Distal Radial Fractures

 

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Search Datebases:Cochrane Library, Medline with full text, pubmed, CINAHL, Search dates: 9/16, 9/21, 10/26.

Search terms: Distal radial fracture, distal radius fracture, distal radial treatment, distal radius treatment, radius physical therapy, RCT

Definition/Description

Fractures occurring in the distal radius often occur in both children and adults and can be referred to as “wrist fractures.” They are defined as occurring in the distal radius within three centimeters from the radiocarpal joint, where the radius interfaces with the lunate and scaphoid bone of the wrist. The majority of distal radial fractures are closed injuries in which the overlying skin remains intact (Handoll et al 2008—EF).

Epidemiology /Etiology

Distal radial fractures in adults is one of the most common fractures, accounting for one-sixth of all fractures in the emergency department and can be seen predominantly in the white and older population. (Abrama, Bienek, Kay, Handoll (EF)) In women, the incidence of occurrence increases with age starting at 40 years old, whereas before this age the incidence in men is much higher. Occurrences in younger adults are usually the result of a high-energy trauma, such as a motor vehicle accident. In older adults, such fractures are often the result of a low-energy or moderate trauma, such as falling from standing height. This may reflect the greater fragility of the bone due to osteoporosis in the older adult. (Handoll (EF), Leung)

Distal radial fractures account for up to 72% of all forearm fractures and 8-17% of all extremity fractures. (Bushnell). Historically, literature has focused on restoring the anatomic radiocarpal alignment, however the distal radioulnar joint (DRUJ) is also important in restoring hand function.(Kleinman)

Multiplanar wrist motion is based on three articulations: radioscaphoid, radiolunate, and distal radioulnar joints. The distal end of the radius forms a “platform” to support the functional demands of the wrist. The medial distal radius ligament and ulnar-syloid based triangular fibrocartilage complex (TFCC) help to stabilize the wrist. (Bushnell) The TFCC is the primary intrinsic stabilizer of the DRUJ and is critical for normal DRUJ biomechanics. (Kleinman) Bony anatomy can result in malunions with radiographic assessment by measuring the radial inclination, radial length, ulnar variance and radial tilt (Figure X). Slight changes may result in malunion and can cause considerable pain and disability. For example, increased dorsal angulation can alter the loading force and result in decreased congruency at the DRUJ thus tightening the interosseous membrane and decreasing pronation-supination.(Bushnell) A concomminant injury due to stress on the TFCC is an avulsion fracture of the ulnar styloid process and can result in significant malalignment. (Kleinman)

A correlation between the severity of the primary displacement and the expectant loss of reduction over a time period is assumed when treating distal radial fractures with immobilization. Predictive factors of instability at an early (1 week) and a late (6 weeks) time period can be established by radial shortening and dorsal tilt in the early phases and radial shortening, dorsal tilt, and decreased radial inclination in the late phases. Instability is defined as dorsal tilt >15°, volar tilt >20°, ulnar variance >4mm and a radial inclincation <10°(split into table) (Leone, Bushnell)

Characteristics/Clinical Presentation

Distal radial fractures can be classified based on their clinical appearance and typical deformity. Dorsal displacement, dorsal angulation, dorsal comminution, and radial shortening may all be used to describe the presentation of the fracture. Classification based on fracture patterns such as intra-articular (articular surfaces disrupted) or extra-articular (articular surface of radius intact) may also be used. (Handoll, Figure1 Bushnell) A Colles fracture is typically due to a fall on an outstretched hand and results in a dorsal displacement of the fractured radius. A “Smith’s” fracture is a reverse Colles with a volar displacement. A “Barton’s” fracture is an intra-articular fracture with subluxation or dislocation of the carpus bone. Of the 8 grades for distal radial fractures in the Frykman classification system, half include ulnar syloid involvement.

Complications are common and diverse and may be the result of injury or treatment and are associated with poorer outcomes. These can include upper extremity stiffness, carpal tunnel syndrome or median nerve involvement, malunion, carpal instability, DRUJ dysfunction, Dupuytren’s disease, radiocarpal arthritis, tendon/ligament injuries, and complex regional pain syndrome. (Kleinman, Bienek, Handoll Conserv, Patel). Residual pain and stiffness at the wrist cannot be compensated for by shoulder or elbow kinematics.

• Malunion--Distal radius malunion is the most common complication, effecting up to 17% of patients. Physical therapists may assess the effect of malunion to determine if surgery is appropriate by performing a detailed physical exam that includes a preoperative history, location and severity of pain, and functional loss. (Bushnell, Patel)
• Compartment Syndrome- Incidence of this complication affects only 1% of patients. If compartment syndrome is suspected, elevate, observe, and loosen cast emergently.(Patel)
•  Complex Regional Pain Syndrome—This complication is observed in 8-35% of patients. CRPS should be suspected when pain, decreased ROM, skin temperature, color, and swelling are out of proportion to the injury. In order to obtain a good functional outcome for this patient population, early recognition and a multidisciplinary treatment approach to address pain and function requires psychiatric and physical/ occupational therapy interventions. (Patel)
•  Dupeytren’s Disease - Patients develop mild contractures in the palm along the fourth rays within six months of a distal radial fracture. The severity of the contractures determines the treatment course. (Patel)
•  Nerve Pathology – Neuropathy may present acutely or throughout treatment. The median nerve is most common (4%), however 1% of patients have ulnar or radial involvement (Beinick) . Physical therapist may need to refer the patient to an orthopedic surgeon. (Patel)
• Acute Carpal Tunnel Syndrome – Physical therapists must be able to identify acute carpal tunnel syndrome, as delayed treatment is associated with poor outcomes, incomplete recovery, or a prolonged functional recovery time. (Beinick, Patel)
•  Tendon Complications - Physical therapists should be prepared to refer patients to surgery in the event of tendon complications secondary to irritation with inflammation or rupture from impingement. (Patel)
  
  

Differential Diagnosis

Because the mechanism of injury for a distal radial fracture is usually a high energy traumatic incident, radiographs should be taken to confirm the diagnosis and ensure that the surrounding tissues are still intact.  Other injuries causing radial sided pain may include TFCC wear or preforation, Galeazzi fracture, fracture to the distal 2/3 of the radius, scaphoid fracture, or radiocarpal ligament injury.

Examination

Physical therapists must conduct a thorough physical exam including subjective and objective information.

• Subjective exam includes any information given by the patient about pain experienced, limitations of ROM of the wrist, and activity limitations. (Bienek)
• Objective exam includes assessment of wrist and digit ROM, grip and forearm strength, bony and soft-tissue abnormalities, skin integrity, and nerve involvement. (Bienek)

Medical Management (current best evidence)

Orthopedic surgeons typically recommend surgical repair of displaced articular fractures of the distal radius for active, healthy people. (H) The sheer variety of reduction and fixation options is noted based on a series of five Cochrane reviews focusing on this topic alone. Methods include: closed reduction and percutaneous pinning, either extra-focal or intra-focal; bridging external fixation with or without supplemental Kirschner-wire fixation; dorsal plating; fragment-specific fixation; open reduction and internal fixation with a volar plate through a classic Henry approach; or a combination of these methods.(H),(B) Surgical “complications include edema, hematoma, stiffness, infection, neurovascular injury, loss of fixation, recurrent malunion, nonunion or delayed union, instability, tendon irritation or ruptures, osteoarthritis, residual ulnar-side pain, median neuropathy, complex regional pain syndrome, and problems with the bone-graft harvest site.”(B p37-38)

• External Fixation – External fixation is typically a closed, minimally invasive method in which metal pins or screws are driven into the bone via small incisions in the skin. These pins can then be fixed externally by either a plaster cast or securing them into an external fixator frame. (Handoll EF) In comparison to a standard immobilization procedure, external fixation of distal radius fractures reduces redisplacement and yields better anatomical results. However, current evidence for better functional outcomes from external fixation is weak and is also associated with high risk for complications such as pin site infections and radial nerve injuries. (Handoll EF) Figure
•  Internal fixation – Internal fixation involves open surgery where the fractured bone is exposed. Dorsal, volar or T-plates with screws may be used. However, due to the invasive and demanding nature of open surgery, there is an increased risk of infection and soft-tissue damage and therefore this type of fixation is usually reserved for more severe injuries. (Handoll IF)Figure
• Bone Grafts - Upon reduction of distal radial fractures, bony voids are common and can be reduced by inserting bone grafts or bone graft substitutes. Autogenous bone material obtained from the patient themselves or allogenous bone material obtained from cadaver or live donors can be used as filler for reducing bony voids. However, current research describes risk of complications including infection, nerve injury, or donor site pain, and limited evidence that bone scaffolding may improve anatomical or functional outcomes. (Handoll BoneGraft). Bone grafting is required by most procedures except closing wedge. (B)
• Percutaneous Pinning - Another strategy in reducing and stabilizing the fractures is percutaneous pinning, which involves insertion of pins, threads or wires through the skin and into the bone. (Hand-pinn, B) This procedure is typically less invasive and reduction of the fracture is closed upon which the pins placed in the bone are used to fix the distal radial fragment. Current indications for the best technique of pinning, the extent and duration of immobilization are uncertain, in which the excess of complications are likely to outweigh therapeutic benefits of pinning. (Handoll Pinning) Figure
•  Closed Reduction - In closed reduction, displaced radial fragments are repositioned using different maneuvers while the arm is in traction. Different methods include manual reduction in which two people pull in the opposite directions to produce and maintain longitudinal traction and mechanical methods of reduction including the use of “finger traps.” However there is insufficient evidence establishing the effectiveness of different methods of closed reduction used in treating distal radial fractures (Handoll closed reduction)
• Arthroscopic-assisted reduction has many advantages over open reduction. In addition to being less invasive, arthroscopic-assisted reduction allows for direct visualization and reduction of articular displacement, opportunity to diagnose and treat associated ligamentous injuries, removal of articular cartilage debris, and lavage of radiocarpal joint. The primary limitations for arthroscopic reduction are due the limited number of surgeons with experience, a longer, more difficult procedure, and the potential for compartment syndrome or acute carpal tunnel syndrome with fluid extravasation. (H)
  

Physical Therapy Management (current best evidence)

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Key Research

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Resources

• American Academy of Orthopaedic Surgeon
• Colles fractures

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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 1. Handoll HHG, Huntley JS, Madhok R. External Fixation versus conservative treatment for distal radial fractures in adults (Review). The Cochrane Library. 2008;4:1-78.