Distal Radial Fractures ("Wrist Fractures")

Question 1

Outline the most common mechanism/aetiology of distal radius fractures (“wrist fractures”).

Answer 1

• Most low energy injuries e.g. fall on out-stretched
  hand (FOOSH), especially elderly/osteoporotic
  (often female)
• High energy injuries e.g. RTA/sporting injuries (often
  in young male patients)

Question 2

Outline important features of history taking in wrist fractures.

Answer 2

• Mechanism of injury (e.g. how they fell & 
landed)
• Hand dominance
• Occupation/career plans
• Hobbies activities
• Smoking status/med Hx/DHx

Question 3

Outline important components of examining a wrist fracture.

Answer 3

• Neurovascular assessment
– Median, radial, ulna
– Cap refill +/- pulses
• Open/closed injury
• Check for other sites of injury 
– elsewhere in the same limb, other arm, or multiple 
injuries as in high energy injuries
– Don’t miss scaphoid fracture or scapholunate
ligament injury in the same wrist

Question 4

Which imaging modalities are appropriate in a wrist fracture?

Answer 4

• X-rays
–wrist: AP & lateral
–Or if scaphoid suspected, do scaphoid views (out
of cast)
–Always x-ray after “doing something “ e.g.
manipulation or cast application

Question 5

What is meant by the term ‘reduction’?

Answer 5

Restoration of normal anatomical position.

Question 6

Expand upon the phrase ‘reduce, stabilise, rehab’.

Answer 6

Reduce:

• Restore radial length, radial inclination and
  volar tilt.

Stabilise (immobilise):
- Cast, percutaneous K-wires, internal fixation,
(external fixation rare).

Rehabilitate:
- Physiotherapy

Question 7

Outline the ‘11, 11, 22’ rule in assessing the placement of the distal radius.

Answer 7

The rule of “11, 11, 22” confirms the distal radius to be undisplaced

1. Radial inclination (on AP view): The distal radial articular surface should be at 22 degrees angulation from the perpendicular to the long axis on the AP view
2. Radial length (on AP view) The radial styloid should be 11mm distal the the ulna at the DRUJ
3. Volar tilt (on lateral view). The distal radial articular surface should be tilted 11 degrees volarly (i.e. towards the palm).

Question 8

What placement is acceptable/unacceptable upon closed reduction?

Answer 8

• Volar tilt is preferable
• Neutral position on lateral (i.e. 0 degrees volar tilt) is often acceptable
• Loss of radial length (shortening) or dorsal tilt are generally unacceptable except in frail/unwell patients with very low functional requirements.

Question 9

What is important about intra-articular fractures in regards to reduction?

Answer 9

• Intra-articular fractures must have NO displacement/loss of alignment in the articular surface
– Harder to achieve & maintain in non-surgical treatment (therefore often require open reduction internal fixation/ORIF)

Question 10

How are stable injuries managed?

Answer 10

• Maintain in acceptable position for 6 weeks in short-arm cast
– Undisplaced/minimally displaced fractures are
often stable injuries
– Casts require moulding during the first 2-3 weeks of
treatment to minimise the risk of fracture
displacement, even if initially undisplaced.
– X-ray at 1, 2, 3 & 6 weeks to check for displacement (&
treat if displacement does arise)

Question 11

How are unstable injuries managed?

Answer 11

• Unstable injuries unlikely to remain in an
acceptable position with just a moulded cast
e.g. may need surgical stabilisation

Question 12

List the 3 key wrist fracture patterns.

Answer 12

• Colle’s fracture
• Smith’s fracture
• Barton’s fracture

Question 13

Describe the typical mechanism and deformity seen in a Colle’s fracture.

Answer 13

• FOOSH (usually low energy)
• May be high energy FOOSH in sporting injury
• Dinner fork deformity

Question 14

Outline how a Colle’s fracture is defined.

Answer 14

• A fracture within 2.5 cm of the wrist joint.
• EXTRA-ARTICULAR
• Dorsal displacement.
• Dorsal angulation.
• Radial displacement.
• Radial angulation
• Impaction (i.e. shortening).
• Osteoporotic bone
• Frequently associated with an ulnar styloid
  fracture.

Question 15

How are Colle’s fractures most often managed?

Answer 15

• Often displaced
• Required closed reduction with sedation/block (manipulation under sedation = MUS)
• Maintained with moulded short arm cast
• Adequate analgesia +/- sedation
  Opioids, entonox, local anaesthetic block (e.g.
  haematoma block), midazolam, or combination as
  per patient’s medical history
• X-RAY FOLLOWING REDUCTION!

Question 16

How are Colle’s fractures managed if still displaced upon closed reduction (manipulation under sedation)?

Answer 16

• Use general anaesthetic for closed reduction
(manipulation)
i.e. manipulation under anaesthetic (MUA)
• Difficulty in achieving initial reduction can mean
difficulty in maintaining acceptable position too
– e.g needs percutaneous wires (Kirschner-wires) for
stabilisation
- if STILL displaced after X-ray –> open reduction internal fixation (ORIF).

Question 17

Again, outline the important caveat to INTRA-ARTICULAR Colle’s fractures (not a true Colle’s fracture).

Answer 17

• Intra-articular fractures difficult to reduce using closed reduction technique.
• Low-threshold for ORIF over MUA/K-wires
• ALWAYS attempt closed reduction urgently regardless in order to minimise tension of soft-tissues , nerves, blood vessels; even if ORIF required.

Question 18

Outline the mechanism/aetiology of a Smith’s fracture.

Answer 18

• Falling on the back of the hand
• Usually while carrying/holding something/handlebars
• Causes displacement and angulation VOLARLY (rather than dorsally)

Question 19

Describe a Smith’s fracture.

Answer 19

• Often referred to as a ‘reverse Colle’s fracture’
• Extra-articular
• Volar angulation
• VERY unstable
• Often requires ORIF but always attempt closed reduction to protect soft tissues

Question 20

Describe a Barton’s fracture.

Answer 20

“Partial articular fracture-subluxation” where
part of the articular surface is still attached to
the shaft, & the carpus is subluxed with the
broken fragment due to strong ligamentous
attachment
• Usually displaced volarly, therefore often called
“volar Barton’s” fractures

Question 21

How are Smith’s/Barton’s fractures managed?

Answer 21

• Attempt initial closed reduction to protect soft-tissues

- ORIF

Question 22

Outline wrist fracture follow-up management (non-operative/K-wired wrists/ORIF).

Answer 22

• Non-operative: review at 1, 2, 3 & 6 weeks with x-rays (to identify & treat any new displacement). Remove cast & mobilise at 6 weeks (often with physio)
• K-wired wrists: Pinsite check & x-ray at 1 week, wires removed & x-ray at 3 weeks &, cast until 6 weeks, then mobilise (often with physio)
• ORIF: Wound check at 1-2 weeks, then usually change to removable splint to gradually wean out of over next 2-4 weeks (if patient compliant)

Question 23

List complications of wrist fractures.

Answer 23

• Pain, stiffness, & arthritis if intra-articular
• N/V damage
• Carpal tunnel syndrome
• Volkmann’s ischaemic contracture (shortening of forearm muscles resulting in claw formation at wrist, hand, and fingers).
• Complex regional pain syndrome (CRPS)

Question 24

Outline common patterns of wrist fractures in children.

Answer 24

• Most are buckle or greenstick pattern.
• These have mild angulation/displacement.
• Potential for remodelling in children.
• Usually stable (3 weeks in a cast)

Question 25

NOTE TO SELF: PLEASE LOOK AT IMAGES OF COLLE’S/SMITH’S/BARTON’S FRACTURES!

Answer 25

Please do that.