Chirurgie de la main 29 (2010) 231–235

Original article
‘‘PAF’’ analysis of acute distal radius fractures in adults. Preliminary results
La méthode « PAF » pour l’analyse des fractures du radius distal de l’adulte.
Résultats préliminaires
G. Herzberg *, Y. Izem, M. Al Saati, F. Plotard
Pavillon M orthopédie, hôpital Édouard-Herriot, 5, place d’Arsonval, 69437 Lyon cedex 03, France
Received 27 October 2008; received in revised form 1 July 2010; accepted 6 July 2010

Abstract
There is not enough evidence in the literature to support the use of any treatment in distal radius fractures, mainly because of the heterogeneous
aspects of most series. There is a need for more standardized analyses of distal radius fractures that should allow the identification of more
homogeneous groups of patients. The authors propose a novel synthetic method to analyse acute distal radius fractures in adults. A one-page chart
includes criteria related to the patient (P), the energy of the accident (A), and the characteristics of the fracture (F) along with associated ulnar and
carpal lesions. The preliminary results of the use of this chart in 258 consecutive patients are presented. Four homogeneous groups of patients are
described and the principles of their treatment are discussed.
# 2010 Elsevier Masson SAS. All rights reserved.

Keywords: Distal radius fracture; Analysis; Epidemiology; Classification

Résumé
Le niveau de preuves actuelles de la littérature est insuffisant pour recommander tel ou tel traitement face à une fracture fraîche de l’extrémité
inférieure du radius, en grande partie à cause de l’hétérogénéité de la plupart des séries. Il est nécessaire de concevoir des méthodes d’analyse plus
standardisées, permettant l’identification de groupes homogènes de patients. Les auteurs proposent une méthode d’analyse nouvelle des fractures
fraîches de l’extrémité inférieure du radius de l’adulte. Une fiche d’une page inclut les critères liés aux patients (P), à l’énergie de l’accident (A) et
aux caractéristiques de la fracture (F) ainsi qu’aux lésions associées ulnaires et carpiennes. Les résultats préliminaires de l’utilisation de cette fiche
chez 258 patients consécutifs sont présentés. Quatre groupes homogènes de patients sont décrits et les principes de leurs traitements sont discutés.
# 2010 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Fracture du radius distal ; Analyse ; Epidémiologie ; Classification

1. Introduction
Distal radius fractures account for about one sixth of all
fractures [1] and yet there is not enough evidence in the literature
to recommend any form of treatment [2]. We believe that this is
due to the number of spectra that cover the topic in terms of
patient populations, accident energy, types of fracture and the
numerous available treatments. We frequently review series of
distal radius fracture that include very wide ranges of population,
which makes therapeutic recommendations rather unreliable.
Surgical treatment was significantly improved during the past 10
* Corresponding author.
E-mail address: guillaume.herzberg@chu-lyon.fr (G. Herzberg).
years [3–5], which explains that the practical results of these
improvements do not appear currently in meta-analyses. These
improvements could be highlighted in more homogeneous series
in terms of populations and types of fractures. One of the most
important issues in the management of distal radius fracture is to
consider the patient’s age and functional needs and not only the
anatomical type of the fracture. Imaging and treatment should
match the expectations and functional needs of each particular
patient. Very few recent epidemiological studies of distal radius
fractures are available [6]. Most of them are retrospective and
their results are not uniform. We designed a detailed monocentric
prospective epidemiological study aimed at recording acute
distal radius fractures from a very active specialized orthopaedic
academic center.

1297-3203/$ – see front matter # 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.main.2010.07.005
232 G. Herzberg et al. / Chirurgie de la main 29 (2010) 231–235

The objectives of this study were:
 To propose a simple practical method for thorough analysis of
acute distal radius fractures;
 To identify homogeneous groups of patients from preliminary
results.
2. Material and methods
Over an 18-month period ranging from September 2008 to
February 2010, 258 consecutive patients referred to our
institution with acute distal radius fractures were included in
[(Fig._1)TD$IG]
a prospective epidemiological study. Criteria related to the
patient, the accident and the type of fracture with the associate
injuries have been included a one-page chart (Fig. 1).
2.1. Patient
In addition to the age and gender of the patients, we
identified their general health status as normal [3], impaired by
disease(s) [2] or by dependence [1]. Similarly, we arbitrarily
identified the patient’s functional needs as maximum [3],
intermediate [2] or minimal [1]. This statement was done by the
physician after preoperative discussion with the patient.

Fig. 1. PAF chart.

 G. Herzberg et al. / Chirurgie de la main 29 (2010) 231–235
2.2. Accident
The amount of energy of the accident is to be considered
because it may be an indirect indicator of the extent of the
anatomical lesions that characterize the fracture, especially in
terms of associate ligament injuries. We identified high-energy
accidents (such as a fall from a roof or high velocity motorcycle
accident) as [3], medium-energy accidents (such as fall while
playing tennis or from a bike) as [2], and low-energy accident
(such as a simple fall) as [1]. Polytrauma patients and patients
with more than one osteo-articular injury (poly-injured) were
identified. The presence of an acute associated carpal tunnel
syndrome was recorded.
2.3. Fracture
2.3.1. Distal radius fracture
The open or close nature of the distal radius fracture was
recorded as well as its AO classification [7,8]. We considered
several anatomical factors that could have an influence on the
prognosis and treatment. Only classes or binary expressions
were considered. ‘‘NA’’ was chosen when a criterion was found
to be non applicable (for example articular displacement in a
type A fracture).
Four metaphyso-epiphyseal criteria were defined on the
initial PA view (Fig. 1). The radial inclination is a traditional
criterion, which influences the ease of the reduction. It was
distributed in three classes around a ‘‘1’’ category in which
radial inclination is considered acceptable (158 to 308). Radial
shortening is an almost constant feature of distal radius
fractures. It was distributed in three classes of ulnar variance,
class 1 (less than 2 mm of positive ulnar variance) being
considered acceptable. The presence or absence of proximal
metaphyso-diaphyseal irradiation is an important factor of the
treatment and it was recorded. Medial translation of the radial
diaphysis with respect to the distal radial epiphysis was
recorded since it has an influence on the reduction [9].
Four metaphyso-epiphyseal criteria were defined on the
initial lateral view (Fig. 1). The palmar tilt is a very important
criterion that was recorded within three classes around an
acceptable ‘‘1’’ class (08 to 158). Anterior or posterior
translation of the distal radius block with respect to the
diaphysis is rarely identified in studies of distal radius fractures
yet it may have an influence on the treatment [9] or be part of an
iatrogenic over-reduction. It was distributed in three classes
around a ‘‘1’’ non-translated position. Anterior, posterior or
circumferential comminution was recorded, as it is a major
factor for treatment and prognosis in distal radius fractures [10].
Articular sagittal widening was also recorded as it has recently
proven to be a simple criterion suggesting a severe involvement
of the articular radio-carpal aspect of the distal radius [11,12].
Within the intra-articular group of fractures, four criteria
were defined from the initial standard X-rays, traction X-rays
and/or a CT scan depending on the exhaustiveness of the
imaging. Radio-carpal and distal radio-ulnar joints articular
step-offs were each distributed in three classes. A step-off of
less than 1 mm was considered acceptable [13]. The step-off of
233
the ulnar notch of the distal radius could only be defined from
transverse CT scan slices. Transverse CT scan slices were also
used to identify the number of major fragments according to
Medoff’s classification [11]. The presence of localized
impaction or complete destruction of the radial distal surface
was recorded.
When available, arthroscopic findings (free or protruding
osteo-articular loose bodies, scapholunate, lunotriquetral or
TFCC tears) were recorded.
2.3.2. Associated DRUJ lesions
Fractures of the neck or head of the ulna were included as
binary criteria. When present, they are very important factors of
the treatment [9]. Displaced fractures of the base or the tip of
the ulnar styloid were recorded since they may be associated
with a higher probability of triangular fibrocartilage complex
(TFCC) deficiency [14]. Distal radioulnar joint (DRUJ)
diastasis, subluxations or dislocations were also included.
2.3.3. Associated carpal injuries
Associated fractures of the carpal scaphoid were recorded as
binary criteria. A scapholunate gap was recorded as a possible
associated scapholunate injury, acknowledging that this is not a
very specific nor sensitive criteria [15]. A rupture of Gilula’s
proximal line at the luno-triquetral interval was recorded as a
possible associated luno-triquetral dissociation [16]. Any volar
or dorsal radio-carpal subluxation was included.
3. Results
Only preliminary results regarding some specific aspects of
the database, i.e., the identification of homogeneous groups of
patients, are presented in this article. Among 258 patients (258
fractures), 157 (61%) were women. Ages ranged from 16 to 94
years with an average of 59 years. Averaged ages of the female
and male populations were respectively 69 and 40 years
(Table 1).
3.1. Polytrauma patients
Five percent (n = 13) of the study population were
polytrauma patients, all from high-energy accidents. There
were 77% men. The mean age was 37 years. All patients had a
normal health status except one (schizophrenia) who had a
history of suicide attempt by defenestration. All patients were
in the maximum functional needs category. Sixty-two presented
with ‘‘C’’ complete intra-articular types of fractures.
3.2. Non-polytrauma patients
This group included 245 patients distributed in three
different populations.
3.2.1. Patients who were dependent with minimal
functional needs (Group 1)
We found 18 patients in this category (7% of the whole
series); 88% were women. The mean age was 83 years. Type
234 G. Herzberg et al. / Chirurgie de la main 29 (2010) 231–235
Table 1
Distribution of the series according to groups of patients, age, sex and AO fracture types.
Number of Mean age
patients (range)
Polytrauma group 13 37 (16–62)
Group ‘‘1’’
Dependent patients 18 83 (57–89)
Group ‘‘3’’
High-needs patients 138 46 (16–78)
Group ‘‘2’’
Intermediate patients 89 76 (40–94)
‘‘C’’ complete intra-articular fractures were observed in 55% of
these 18 patients.
3.2.2. Patients with normal general health and maximum
functional needs (Group 3)
We found 138 patients in this category (53% of the whole
series); 54% were men. Their mean age was 46 years.
Within this group 42 fractures were extra-articular (AO type
A). Their mean age was 45 years.
Thirteen were partially articular (AO type ‘‘B’’). Their mean
age was 26 years. These fractures may have been associated
with ligament lesions. Indeed we found associated ulnar styloid
fractures with possible TFCC injury in 54% and possible
scapholunate dissociation in 46%.
Eighty-three were complete articular fractures (AO type
‘‘C’’). Their mean age was 50 years. Within this group, we
found associated ulnar styloid fractures with possible TFCC
injury in 52% and possible scapholunate dissociation in 12%.
3.2.3. Patients who were in an ‘‘intermediate’’ group in
between the above-mentioned groups (Group 2)
Eighty-nine (35%) patients were in an ‘‘intermediate’’ group
in between the above-mentioned groups in terms of general
health status and functional needs. Within this group there were
32 (36%) AO type ‘‘A’’ fractures, one (1%) AO type ‘‘B’’
fracture, and 56 (63%) AO type ‘‘C’’ fractures. Eighty-three
percent were women. Their mean age was 76 years.
3.3. Distribution of the AO type of fractures with respect to
the ages of the patients
Within the whole series, the mean age of the 85 patients with
AO type ‘‘A’’ fractures was 60 years. The mean age of the 157
patients with AO type ‘‘C’’ fractures was also 60 years. The
mean age of the 16 patients with AO type ‘‘B’’ fractures was 33
years.
4. Discussion
Because current classification systems of acute distal radius
fractures based on pathology have only moderate or poor
reproducibility [8,17–19] and because the available series often
consider wide ranges of patients age [14,20–22], we designed a
Percentage Distribution AO type AO type AO type
of female among 258 ‘‘A’’ (%) ‘‘B’’ (%) ‘‘C’’ (%)
cases (%)
23 5 1 1 3
88 7 3 0 4
46 53 16 5 32
83 35 12 0 23
new method of analysis using binary and qualitative criteria in a
consecutive series of 258 patients from a single centre, treated
over a 18-months period, and of whom the preliminary results
are presented. The general distribution of our study population
did not differ from that of previous large epidemiologic studies
of distal radius fractures [23] in that the sex ratio shows a larger
proportion of female patients and that women are on average
older than men.
Our preliminary results suggest that four homogeneous
groups of distal radius fractures may be individualized both in
terms of patients and fracture types. This may facilitate future
comparison studies, as each group may deserve specific
management in terms of imaging modalities and treatment.
4.1. Polytrauma patients
This group was very specific due to the immediate vital
prognosis. The treatment of distal radius fracture was not a
priority and it was often delayed. In this category the mean age
was 37 years and treatment objectives were at maximum levels.
We believe that this category of patients must be individualized
because practical and vital considerations are likely to
jeopardize both treatment modalities and prognosis. Concerned
patients deserve specific management, for example immediate
external fixation followed by delayed definitive treatment after
CT scanning with external fixator [24] taking into account
priorities related to other injuries.
4.2. Non Polytrauma patients
4.2.1. Patients who were dependent with minimal
functional needs (group ‘‘1’’)
Their mean age was 83 years. In this category the therapeutic
objectives were at minimal levels. We believe this category of
patients has to be individualized because a simple and reliable
one-stage treatment allowing for healing in an acceptable
position, with warranted outcome. Sophisticated imaging
should be contra-indicated in this category.
4.2.2. Patients with normal general health and maximum
functional needs (group ‘‘3’’)
The mean age in this group of patients was 46 years. Such
category of patients deserves individualization because in this
 G. Herzberg et al. / Chirurgie de la main 29 (2010) 231–235
category, the high-level therapeutic objectives aim restoration
of anatomy and expect functional results.
Within this group 42 fractures were extra-articular (AO type
A). Treatment may be adapted to surgeon’s preferences and
good results may be obtained with various methods.
Thirteen were partial articular fractures (AO type ‘‘B’’). We
believe that sophisticated imaging and treatment modalities are
suitable for these fractures, including arthroscopically-assisted
reduction and internal fixation if necessary. Within the whole
series, the average age of the patients with AO type ‘‘B’’ fractures
(26 years) was significantly lower than the average age of the
patients with AO type ‘‘A’’ and ‘‘C’’ fractures (60 years).
Eighty-three were complete articular fractures (AO type
‘‘C’’). Sophisticated imaging and treatment modalities must be
considered for such fractures. The significant percentage of
possible associate ligament lesions (which are underestimated
by standard X-rays) makes us believe that arthroscopically-
assisted reduction and internal fixation may be discussed at
least in some cases.
4.2.3. Intermediate group of patients (group ‘‘3’’) in terms
of general health and functional status
It was noticeable that in this category, the mean age was 76
years (mini: 40, maxi: 94). We think that in this category of
patients, imaging and treatment modalities should be tailored to
each patient and each type of fracture.
In conclusion, this new method of analysing acute distal
radius fractures may contribute to the constitution of more
homogeneous patient categories and patient-related treatment
options. This may consequently improve the quality of future
outcome studies.
Conflict of interest statement
No conflict of interest.
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