Fractures of the Distal Radius : a Contemporary Approach

Acta chir belg, 2004, 104, 401-412
Fractures of the Distal Radius : a Contemporary Approach
S. Nijs, P. L. O. Broos
Dpt. of Traumatology, University Hospitals Leuven, Belgium.
Key words. Distal radius ; wrist ; functional anatomy ; fracture ; treatment ; review.
Abstract. The fracture of the distal radius is the most common fracture we treat. Although sometimes stated otherwise,
the outcome of these fractures is not uniformly good regardless the treatment instituted. A thorough understanding of
the anatomy and biomechanics of the wrist is a prerequisite when treating these lesions. The literature proves that there
is a strict relationship between the quality of anatomical reconstruction and the long-term functional outcome. We try
to clarify the complex functional anatomy of this region.
No single treatment is the solution for every type of fracture in every kind of patient. Based on the functional anatomy,
we analyze the actual treatment possibilities and try to develop strategies in the choice of treatment for different fracture types in different patient groups. Treatment aims should be to reconstruct the anatomy as good as possible, to guarantee that there is no loss of reduction and to allow for a functional after treatment as soon as possible.
Introduction
Fractures of the distal radius are the most common fractures we treat. More than a sixth of all fractures we see
at our emergency department are fractures of the distal
radius. Although the frequency of presentation of this
fracture is extremely high, there are little or no evidencebased guidelines for its treatment (19, 30). Of course,
there can be no general treatment advice covering all
fractures, since the polyfragmentary articular fracture
resulting of a high-energy trauma, can by no means be
compared to the extra-articular, hyperextension fracture
of the aged, osteoporotic women.
On the other hand, this lack of overall guidelines may
not lead to therapeutic nihilism based on the almost two
hundred year old, famous statement of Abraham
COLLES (1) : “One consolation only remains, that the
limb will at some remote period again enjoy perfect
freedom in all of its motions and be completely exempt
from pain : the deformity, however, will remain undiminished through life”. Treatment advices that are more
than 200 years old, dating of an era where there was no
roentgen technology, little or no anaesthesia, no plaster
of Paris, no osteosynthesis … have little or no impact on
today’s treatment. When discussing the treatment of distal radius fractures, one is often confronted with this
statement of Abraham COLLES, despite 200 year of medical literature proving the complexity and non-solved
problems in treating distal radius fractures. In no other
fracture, intra-articular malunion and metaphyseal
malalignment is so broadly accepted.
When treating these fractures, the surgeon must have
a thorough knowledge of the anatomy of this region. The
wrist joint is composed of three separate joints : the
radio-carpal, the ulno-carpal and the distal radio-ulnar
joint. A malalignment or dysfunction of one of these
joints inevitably leads to a dysfunction of the wrist as
a whole. Beside the bony cartilaginous anatomy, also
the radio-carpal, ulno-carpal and intercarpal ligaments
and the triangular fibro cartilaginous complex seem
to be of utmost importance. Although the exact role of
the separate anatomical structures and their interactions
is not yet fully clarified, we know that a dysfunction
of these structures can lead to a bad outcome after a
fracture of the distal radius.
Considering the complexity and heterogeneity of the
fracture and considering the importance of the soft tissues, it is clear there is no tailor-made answer to the
question how to treat a fracture of the distal radius. The
surgeon will have “to read” the fracture and soft tissues
and will than have to make up a treatment plan. Not only
anatomical and biomechanical facts should be taken into
account in this plan, but also the specific demands and
needs of the patient should have a place in the plan,
since we are not treating bones but patients. Today’s surgeon needs to master different techniques, conservative
and operative, when treating fractures of the distal
radius. We will try to give some objective tools to differentiate between different types of fracture treatment.
Of course, these tools cannot replace sound surgical
judgment and expertise.
Epidemiology and fracture mechanism
The fracture of the distal radius accounts for 10-25% of
all fractures seen at our emergency department (2).
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Traditionally a bi-modal incidence peak is described. A
first peak is seen in young men related to high-energy
trauma ; a second much more important peak is recorded in the post-menopausal female and is related to lowenergy trauma. A clear relationship to osteoporosis (3)
and repeated falling (4) can be demonstrated. It is typically the middle-aged female patient who -, being less
debilitated than the more elderly - tries to stop her fall
and lands on the outstretched hand. The more debilitated elderly person lacks this defensive response and lands
directly on her/ his hip. This can explain why hip fractures become more frequent than wrist fractures in
females older than seventy-five. Especially in the middle-aged group, postural instability is much more present in the female population as in the male, explaining
the gender difference in prevalence to some account.
Most certainly a wrist fracture can be the signal that postural stability and osteoporotic changes should be investigated and if possible corrected. If not, it can be the start
of a series of osteoporosis-related fractures to the hip,
vertebral column and proximal humerus.
The fracture with dorsal dislocation (Pouteau or
Colles’ fracture) has traditionally been seen as the extension fracture, caused by a fall on the outstretched hand
and the fracture with volar displacement (SmithGoyrand) as the flexion fracture caused by a fall on the
hyperflexed wrist. This view has been challenged by
both STOFFELEN (5) and PECHLANER (6), both proving that
every fracture pattern can be caused by a fall on the outstretched hand with exclusion of the avulsion fracture. In
the female osteoporotic bone in 90% of all cadaver
models resulted in a fracture loco typico, in the male
only in 55% of the models a fracture loco typico could
be realized.
In a prospective one-year study in Bergen (Norway),
a fall while walking was the most common cause of fractures of the distal radius. In this study, fractures of the
distal radius occurred twice as often as fractures of the
proximal humerus in the same population, but persons
sustaining fractures of the distal radius were relatively
more healthy and active than those sustaining a fracture
of the proximal humerus (7).
Classification
There will only be few body regions in which as many
eponymous classification systems exist as for the distal
radius. Many of them are merely of historical interest. A
good classification system should have a low inter- and
intra-observer variance, should be easy to use, should be
easy to compute, should have a prognostic value and
should have direct therapeutic consequences. Many of
the proposed systems tend to have these advantages, but
mostly the inter- and intra-observer reproducibility
seems to be a major problem. The AO/ASIF classifica-
S. Nijs and P. L. O. Broos
tion as proposed by MÜLLER (8) seems to combine most
of the required criteria, although this is also controversially discussed. The classification differentiates
between non-articular (A-type), partially articular (Btype) and complete articular (C-type) fractures. The further differentiation is based on comminution and direction of fracture lines. This results in 27 subgroups which
are useful for scientific differentiation. In daily praxis,
the 9 groups are more useful (Fig. 1).
Functional anatomy
Of course, the thorough description of the anatomy of
the distal radius and carpal region is not the scope of this
article. On the other hand, a basic knowledge of the
functional anatomy is a prerequisite for fracture understanding and good treatment.
The articular surface of the distal radius is biconcave
and triangular with the apex of the triangle directed
towards the styloid process, the base represents the sigmoid notch for articulation with the ulnar head. The surface is divided into two facets by a well-defined ridge.
One facet, the fossa lunata articulates with the lunate
bone ; the second, the fossa scaphoidea articulates with
the scaphoid bone.
The volar surface of the distal radius is relatively flat.
It is covered proximally by the pronator quadratus muscle. The flexor tendons and the median nerve lay more
superficially. The dorsal surface is convex. Between the
second and the third extensor compartment there is a
bony ridge, Lister’s tubercle. The extensor tendons are
only separated from the bony surface by the floor of the
extensor retinaculum and the periostium. These anatomic relations between the six extensor compartments, the
retinaculum extensorum and the dorsal radial cortex are
of extreme importance for the dorsal surgical approaches to the distal radius. The direct articulation between
the distal ulna and the carpus is less important. It is covered by a complex cartilaginous structure, the triangular
fibro cartilaginous complex (TFCC). It is the development of this TFCC combined with the lack of a true
ulno-carpal joint that differentiates the hand of the
human of that of lower primates and gives the human
wrist its extreme freedom of movement. On the other
hand, the TFCC is a structure that is very sensible to
trauma and degeneration and can be a source of ulnar
wrist pain that is difficult to treat.
The distal radio-ulnar joint (DRUJ) is of equal importance as the radio-carpal joint. It is composed of the
fixed ulnar head and the sigmoid notch. This sigmoid
notch not only rotates around the ulnar head, but it
makes at the same time a translational movement. In
pronation, the ulnar head moves dorsally in the sigmoid
notch ; in supination it is displaced anteriorly. The
most important stabilizer of the DRUJ is the TFCC,
Distal Radius Fractures
403
Fig. 1
The AO classification
additional stabilizers are the interosseous membrane of
the forearm, pronator quadratus muscle and the tendons
and sheets of the extensor and flexor carpi ulnaris muscles. As the interaction of all of these structures is of the
utmost importance for stability and motion, deformity
after injury or fracture has an important influence on the
function of the entire wrist.
The bony architecture of the distal radius can be
viewed in terms of columns. RIKLI and REGAZZONI (7)
divided the distal forearm in three columns : the medial
column consisting of the ulna, the TFCC and the DRUJ
; the intermediate column made up of the fossa lunata
and the sigmoid notch and the lateral column including
the fossa scaphoida and the styloid process. Fracture
lines often run between these columns. The intermediate
column can also be split in a sagittal plane, creating the
dorsal and the volar intermediate fragment. The surgical
reconstruction of the distal radius should be based on the
knowledge of these columns. Almost 80% of the transmitted forces go over the distal radius by longitudinal
loading of the wrist, if radius and ulna are equally long
(ulna neutral). Lengthening of the ulna shifts force transmitting in the direction of the ulna, whereas ulnar shortening shifts forces towards the radius.
Radiological anatomy
Besides the knowledge of the bony and ligamentous
architecture of the distal radius, the surgeon treating
fractures of the distal radius needs to have a thorough
knowledge of the radiological anatomy of the wrist. One
considers the ulnar inclination, the palmar inclination,
the radial length, the ulnar variance and the radial width.
Ulnar inclination (Fig. 2) is defined as the angle between
a line perpendicular to the long axis of the radius and a
line drawn from the tip of the radial styloid process to
the ulnar corner of the articular surface of the distal
radius. The mean ulnar inclination is 22-23°. There is
however a strong interindividual variability and strong
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S. Nijs and P. L. O. Broos
Fig. 2
Ulnar inclination
influence of choice of anatomical landmarks and positioning (pro-supination).
Palmar inclination (Fig. 3) is defined as the angle
between a line connecting the most distal point of the
dorsal and palmar cortical rims and a line perpendicular
to the longitudinal axis of the radius. The angle is on
average 10-12°, but again an interindividual variability
of 4-22° among normal individuals is observed.
Radial height (Fig. 4) is measured on an AP-radiograph. It is the distance between two lines perpendicular to the long axis of the distal radius ; the first one
going through the tip of the styloid process, the second
one at the level of the articular surface of the ulnar head.
The distance between a line parallel to the fossa lunata and a line parallel to the ulnar head is considered to be
the ulnar variance (Fig. 5). This should be compared
with the uninjured side as again interindividual variance
is large (ulna – 2mm to + 2 mm). In case of a fracture,
Fig. 3
Volar tilt
the ulna is mostly in a relatively positive variation due to
the shortening of the radius.
Radial width (Fig. 6) is defined as the distance
between two lines parallel to the longitudinal axis, one
going through the most lateral tip of the styloid process
and one going through the centre of the radius on an APradiograph. An increased radial width as compared with
the non-injured side is a strong indication for rotational
malalignment and as such a predictor of bad functional
outcome.
Additional radiological investigations can be of
value. The true comminution at the articular surface and
the dislocation of intra-articular fragments can better be
Distal Radius Fractures
405
Fig. 4
Radial height
Fig. 5
Ulnar varience
judged on computed tomography. Of course, this should
not be part of the routine investigations for distal radius
fractures. Arthrography or computed tomography with
intra-articular contrast can be of value to detect associated lesions of the intrinsic carpal ligaments and/or the
TFCC. Theoretically, MRI seems to have the same
potential, but its feasibility and accuracy in the acute setting still has to be proven by well documented series, as
some of the published early experiences show a rather
low sensitivity and specificity (8). After stable fixation,
cinematography can be used intra-operatively to demonstrate ligamenteous instabilities at the wrist (9).
soon as possible. Socio-economic goals should be taken
into consideration too (a discussion falling out of the
scope of this article) at the lowest possible price. When
considering these goals, it must be clear that no single
therapy can be offered for all fracture types and that
patient specific criteria (biological age, degree of osteoporosis, pre-existing limitations, etc.) are often more
indicating what therapy should be offered than pure
anatomical considerations.
In case of intra-articular fractures (i.e. when the
radio-carpal joint is involved), the work of Jupiter
demonstrates that anatomical reconstruction is of utmost
importance to obtain good functional results (10).
According to this study, an intra-articular step of more
than 2 mm inevitably leads to osteoarthritis and a functional deficit. Many authors agreed to this statement,
some even stated that an intra-articular step of 1mm is
unacceptable. Beside the anatomical reconstruction,
Treatment goals
As for all fractures, the goal of the treatment should be
to restore function of the affected wrist at the best, to
limit pain as much as possible and to reach this goal as
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S. Nijs and P. L. O. Broos
vage procedures such as the Sauvé-Kapandji or Darrach
procedure necessary. These can often bring pain relief,
but limit power and range of motion.
Malalignment at the metaphyseal area leads to a
changed load distribution at the wrist joint as demonstrated by TALEISNIK and WATSON (15). FERNANDEZ
demonstrated that this leads to a loss of motion and the
development of osteo-arthritis at the wrist joint (14).
Here corrective measures, even in the older non debilitated patient, can bring a gain of function and a reduction of pain (16). Radial shortening, often seen after
fractures of the distal radius, leads to a radio-ulnar
incongruence (17), subluxation of the ulnar head at the
DURJ and painful impingement of the TFCC (14). The
amount of metaphyseal comminution is related to the
shortening and the tendency to loose radial length, even
after adequate reduction. As such BATRA (18) calls the
radial shortening the most important factor to determine
the outcome after fractures of the distal radius.
One could summarize the above-criteria stating that
anatomical reduction of both the metaphyseal area and
the radio-carpal and distal radio-ulnar joint are essential
to obtain good functional results. This is stressed by
many studies proving the good correlation between radiological and functional outcome in fractures of the distal radius.
Conservative treatment
Fig. 6
Radial width
timely diagnosis and treatment of associated intra-articular lesions seems to be of importance too. Some series
report associated TFCC-lesions in up to 60%, SLlesions in up to 85% an LT-lesions in 61% of cases (11).
Although conventional radiography, intra-operative cinematography and intra-operative arthrography can help
us to diagnose associated lesions, arthroscopy seems to
be the most sensitive and specific and offers the possibility to treat the diagnosed lesion immediately.
Especially fracture lines going into the direction of the
SL-band seem to be correlated to a very high percentage
of SL-band lesions.
Not only the radio-carpal joint is of importance to the
outcome. As already stated by FRYKMANN in 1967 (12)
and later confirmed by MELONE (13) and FERNANDEZ (14)
among others, incongruence at the distal radio-ulnar
joint leads to a painful and function-limiting arthritis.
This painful condition can be hard to treat, making sal-
Of course, the conservative treatment of fractures of the
distal radius still has its place in our treatment protocol.
It is the treatment of choice for all undisplaced fractures
and all “stable” fractures of the distal radius showing
less than 10° of dorsal angulation, less than 1mm of lateral shift and less than 2 mm of initial shortening.
Articular fractures should have an articular step of less
than 2 mm (1 mm in young patients). When we obtain a
stable, anatomical closed reduction we can treat the fracture non-operatively.
Discussion exists about how to immobilise the wrist
in case of conservative treatment of fractures of the distal radius. “There”, and I cite the Cochrane Database,
“remains insufficient evidence from randomised trials to
determine which methods of conservative treatment are
the most appropriate for the more common types of distal radius fractures in adults. Therefore practitioners
applying conservative management should use an
accepted technique with which they are familiar, and
which is cost-effective from the perspective of their
provider unit. Patient preferences and circumstances,
and the risk of complications should also be considered” (19).
Initially non-displaced fractures can be treated by
immediate mobilisation. One can immobilise for one
week for comfort reasons. Immediate mobilisation does
Distal Radius Fractures
407
Fig. 7
Failed conservative treatment (closed reduction) in a 25-year old female
not result in secondary displacement, but results in an
earlier functional recovery (5).
Earlier severe palmar flexion and ulnar deviation has
been advocated to prevent secondary dislocation after
reduction. This should however never be necessary. This
position not only puts more pressure on the carpal tunnel structures, but it is a non-physiological immobilisation position leading to soft tissue- and vascular complications (22).
Whenever choosing to treat a fracture non-operatively, we have to ensure that no secondary dislocation
occurs. This means that radiological re-evaluations are
necessary on a regular base until sound fracture healing
becomes obvious. (Fig. 7). Whenever secondary displacement occurs, surgical reconstruction in an early
stage yields better results than later reconstruction (20).
A second attempt of closed reduction and cast immobilisation only gives a good or excellent result in one third
of all cases (21).
In the older debilitated patient, a good functional outcome should be judged to other criteria than in the
young patient. Malalignment is often tolerated relatively
well in these patients already having a limited functionality and the development of arthritis seldom becomes
painful before the end of their lives. Closed reduction is
of no use in these patients as redislocation almost always
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occurs despite reduction and immobilisation as clearly
demonstrated by BEUMER et al. (23). In these patients,
the fracture should be immobilised until sound fracture
healing is documented. No further treatment should be
initiated.
Percutaneous pinning
The Cochrane database (30) states that there is no evidence for choosing a particular operative treatment for
unstable fractures of the distal radius. It is difficult to
discuss percutaneous pinning as there are almost as
much pinning techniques, as there are surgeons treating
fractures of the distal radius. The advantages of percutaneous pinning are : K-pins are readily available in most
hospitals of the world, it is a low cost technique, it augments the stability of the reduction (or at least it should)
and it allows, when used as joy-sticks, exact reconstruction of the joint surface and metaphyseal area.
The disadvantages are : the need for an additional
immobilisation (plaster of Paris or external fixation), the
risk of pin-tract infection, the risk of injuring neuro-vascular structures or tendons, the risk of hardware migration and the risk of secondary displacement after pin
removal.
In young patients, percutaneous pinning can be beneficial. The good bone quality often allows for a relatively stable reduction, of which the stability can be augmented by pinning. There is no evidence that proves one
pinning technique to be superior to the other. The use of
Kapandji intrafocal pinning is however limited to relatively simple extra-articular fracture patterns (5). The
functional benefit in these rather simple fracture patterns
also has to be questioned as in a randomised prospective
trial conducted at our institution no benefit in functional
nor in radiographic outcome at one year for Kapandji
pinning as compared to closed reduction could be
demonstrated (24).
Although many authors report favourable outcome
after closed reduction and percutaneous pinning, some
series show disastrous results. Sommer among others
reports a 93.3% secondary fracture dislocation rate after
percutaneous K-wire pining (25). The reason for this
high percentage of secondary displacements, often related to an angulation resembling the initial displacement,
is the comminution of the dorsal metaphyseal cortex.
After reduction an enormous hole is left in this metaphyseal area. This hole can make the reposition, even in
the presence of wire fixation, so instable that reduction
is lost. When the hardware is removed after 6 weeks, this
hole is not yet filled with bone. This allows - in combination with the still elastic callus - for secondary displacement at the volar side. Many groups tried to solve
this problem by augmenting their reduction and pin fixation with a bone substitute. In the younger patient
S. Nijs and P. L. O. Broos
autologous bone grafts are used, in the older patient one
can use homologous grafts or one of the various commercially available bone substitutes or bone cements.
This augments stability and prevents theoretically secondary displacement. Biomechanical analysis shows
that the use of calcium phosphate bone cement alone is
insufficient to withstand physiologic flexion-extension
motion of the wrist without supplemental wire fixation.
When supplemented with K-wires, fixation with bone
cement is more stable than are K-wires alone, but is significantly less stable than a cement augmented external
fixation (26). Of course this augmentation, especially
when autologous bone grafts are used, makes the treatment much more invasive. These augmentive techniques
are also of use in stabilizing articular fragments, by supporting them through filling up the metaphyseal cavity.
External fixation
The use of joint bridging external fixation to treat fractures of the distal radius is widely accepted. It is based
on the principle of ligamentotaxis. By distracting the
joint area, the fragments are reduced by traction on the
capsuloligamentous attachments. Sometimes an additional reduction is achieved by creating a vacuum in the
joint. The latter may explain how successful reduction of
fragments without capsular attachment can be achieved
in some cases. By maintaining the traction throughout
the healing process, the fragments are kept aligned. The
negative effects of the maintained traction can be the
creation of extrinsic extensor tightness and a loss of
radiocarpal and intercarpal motion. Furthermore extensive traction can be associated with an increased risk of
algoneurodystrophy. When excessive traction is needed
to maintain reduction, additional fixation by K-wires
should be used in order to allow for lower distraction
forces. Filling up the metaphyseal defect by autologous
bone grafts or bone substitutes can also add extra stability (Fig. 8).
Furthermore the external fixator can be used as a
device to neutralize forces acting on an unstable
osteosynthesis or in anatomically reduced extra-articular
bending fractures. In case of high-energy fractures with
meta-diaphyseal comminution and/or bone loss, the
fixator can be used to bridge the defect and to act as a
buttress.
Some authors advocate the use of non-joint bridging
fixators to overcome the problem of radio-carpal and
intercarpal loss of motion. The use of these fixators is
limited to extra-articular fractures in which the distal
fragment is large enough to accommodate two pins,
which can be placed transversally. In case of simple
articular fractures, one can first reconstruct the joint
block using pins or screws and fix this reconstructed
block to the diaphyseal fragment using an external
Distal Radius Fractures
409
Fig. 8
Articular fracture treated with external fixator, additional pinning and autologeous bone grafting
fixator. In this kind of construction, the fixator is often
used in a compression mode. In multifragmentary articular fractures or fractures with a very small distal fragment, this approach is not applicable. For those cases
some authors developed a “dynamic external fixator”.
This device allows movement in the radiocarpal joint.
The potential advantages : less stiffness, earlier return of
function, better reconstruction of the articular cartilage
and reduction of digital stiffness could however not be
confirmed by SOMMERKAMP (27) in a prospective randomized study.
Whenever using techniques with transcutaneous
materials, such as K-wires or Schanz screws, meticulous
pin-care is essential to avoid pin-tract infections.
Traction of the pins on the skin is associated with a high
incidence of pin tract-infections and thus should be
avoided by properly placed and large enough skin incisions.
It can be useful in comminuted fractures to use the
external fixator as temporary reduction and fixation tool
to allow for more precise evaluation of the fracture and
the associated soft tissue lesions. Then a more accurate
definitive treatment can be installed.
Arthroscopy
Arthroscopy as such does of course not reduce the fracture or stabilize it. It can however be of value in articular fractures, especially in the younger patient.
Arthroscopy offers the opportunity to control the quality of the articular reduction. Under direct vision, fragments can be manipulated percutaneously or with Kwires as joy-sticks. When perfect articular reduction is
obtained, the K-wires introduced for fragment manipulation can be advanced in adjacent fragments to secure
reduction. If necessary, reduction clamps can be used
percutaneously to obtain interfragmentary compression.
To ascertain the reduction of the articular bloc to the
shaft, supplementary techniques such as pinning, external fixation or plate osteosynthesis have to be used,
depending on the fracture type, the surgeons experience
and the patient’s preferences.
Besides controlling the articular reduction,
arthroscopy allows us to diagnose associated carpal
lesions. Articular fractures of the distal radius are associated with high incidences of SL-band lesion, LT-band
lesions and TFCC ruptures. SL-band lesions are reported with a frequency varying from 20% to 85% (11, 28).
Sagittal fractures of the distal radius and fractures with
avulsion of the styloid process of the distal radius seem
to be associated with a very high incidence of SL band
lesions. Early repair of these lesions, often by simple
reduction and pinning, is related to a better outcome. LTband lesions are much less frequent, but here again ;
early treatment results in a better outcome. TFCC
lesions are reported in 50-60% of articular distal radius
fractures. There still is much controversy about the radial avulsion lesions and their treatment. Ulnar avulsions,
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Fig. 9
Volar plate for dorsally displaced distal radius fracture
that are treated early however seem to have favourable
results (29).
Screw osteosynthesis
In avulsion fractures or sagittal split fractures of the
radial styloid process, a stable osteosynthesis can often
be achieved by using one or two lag screws through the
styloid.
In most cases, the stability of this osteosynthesis is
big enough to allow for immediate mobilisation. If the
fragment is too small, percutaneous pinning can be necessary combined with plaster cast immobilisation.
Plate osteosynthesis
Almost all authors have considered plate osteosynthesis
by as the best solution for volar displaced (Smith) fractures of the distal radius (31). The buttressing effect of
the plate, if necessary augmented with screws in the distal fragments, yields in most cases of A- and B-type fractures in good or excellent results. Of course, the amount
of intra-articular comminution and the consequent quality of articular reduction are predictive for the outcome
in C-type fractures.
Volar plating for dorsally displaced fractures has the
problem that the plate was laying at the opposite site
than the direction of dislocation. The plate can thus not
act as a buttress and the poor quality of bone in this area
does not give much grip for the screws to act as pulling
screws. Often loss of reduction can be witnessed.
Dorsal plating, certainly with 3.5 mm plates was
often complicated with extensor tendon problems. The
S. Nijs and P. L. O. Broos
extensor tendons run directly over the implant and adhesion between the plate and the tendons or even secondary tendon ruptures are often seen (32).
RIKLI and REGAZONNI (7) tried to solve this problem
using smaller implants (2 or 2.4 mm), placed in a dorsal
and lateral fashion based on their three pillar concept.
The smaller size and smooth titan polishing reduce the
risk of tendon irritation, but cannot eliminate it completely. The smaller size and two plate technique make it
also possible to have more screws in the distal fragment,
allowing for reconstruction of complex fractures.
The angular stable plates make it possible to treat
most fractures from the volar side. The screws, which
are locked in the plate, are placed just proximal to the
subchondral bone. (Fig. 9) Here we can almost always
find dense bone. The screws will act as a buttress for this
dense bone and theoretically no secondary loss of reduction is witnessed. The relatively large distance between
the flexor tendons and the plate and the protection of the
pronator quadratus muscle, make flexor tendon problems extremely seldom (33).
We demonstrated the stability of this construction in
an unpublished series of 20 unstable fractures of the distal radius in osteoporotic females over 65 years of age,
in which a volar angular stable 3.5 mm plate osteosynthesis (LCP Mathys medical) has been performed without bone grafting. In this series, we witnessed no significant loss of reduction or loss of radial length (34). The
use of this technique is however limited to A, B and C1type of fractures. The more complex articular C2-and
C3-fractures are not treatable using the 3.5 mm plate
alone, since too little screws can be introduced in the
distal fragment. A possible solution is to reconstruct the
articular block using pins or separate screws and fix this
to the meta-diaphyseal fragment using a 3.5 mm plate.
Recently, a 2.4 mm pre-shaped plate has been introduced which gives the opportunity to introduce 5 screws
in the distal fragment. The pre-shaping of the plate also
makes it possible to fixate small distal fragments.
A dorsal approach using 2.4 mm angular stable dorsally and laterally can be used for comminuted fractures,
which cannot be reconstructed using a volar plate. This
combines the advantages of the Rikli-technique with
these of pre-shaped, angular stable plating. In these fractures, the use of a bone substitute into the metaphyseal
hole is almost always mandatory. This bone substitute
not only serves to prevent secondary dorsal dislocation,
but also helps to reduce the articular fragments and to
hold them in their reduced position.
In some C2-C3 fractures, we combine a dorsal and
volar approach (Fig. 10) to obtain acceptable reconstruction of the distal radius. Angular stable osteosynthesis in whatever form is normally stable enough to
allow for immediate mobilisation, preventing excessive
scarring and joint stiffness.
Distal Radius Fractures
411
Fig. 10
Volar and dorsal plates for distal radius fracture
Conclusion
It will be clear there is no tailor-made solution for all
fractures of the distal radius. It is important to reconstruct the anatomy of the distal radius as good as possible, since anatomical reconstruction is a prerogative for
good functional outcome, especially in the active
patient. Only in the debilitated patient, malalignment
and articular incongruence can be accepted. In these
patients, reduction of the fracture and operative treatment seems to be of no benefit. For all other patients,
anatomical reconstruction of the articular surface and
the metaphyseal area must be the goal of treatment.
The non-displaced fracture can be treated functionally with little or no immobilization. Stable fractures or
fractures that are stable after anatomical reduction are
treated conservatively. All other fractures should be
treated operatively. As prolonged immobilisation leads
to scarring of the soft tissues, stable osteosynthesis
allowing for early movement is the therapy of first
choice. Immobilisation in an non-natural position should
be avoided as it not only leads to stiffness but is also
associated with an high incidence of algoneurodystrophy. Only angular stable plates can give long enough
resistance to the displacing forces acting on the early
callus to prevent secondary displacement in case of a
large (dorsal) metaphyseal defect after reduction. If one
chooses to use an other form of stabilisation, the use of
bone substitutes to fill the defect most seriously should
be considered.
In case of articular fractures, the articular surface
should be reconstructed anatomically. To do so,
arthroscopy can be of use to guarantee the quality of
reduction. Furthermore arthroscopy can help us to diagnose associated carpal lesions in an early phase and to
treat them as needed. Especially in the younger patient
with articular fractures this should be advocated.
The choice of treatment should be based on the
fracture type, the patient’s characteristics, the patient’s
demands and last but not least on the treating surgeon’s
experience and preference. As long as stable reduction
and anatomic reconstruction are guaranteed, many ways
can lead to a successful treatment of fractures of the distal radius.
References
1. COLLES A. On the fracture of the carpal extremity of the radius.
Edinb Med Surg J, 1814, 10 : 182-186.
2. LINDEMANN-SPERFELD L., PILZ F., MARINTSCHEV I., OTTO W. Der distale Speichenbruch. Minimalinvasive Kirschnerdrahtosteosynthese.
Indikation und Ergebnisse. Chirurg, 2003, 74 : 1000-1008.
3. NGUYEN T., SAMBROOK P., KELLY P. et al. Prediction of osteoporotic
fractures by instability and bone density. BMJ, 1993, 307 : 11111115.
4. CRILLY R. G., DELAGUERRIERE-RICHARDSON L. D., ROTH J. H.
Postural instability and Colles’fracture. Age Agening, 1987, 16 :
133-138.
412
5. STOFFELEN D. Fractures of the distal radius : an experimental and
clinical approach. Thesis, Leuven, 1997.
6. KUHN V., PECHLANER S., KETTLER M. et al. Distale Unterarmfracturen in einer Neuen biomechanischen Sturzsimulation. DGUcongress oral presentation, November 2003.
7. RIKLI D. A., REGAZZONI P. Fractures of the distal end of the radius
treated by internal fixation and early function. J Bone Joint Surg
Br, 1996, 78 : 588-592.
8. SCHADEL-HOPFNER M., IWINSKA-ZELDER J., BOHRINGER G. et al.
MRI or arthroscopy in the diagnosis of scapholunate ligament
tears in fractures of the distal radius ? Handchir Mikrochir Plast
Chir, 2001, 33 (4) : 234-238.
9. RAPPOLD G., LEIXNERING M., PEZZEI C. Carpal injuries associated
with distal radius fractures. Diagnosis and therapy. Handchir
Mikrochir Plast Chir, 2001, 33 (4) : 221-228.
10. KNIRK J. L., JUPITER J. B. Intra-articular fractures of the distal end
of the radius in young adults. J Bone Joint Surg Am, 1986, 68 (5) :
647-659.
11. METHA J. A., BAIN G. I., HEPTINSTALL R. J. Anatomical reduction of
intra-articular fractures of the distal radius. An arthroscopicallyassisted approach. J Bone Joint Surg Br, 2000, 82 (1) : 79-86.
12. FRYKMANN G. Fractures of the distal radius including sequellaeshoulder-hand-finger syndrome, disturbance in the distal radioulnar joint and impairment of nerve function.A clinical and experimental study. Acta Orthop Scand, 1967, Suppl 108 : 1-124.
13. MELONE C. P. Jr. Open treatment for displaced articular fractures
of the distal radius. Clin Orthop, 1986, 202 : 103-111.
14. FERNANDEZ D. L. Malunion of the distal radius : current approach
to management. Instr Course Lect, 1993, 42 : 99-113.
15. TALEISNIK J., WATSON H. K. Midcarpal instability caused by malunited fractures of the distal radius. J Hand Surg Am, 1984, 9 (3) :
350-357.
16. JUPITER J. B., RING D., WEITZEL P. P. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years.
J Hand Surg [Am], 2002, 27 (4) : 714-23.
17. TRUMBLE T. E., SCHMITT S. R., VEDDER N. B. Factors affecting
functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am, 1994, 19 (2) : 325-340.
18. BATRA S., GUPTA A. The effect of fracture related factors on the
functional outcome at 1 year in distal radius fractures. Injury,
2002, 33 (6) : 499-502.
19. HANDOLL H. H., MADHOK R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev,
2003, (2) CD000314.
20. JUPITER J. B., RING D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone
Joint Surg Am, 1996, 78 (5) : 739-748.
21. LEUNG F., OZKAN M., CHOW S. P. Conservative treatment of intraarticular fractures of the distal radius-factors affecting functional
outcome. Hand Surg, 2000, 5 (2) : 145-153.
S. Nijs and P. L. O. Broos
22. PETERSON T., DRESING K., SCHMIDT G. Druckmessung im
Karpalkanal bei distaler Radiusfraktur. Unfallchirurg, 1993, 96 :
217-223.
23. BEUMER A., MC QUEEN M. M. Fractures of the distal radius in lowdemand elderly patients : closed reduction of no value in 53 of
60 wrists. Acta Orthop Scand, 2003, 74 (1) : 98-100.
24. STOFFELEN D. V., BROOS P. L. Closed reduction versus Kapandjipinning for extra-articular distal radial fractures. J Hand Surg Br,
1999, 24 (1) : 89-91.
25. SOMMER C., BRENDEBACH L., MEIER R., LUETENEGGER A. Distal
radius fractures-retrospective quality control after conservative
and operative treatment. Swiss Surg 2001, 7 (2) : 68-75.
26. HIGGINS T. F., DODDS S. D., WOLFE S. W. A biomechanical analysis of fixation of intra-articular distal radial fractures with calcium-phosphate bone cement. J Bone Joint Surg Am, 2002, 84 (9) :
1579-1596.
27. SOMMERKAMP G., SEEMAN M., SILLIMAN J. et al. Dynamic external
fixation of unstable fractures of the distal part of the radius. J Bone
Joint Surg Am, 1994, 76 : 1149-1161.
28. SCHADEL-HOPFNER M., BOHRINGER G., JUNGE A. et al. Arthroscopic
diagnosis of concomitant scapholunate ligament injuries in fractures of the distal radius. Handchir Mikrochir Plast Chir, 2001,
33 (4) : 229-233.
29. RUCH D. S., YANG C. C., SMITH B. P. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy, 2003,
19 (5) : 511-516.
30. HANDOLL H. H., MADHOK R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev, 2003,
(3) CD003209.
31. KEATING J. F., COURT-BROWN C. M., MC QUEEN M. M. Internal fixation of volar displaced distal radius fractures. J Bone Joint Surg
Br, 1994, 76 (3) : 401-405.
32. HERRON M., FARAJ A., CRAIGEN M. A. Dorsal plating for displaced
intra-articular fractures of the distal radius. Injury, 2003, 34 (7) :
497-502.
33. SAKHAII M., GROENEWOLD U., KLONZ A., REILMANN H. Ergebnisse
nach palmarer Plattenosteosynthese mit der winkelstabilen Tplatte bei 100 distalen Radiusfrakturen. Eine prospective Studie.
Unfallchirurg, 2003, 106 (4) : 272-280.
34. NIJS S., BROOS P. Oral Communication on AO-LCP Anwender
Symposium, September 2002, Berlin.
Dr. S. Nijs
Dpt. of Traumatology
U.Z. Gasthuisberg
Herestraat 49
B-3000 Leuven
E-mail : [email protected]