Distal Radius Fracture

The distal radius fracture is a relatively common fracture seen in the ED.  Distal radius fractures are often the result of a fall on an outstretched hand (FOOSH).  Pattern of injury is dependent upon the position of the wrist at the time of impact.  Of note, distal radius fractures are the third most common fracture seen in patients with osteoporosis.  Post-menopausal and elderly patients that present with these injuries should have their bone density evaluated and the findings treated appropriately. 

When evaluating injury to the distal radius,  a complete physical exam and evaluation of neurovascular status should be completed.  PA and lateral radiographs should be obtained.  The wrist and elbow should be imaged.  In assesing the distal radius, several radiographic parameters are important.  The first is the radial height, which should be approximately 11mm.  Volar tilt should be approximately 11 degrees.  Lastly, radial inclination should measure approximately 22 degrees.

There are a variety of classification systems for distal radius fractures.  Most commonly, when called from the ED, the consulting physician will describe the injury or use an eponym.

Colles (top left) - This is the most common fracture pattern, with over 90% of distal radius fractures having a dorsal angulation.  These can range from simple non-displaced fractures to intra-articular fractures with disruption of the distal radial-ulnar joint (DRUJ).  This is the fracture pattern seen after FOOSH injury.
Smith (top right) - In this pattern of injury, the angulation is volar.  This injury occurs when the fall occurs onto a flexed wrist.
Barton (bottom left) - Fracture of the dital radius and dislocation of the radial-carpus articulation.
Chaffeur (bottom right) - Fracture of the radial styloid process.  These injuries are sometimes associated with disruptions of the carpal bone articulations.

 

 

Displaced fractures should undergo closed reduction in the emergency department.  A hematoma block and some IV narcotics can provide adequate anesthesia for the reduction.

Reduction of a Colles Fracture
-Hang the wrist with 5-10 pounds of weight at the elbow for 10-15 minutes.  The allows ligamentotaxis to assit in the reduction and to bring the fracture out to length.
-Extend the wrist while providing logitudinal traction.
-Use a thumb on the dorsal fragment to push and then flex the wrist to reverse the dorsal deformity of the fracture.
-The wrist should then be placed in a well-molded sugar-tong splint.  The wrist should be splinted at neutral.  Avoid over extension or flexion as this may place extra tension on the median nerve.
-Post-reduction radiographs should be obtained to confirm adequate reduction. 
-Neurovascular exam should be completed.

Non-displaced, minimally displaced, and stable fracture patterns can be treated non-operatively in a cast.  Unstable fractures and those that cannot be adequately reduced require operative fixation.  Options include percutaneous pinning, use of an external fixator or open reduction and internal fixation with either a dorsal or volar plate depending on the fracture pattern.

**As usual, information for this post taken from The Handbook of Fractures, 3rd ed.  Images have been borrowed from Dr. Google.