Distal radius fractures

=Background

• Distal radial metaphysis fx that is dorsally displaced and angulated
  • Fracture line may extend into radioulnar or radiocarpal joint ("die-punch" fx)
• Occurs due to FOOSH
• Ulnar styloid fx is often present and suggests injury to TFCC

=Clinical Features

• Characteristic dorsiflexion or "dinner-fork" deformity
• Palmar paresthesias (pressure on median nerve)

Imaging

• PA
  • Distal metaphyseal fx that often appears shortened from angulation or comminution
• Lateral
  • Provides best view of dorsal angulation and comminution

Management

• Assess for instability:
  • >20 degrees angulation
  • Intra-articular involvement
  • Marked comminution
  • >1cm shortening
• Stable Fracture
  • Compression dressing and sugar tong splint
  • Closed reduction may be attempted
• Unstable Fracture
  • Immediate ortho referral

Smith Fracture

Background

• Volar angulated fx ("reverse Colles fracture" or "garden-spade deformity")
• Occurs due to fall or direct blow to dorsum of hand/wrist

Imaging

• Similar but opposite to Colles fracture

Management

• Similar to Colles fracture

Barton Fracture

Background

• Dorsal or volar rim fx
• Often fx-dislocations or subluxations because carpus is displaced in direction of the fx

Imaging

• PA
  • Communiuted fx of distal radial metaphysis
• Lateral
  • Intra-articular fx of volar or dorsal rim of radius

Management

• Minimally displaced: sugar tong splint and ortho referral
• Unstable requires ORIF
  • >50% of radial articular surface
  • Accompanying carpal subluxation

Radial Styloid Fracture

Background

• Often accompanied by lunate dislocation
• Often assoc w/ carpal instability (carpal ligaments insert on the radial styloid)

Management

• Short arm splint; position wrist in mild flexion and ulnar deviation

1. Hutchinson's Fx
   1. Radial styloid avulsion +/- lunate or scapholunate dissocation
2. Galeazzi Fx
   1. Radial shaft Fx + dislocation of the distal radioulnar joint (ulna positive variance)

Treatment

1. Immediate reduction only required for neurovascular invovlement
2. Nondisplaced extra-articular fx
   1. Relatively stable
   2. Sugar tong, reverse sugar tong, or double sugar tong splint
      1. Elbow flexed to 90 degrees, arm in neutral position
3. Displaced fx
   1. Splint, arrange next-day f/u; reduction by experienced clinician is appropriate, but not required
      1. Adequate reduction:
         1. No dorsal tilt of the distal radial articular surface
         2. Less than 5 mm of radial shortening
         3. Less than 2 mm of displacement of fracture fragments

Disposition

1. Refer all of the following:
   1. Palmarly displaced fx
   2. Articular step-off >2mm
   3. Large ulnar styloid fx with displaced fragments at the styloid base
   4. Fracture dislocations
   5. Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries
   6. Fractures with significant displacement or comminution
2. Unstable fx
   1. Greater than 20 degrees of dorsal angulation
   2. Fracture displacement in any direction greater than two-thirds the width of the radial shaft
   3. Metaphyseal comminution with more than 5 mm of radial shortening
   4. Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm
   5. Intraarticular component (especially involving the DRUJ)

Source

• UpToDate
• Tintinalli