap traction and manual reduction. Compared to procedural sedation, local anesthesia (hematoma block) is a safe and effective alternative anesthesia for reduction of DRFs, which provides excellent pain relief in adult and pediatric patients.…

Advanced Imaging in Distal Radius Fractures

Key Points CT scan can allow for improved identification of intraarticular fracture fragments in distal radius fractures. Use of CT scan for preoperative planning can allow for improved guidance of fracture fragment fixation intraoperatively. Utilization of CT in association with 3D printing can allow for improvement in the surgical treatment of distal radius malunions. Currently available 3D CT reconstruction technology has significant limitations as it is…

Radiographic Parameters of Distal Radius Fractures

Key Points 1. Radiographs are essential for evaluation and treatment of distal radius fractures. 2. Complete radiographic assessment requires proper technique and all projections necessary to fully evaluate the injury. 3. Interpretation of distal radius fracture radiographs requires more than simple identification of radial inclination, volar tilt, and radial length; routine assessment of several other essential landmarks and parameters is needed to avoid missed pathology and…

Biomechanics of Distal Radius Fractures

Key Points The ideal classification meets three objectives: to describe the lesion, to guide treatment choice, and to predict the functional outcome. An example of such is the Patient Accident Fracture (PAF) classification as it allows an exhaustive analysis that also puts into perspective patient and mechanism of injury characteristics. An altered anatomy of the distal radius leads to biomechanical disorders such as altered load transfer,…

Surgical Anatomy of the Distal Radius

Key Points – The precise knowledge of the evolution of the anatomy of the radius is essential to understand the main points of the treatment decision and the surgical principles. – General anatomy of the distal radius subdivides it in a diaphysis, metaphysis, and epiphysis. Each surface of different shape is covered by a different structure, mostly tendoninous. The angulations of the ulnar and the radial…

Epidemiology of Distal Radius Fractures

Key Points Distal radius fractures primarily affect children, young adults, and the elderly. The incidence of distal radius fractures is increasing worldwide. Understanding the epidemiology of distal radius fractures helps guide treatment. Panel 1: Case Scenario A 65-year-old, right hand dominant female visited the emergency room with a swollen and deformed right wrist after a fall on an outstretched hand when she slipped on a wet…

Principles of Evidence-Based Management of Distal Radius Fractures

Key Points Evidence-based management requires combination of the best evidence with patient values and provider preferences to make treatment decisions. The practice of evidence-based management involves question formulation, acquisition of related literature, appraisal of study quality, and the appropriate application of research findings to individual patients. Evidence-based management does not strictly depend on the results of randomized controlled trials, but more accurately involves the informed and…