Distal radial fractures

The distal radial fracture is the most

common forearm fracture. It is usually
caused by a fall onto an outstretched
hand (FOOSH). It can also result from
direct impact or axial forces. The
classification of these fractures is based
on distal radial angulation and
displacement, intra-articular or extraarticular involvement, and associated
anomalies of the ulnar or carpal bones.

Distal radial fractures

Kirmani et al at the Mayo Clinic noted that
distal forearm fractures peak during the
adolescent growth spurt but that the structural
basis for this is unclear. They concluded, on the
basis of their study findings, that regional
deficits in cortical bone may underlie the
adolescent peak in forearm fractures.
In the United States, 17% of all emergency
room visits result from wrist injuries. McMurtry
and colleagues reported that distal radial
fractures account for one sixth of all fractures
seen in the emergency department.

Distal radial fractures

Most wrist fractures occur in older
postmenopausal women, with a female-tomale ratio of 4:1.[11 ]However, in
adolescent boys and girls, the ratio is 3:1,
reflecting a differing level of sports
involvement between boys and girls.
A bimodal age distribution has been
documented for distal radial fractures;
peaks occur at ages 5-14 years and at
ages 60-69 years.

Distal radial fractures

Extra-articular metaphyseal fractures occur in
elderly patients because of the thin osteoporotic
cortex. Intra-articular fractures with joint surface
displacement occur in young patients.
Age influences the location of fractures in the
forearm and wrist. Young children present with
metaphyseal fractures of the radius and ulna;
adolescents, with physeal separations of the
radius; and young adults, with scaphoid
fractures. Middle-aged and elderly patients
present with fractures of only the distal radius or
ofthe radius and ulna.

Anatomy
The radiocarpal joint is a synovial joint
thatconnects the hand to the forearm. The
distal radius and ulna articulate at the
radioulnar joint.
The pronator quadratus muscle is located
across the volar aspect of the distal radius
and ulna. This muscle is associated with an
underlying fat pad that is seen as a flat,
lucent line anterior to the distal end of the
radius on the lateral image and that, if a
bulge is present, is indicative ofa soft-tissue
injury.

Presentation
Wrist injuries that cause pain,
edema, crepitus, deformity, or
ecchymosis should be evaluated for
radial fractures. Missed distal radial
fractures can lead to significant
morbidity.

Distal radial fractures

Common complications of distal
radial fractures also include ulnar
nerve injury, carpal tunnel syndrome,
posttraumatic radiocarpal
osteoarthritis with possible limited
range of motion, heterotopic
ossification, reflex sympathetic
dystrophy (RSD), tendon rupture,
nonunion, and radial shortening.

Distal radial fractures

The most common complication of
associated soft-tissue injury is peripheral
nerve dysfunction. The median nerve is
most commonly affected, but the ulnar
nerve also may be injured. Mechanisms for
neuropathy of the median nerve include
direct trauma by fracture or displacement,
injury through a proximal radial
fragment,and injuryfrom displacement of a
volar fragment. The ulnar nerve is damaged
by medial displacement of the radial
fragment or by the ulnar head being volarly
displaced.

Distal radial fractures

Injury to arteries occurs with open and
closed fractures. It can also occur with
markedly displaced fractures and with
dislocations of the radius and ulna.
Tendon lacerations occur from high-energy
injuries and should be suspected with open
fractures and high-velocity injuries. The
incidence of tendon rupture is less than
0.2%, and tendon rupture is a late sequela
of distal radial fractures.

Distal radial fractures

Intercarpal injuries may accompany
fracture dislocations of the distal forearm.
Scaphoid fractures are not uncommon.
Intercarpal ligament injuries also may
occur. Fractures through the radial styloid
can disrupt the radioscapholunate and
scapholunate interosseous ligaments,
causing a disruption between the 2
bones.The extensor pollicis longus tendon
is most frequently ruptured.

Diagnostics
Posteroanterior (PA), lateral, and oblique
radiographs of the injured forearm should
be obtained. Oblique views reveal intraarticular involvement that is not apparent
on the other views. The semisupinated,
oblique view demonstrates the dorsal
facet of the lunate fossa, whereas the
partially pronated, oblique PA view allows
visualization of the radial styloid.

Radial height is assessed on the PA view. It is a measurement between 2 parallel lines that
are perpendicular to the long axis of the radius. One line is drawn on the articular surface
of the radius, and the other is drawn at the tip of the radial styloid. The normal radial
height is 9.9-17.3 mm. Measurements of less than 9 mm in adults suggest the presence of
comminuted or impacted fractures of the radial head. Comparison with the contralateral
normal wrist is recommended if the diagnosis is unclear. Shortening of RH may indicate
impaction of the radial head when compared with a normal contralateral wrist.

 Radial inclination is measured on the PA view; this is a

measurement of the radial angle. A line is drawn along the articular
surface of the radius perpendicular to the long axis of the radius,
and a tangent is drawn from the radial styloid. The normal angle is
15-25. Angulation of the radial head alsoprovides impaction clues

 The volar tilt, or palmar

inclination, is measured
on the lateral view. A
line perpendicular to the
long axis of the radius is
drawn, and a tangent
line is drawn along the
slope of the dorsal-topalmar surface of the
radius. The normal angle
is 10-25. A negative
volar tilt indicates dorsal
angulation of the distal,
radial articular surface.

Bartons fracture
John Rhea Barton characterized the Barton fracture in
1838. This fracture involves a dorsal rim injury of the
distal portion of the radius. Carpal displacement
distinguishes this fracture from a Smith's or a Colles'
fracture and that the dislocation is the most striking
radiographic finding.
2 types
Volar Barton fracture is thought to occur with the same
mechanism as the Smith fracture, with more force and
loading on the wrist.
Dorsal Barton fracture is caused by a fall on an extended
and pronated wrist, increasing carpal compression
force on the dorsal rim. The salient feature is a
subluxation of the wrist in this die-punch injury.

Bartons fracture
The Bartonfracture involves either
the palmar or dorsal radial rim, and
the mechanism is intra-articular. By
definition, this fracture has some
degree of carpal displacement, which
distinguishes it from a Colles or
Smith fracture. The palmar variety is
more common than the dorsal type

Differential diagnosis
Colles fracture
Most common distal radial fracture.
The injury is usually produced by a fall onto an
outstretched hand (FOOSH) mechanism with the
wrist in dorsiflexion.
The fracture is dorsally displaced and may be
comminuted.
The fracture pattern is often described as a silver or
dinner-fork deformity.
The fracture fragments are usually impacted and
comminuted along the dorsal aspect; the fracture
can extend into the epiphysis to involve the distal
radiocarpal joint or the distal radioulnar joint.

 Lateral view of the wrist demonstrates a

Colles fracture (in which there is a dorsal
angulation of the fracture fragment)

Differential diagnosis
Smiths fracture
An impact to the dorsum of the hand or a
hyperflexion or hypersupination injury is
thought to be the cause.
Smiths fracture is usually called a reverse
Colles fracture because the distal fragment
is displaced volarly.
It is often described as a garden-spade
deformity.
The ulnar head can be displaced dorsally

 Smiths fracture (in which there is a volar

displacement of the distal fracture fragment).

Bartons fracture:
radiographs
PA and lateral views of the
wristinvolve a minimal examination,
but a true lateral projection is
needed to evaluate the degree of
carpal subluxation. In 1992, Wood
and Berquist suggested that trispiral
tomograms or coronal and/or sagittal
CT scanscould be used to evaluate
articular congruity of the distal radius

 Posteroanterior
radiograph of a
Barton fracture.
Note the intraarticular fracture
of the radius
with the
widening of the
space between
the scaphoid and
lunate
structures.

 Lateral
radiograph of a
Barton fracture.
Note the volar
displacement of
the scaphoid
associated with
an intraarticular distal
radial fracture.

Bartons fracture: treatment

Non Operative Treatment:
- many of these frxs will fail nonoperative treatment;
- manipulative reduction is same as for Colles Fracture;
- stability of reduction of dorsal Barton frx is best
obtained with
wrist extension to take advantaage of intact
volar carpal ligament;
- immobilization for 6 weeks in short arm plaster cast;
Operative Treatment:
- is best treated by closed reduction, application of
external fixation, followed by percutaneous pin insertion;
- if reduction is not anatomic, fraying of the tendon at
this level may to late rupture;
- tendency to redisplace may require ORIF thru dorsal
approach;