Introduction
The forearm consists of two large bones, the radius and the ulna; the radius is the largest bone, and the ulna is the longest bone. The radius bone lies parallel to the ulna and pivots around it, producing movements. The radioulnar joint is formed by the articulation of the proximal surface of the radius bone with the ulna and the radiocarpal joint, or the wrist joint is formed by the articulation of the distal surface of the radius with the scaphoid and lunate bones.
What Are Distal Radius Fractures?
A fracture or a break in the radius bone close to the wrist is called a distal radius fracture. It is a common fracture of the forearm commonly seen in young individuals due to trauma or falls in elderly women with osteoporosis or low bone density.
What Are the Types of Distal Radius Fractures?
Distal radius fractures are classified based on the fracture pattern and involvement of the radioulnar joint by Frykman as follows:
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Type I: Transverse metaphyseal fracture, which includes Colles’s fracture and Smith’s fracture.
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Type II: Type I with ulnar styloid fracture.
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Type III: Fractures that involve the radiocarpal joint, including Barton’s fracture, reverse Barton’s fracture, and Chauffeur’s fracture.
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Type IV: Type III with ulnar styloid fracture.
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Type V: Transverse fracture, which involves the distal radioulnar joint.
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Type VI: Type V with ulnar styloid fracture.
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Type VII: Comminuted fractures which involve both radiocarpal and radioulnar joints.
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Type VIII: Type VII with ulnar styloid fracture.
What Are the Causes of Distal Radius Fractures?
Some of the causes of distal radius fractures include:
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High energy trauma due to motor accidents and sports injuries.
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Fall on an outstretched hand (FOOSH).
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Low-energy trauma, like a fall from a standing height, is mainly seen in elderly women with osteoporosis.
What Are the Signs and Symptoms of Distal Radius Fractures?
Some of the signs and symptoms of distal radius fractures include:
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Severe sharp pain and swelling in the wrist.
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Bruises and lacerations in case of high-energy trauma.
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Deformity of the wrist or forearm, wherein the wrist presents in an odd way.
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Numbness or loss of sensation.
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Stiffness of the wrist joint.
How Are Distal Radius Fractures Diagnosed?
If the wrist injury is not painful or no visible deformity is seen, an ice pack is applied, and the wrist is kept in an elevated position until a doctor is consulted. If the wrist injury is very painful and associated with numbness, swelling, or a deformity, it is required to seek immediate medical attention and treatment. The doctor takes a medical history, followed by a physical examination to determine the nerve involvement and range of motion. Patients usually present with an episode of injury or fall on an outstretched hand, followed by immediate pain and swelling around the wrist. On examination, it is associated with tenderness and also numbness or loss of sensation in cases of nerve involvement. In cases of loss of sensation, a neurological examination is performed.
Radiological investigations include
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X-Rays: These help to evaluate the number, location, open or closed status, and extent of the fracture. It also shows the presence of displacement, which helps in treatment planning. Anteroposterior and lateral views are advised, and the radial height, radial tilt, and radial inclination are measured on the radiograph. It also determines the involvement of the ulnar styloid fracture and the widening of the radioulnar joint.
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Computed Tomography (CT Scan): It is preferred in complex cases to confirm the diagnosis as it shows a three-dimensional view of the fracture and aids in the evaluation of the joint surface and joint involvement. It helps during surgical planning, fixation, and also during post-surgical evaluation.
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Magnetic Resonance Imaging (MRI): It is a powerful tool preferred in cases of severe fractures to determine the extent of soft tissue damage, like scapholunate ligament, lunotriquetral injuries, or triangular fibrocartilage complex injuries, injuries to the flexor or the extensor tendons, median nerve involvement, etc. It is also helpful in post-surgical assessment in diagnosing malunion or carpal tunnel disease.
How Are Distal Radius Fractures Managed?
Distal radius fractures require immediate care and attention or may result in further complications, which may hamper daily activities and quality of life. The aim of the treatment is to obtain accurate reduction and immobilization to restore normal function. The treatment of distal radius fractures depends on the severity, presence, or absence of displacement.
Non-surgical treatment methods include:
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Closed Reduction And Immobilization: Most fractures without joint extensions, without any displacement, or fractures with minimal displacement are managed conservatively by closed reduction followed by immobilization with a cast. Immobilization helps in limiting injuries to the soft tissues, tendons, and nerves that may be caused by a displaced bony fragment. Frequent monitoring is required to prevent any displacement.
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Percutaneous Pinning: Fractures that do not extend into the joints (extra-articular) are treated by percutaneous pinning of the fracture fragments after anatomical reduction, followed by an application of a plaster cast. It cannot be employed in case of fractures caused by high-energy trauma or injuries with soft tissue involvement.
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External Fixation: It is recommended for open or comminuted fractures, multiple traumas, severe soft injuries, and failed attempts of closed management with the cast. External fixators are used to apply traction, wherein pins, pulleys, and weight application are used to help in the healing process of fractures. Pins are placed inside the bone, mainly in the carpals and radius shaft, that provide the base for the pulley system to apply force and realign the broken ends to promote healing. It effectively counters the muscle force that pulls the fracture fragments into a position of collapse.
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Open Reduction And Internal Fixation: It is often used to treat intra-articular fractures (fractures extending into the joint), shear fractures with displacement of radius and carpal bones (Barton’s fracture), or severely displaced or rotated or impacted fracture fragments. Percutaneous pinning with the help of volar locking plates (VLP) or external fixation is done using Kirschner wires (K- wires) or other external fixators. VLP is often associated with complications due to excessive soft tissue manipulation during surgery.
What Are the Complications of Distal Radius Fractures?
Some of the complications of distal radius fractures include:
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Healing of the bone may occur in an abnormal position (malunion), or healing of the fractured ends may fail to occur (non-union).
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Complex regional pain syndrome is characterized by continuous burning or throbbing pain associated with swelling and joint stiffness.
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Carpal tunnel syndrome is characterized by pressure on the median nerve caused due to trauma, leading to numbness or tingling sensation in the wrist.
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Damage to soft tissues like the median and ulnar nerves, ligament, or tendon ruptures.
Conclusion
Distal radius fractures are fractures of the radius bone close to the wrist, occurring in young individuals mainly due to high-energy trauma or in elderly individuals due to falling on an outstretched hand. It is associated with sharp pain, swelling, and in some cases, a significant deformity and stiffness of the wrist joint. It may be treated by closed reduction and immobilization or by surgical management, depending on the severity and displacement criteria, followed by physical therapy and rehabilitation.
