Distal radius fracture
Illustration of the distal radius (larger bone) during pronation (left) and supination (right) of the wrist

Definition

Distal radius fracture consists of a fracture of the larger bone of the forearm, the radius, in proximity of the wrist joint on the inner side of the forearm.

X-rays in frontal and side view showing fractures of both the distal radius and ulna

Pathology

The radius bone bears 80% of the energy load of the wrist and is therefore easily subject to injury. A fracture of the distal radius is the most frequent fracture amongst adults and elderly people (15% of all fractures) due to the high incidence of falls and osteoporosis. 

In younger individuals, it often results from high-energy impacts and is associated to other injuries to smaller wrist bones such as ulnar fracture, scaphoid fracture, other carpal bone fractures and carpal tunnel syndrome. 

In children, a distal radius fracture may involve the growth plate and potentially impair bone growth.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

In young individuals falls during sport and leisure activities can cause a distal radius fracture

Causes

A distal radius fracture mostly occurs with a traumatic weight bearing force through the wrist particularly when falling with an outstretched hand onto a hard surface (hyperextension type fracture) or in a roll over (hyperflexion type injuries). It is common in sports such as skateboarding and snowboarding and after car and bike accidents.

Elderly people with poor balance, impaired vision and medical problems have a higher risk of falls and fractures

Risk factors

Intensive sport activities in the younger population and falls in the elderly suffering from degenerating bone conditions are prominent risk factors for a distal radius fracture. Postmenopausal women are more frequently affected than men. 

Additional risk factors are:

Chronic inflammatory diseases: rheumatoid arthritis, gout (accumulation of uric acid in the joint)

Kienböck’s disease

Septic arthritis (infection of the joint)

Poor muscle training

Diabetes

Wrist deformation is a clear symptom of a fracture of the distal radius

Symptoms

The fracture of the distal radius causes an immediate variety of symptoms including:

Audible noise

Pain

Swelling

Tenderness at touch

Deformity and hanging of the wrist

Bruising

Reduced range of movement

Wound in case of open fractures

X-ray showing a distal radial fracture associated with the fracture of the ulnar stylus (left)

Diagnosis

Clinical examination begins by discussing the medical history including the causes leading to a distal radius fracture. The main scope of the diagnosis is to identify the type of fracture in order to develop a suitable treatment plan. 

It is critical for the examiner to assess potential damage caused to the nerves and the vasculature. The examiner palpates the wrist and performs gentle movements to assess pain level, joint instability and possible grinding noise. The presence of open fractures is determined by examining the skin around the wrist. Other elements of the examination include:

Associated injuries to the forearm, elbow and shoulder

Changes in the range of movement of elbow and shoulder

Vascular damage by testing pulses

Nerve damage via loss of sensation, e.g. drop hand

The diagnosis is confirmed with X-rays, CT scan and MRI in case of more complex (displaced, comminuted) fractures.

Treatment

Chinese finger traps are used for traction of the fractured distal radius

Nonoperative treatment

Conservative treatment is recommended in uncomplicated distal radius fracture (undisplaced and stable) or when bone quality is compromised in elderly patients. This approach includes:

Closed reduction under anaesthesia to reposition the bone in case of minor displacement

Traction of the fracture with a Chinese finger trap (see figure)

Plaster above elbow that is replaced as swelling subsides

Monitoring fracture healing with X-rays every 3 weeks to confirm a correct bone alignment

Cast removal and rehabilitation after 6 weeks

Three methods for surgical treatment of the fractured distal radius: external fixator (left), ORIF with plate and screws (middle) or simply screws (right)

Surgical treatment

if the fracture is complicated surgery is necessary. This achieves a reposition of the bone fragments into a correct and functional anatomy to prevent secondary complications such as arthritis, nerve and vascular damage and bone necrosis, among others. Several surgical techniques are available for the treatment of distal radius fracture:

Open reduction and internal fixation (ORIF) using plates and screws

Screws in unstable fracture of the radial process styloid

Dorsal plate with bone graft for unstable fractures

Volar plate

External fixator in open fractures with severe soft tissue damage (screws inserted from the skin into the radius)

Joint replacement with artificial joint or wrist arthroplasty

Complications

A number of complications can occur following distal radius fracture such as:

Damage to blood vessels and bleeding

Compression or injury to the median nerve at the carpal tunnel (temporary or permanent)

Chronic Regional Pain Syndrome (CRPS) of the fractured area with persisting symptoms

Defects in fracture healing: non-union and mal-union when closure and alignment of the fracture fail

Damage to the cartilage leading to arthritis of the wrist joint (stiffness, pain) possibly requiring surgery

Wrist fusion consequent to chronic arthritis, meaning fusion of the radius with carpal and metacarpal bones

Anatomical reduction of bone fragments to minimise the risks of post-traumatic arthritis arising from mechanical grinding

Development of avascular necrosis of the fractured bone(s).

Wrist mobilisation is critical to restore flexibility after a distal radius fracture

Rehabilitation

Early after distal radius fracture, the rehabilitative therapy focuses on:

Arm elevation (to reduce swelling/pain)

Pain management with NSAIDs or morphine for a few days, if pain is severe

Ice or heat pads

Antibiotics in case of open fractures

Replacement of cast when swelling subsides to keep the arm firm

Intensive physical therapy one to two months after cast removal or surgery and includes:

Massage

Joint mobilisation

Stretches

Dry needling

Electrotherapy

Activity modification advice

Return to sport/work plan

Postural taping

Gentle exercise to improve flexibility and strength.

Vigorous exercises can commence after three to six months from injury. Full recovery is expected after one year or longer in more complex fractures or in case of poor bone healing. Although most patients return to normal activities after radius head fracture, some may suffer some degree of pain, which will decrease over two years.

The use of devices for prevention of falls can reduce the incidence of injuries such as a distal radius fractures

Prevention

In older osteoporotic patients, assessment of bone density and administration of calcium and Vitamin D may be necessary to help preventing bone fractures. Reducing the risk of falls in elderly patients remains an efficacious prevention for future distal radius fractures and other injuries. In young individuals, wearing a wrist brace or taping is advised especially when sport is resumed after the fracture.