WHEN TO OPERATE AND HOW ON

AN EXTRA ARTICULAR DISTAL RADIAL

FRACTURE

Heri Suroto. MD.PhD.

Orthopaedic & Traumatologic surgeon
Consultant of Hand & Microsurgery
Dr. Soetomo Hospital/ School of Medicine Airlangga
University

a 78-year-old woman showing a distal radius fracture with

extension, radial shortening, dorsal comminution.
Initial postreduction x-ray of the fracture showing correction of
radial shortening, extension, and articular step-off deformities

Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg
2004;29A:11281138

Four-week x-ray of the patient showing loss of reduction for an

unacceptable radiographic result

At 4 weeks after reduction

46% of these unstable
distal radius fractures
maintained an adequate
reduction.
Of the 54% of fractures
that failed to maintain an
adequate reduction.
Age was the only
statistically signicant
predictor of secondary
displacement.

Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg
2004;29A:11281138

Mr. Y. 35 y o man with Distal Radius Fracture

Initial X-ray

Initial
Postreduction

8 w post
reduction

3 m post
reduction

Despite the frequency of distal radius fractures, the

optimal treatment remains without consensus opinion.

What should we do with this

kind of distal radial
fracture?
( Operative vs
Nonoperative )

Despite the frequency of distal radius fractures, the

optimal treatment remains without consensus opinion.

What should we do with this

kind of distal radial fracture?
( Operative vs Nonoperative
)

There is no Level-I clinical

evidence suggesting a superior
modality for treatment of distal
radial fractures
Neal C. Chen and Jesse B. Jupiter. J Bone Joint Surg Am. 2007;89:2051-62

Despite the frequency of distal radius fractures, the

optimal treatment remains without consensus opinion.

What should we do with this

kind of distal radial fracture?
If we do surgery, what kind
of xation?
- Percutaneous pinning
- External Fixation
- Plating
- Locking Plate

Closed reduction and external xation

Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture

Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture

Osseous Anatomy
Distal radius 80% of axial
load
Scaphoid fossa
Lunate fossa
Sigmoid notch DRUJ

Distal ulna

Anatomic and biomechanic of distal

radius
Three Collumn Concept
The functions of radial collumn as an
osseous buttress for the carpus radially
and serves as the origin of important
intracarpal stabilizing ligaments.
The intermediate column is the important
area for load transmission from the
lunate to the radius through the lunate
fossa.
The ulnar column serves as an axis for
forearm and wrist rotation as well as
for secondary load transmission.

Anatomy
scaphoid and lunate
fossa
Ridge normally exists
between these two

sigmoid notch: second

important articular
surface
triangular brocartilage
complex(TFCC): distal
edge of radius to base
of ulnar styloid

The Volar extension of the lunate facet.

The arrow delineates the

length of the lunate facet on
this lateral view of the distal
part of the radius.

The lunate facet has a

considerable volar extension at
the distal extent of the
pronator quadratus and
subsequently has an important
role in fracture
pathomechanics and stability.

Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar

extension of the lunate facet of the distal radius: a quantitative anatomic
study. J Hand Surg [Am]. 2006;31:892-5.)

 Orbay and Touhami (2006) dened the Watershed line as a transverse ridge
bordering the pronator fossa distally.
- The watershed line is a useful surgical landmark for positioning a volar plate.
- Implant placed on or distal to it can impinge on flexor tendon and cause
injury

 TFCC major stabiliser of ulnar carpus

& radioulnar joint
normal wrist movement
-150 degree of motion (flex/ext)
-50 deg radial/ulnar deviation
-150 deg pron/sup
axial load-80% radius
-20% TFCC

Mechanism Of Injury
Low energy trauma:
In young adult, injury usually is as
result of high energy trauma &
results in comminuted, intraarticular
injuries
Tension on the volar cortex,
comminution of the dorsal cortex,
and ligamentous injury

A greater understanding of the patterns of injury is leading

to treatment based on the specics of each individual injury.

Computed tomography scans

demonstrating
hyperextension injury to
the distal part of the
radius.

Pechlaner S, et al. Distal radius fractures and concomitant lesions.

Experimental studies concerning the pathomechanism. Handchir
Mikrochir Plast Chir. 2002;34:150-7.

Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture

Diagnosis: History and Physical

Findings
History of a fall on the outstretched hand or
an episode of trauma
A visible deformity of the wrist is usually
noted, with the hand most commonly
displaced in the dorsal direction.
Movement of the hand and wrist are
painful.
Adequate and accurate assessment of the
neurovascular status of the hand is
imperative, before any treatment is carried
out.

Diagnosis
History
Physical exam, look for other injury
injury should be evaluated for:-

open/closed
degree of soft tissue injury
neurovascular injury- median nerve injury
common

Imaging
Wrist PA, Lat, and oblique
AP and lat. Of the contralateral wrist
Ct scan

DISTAL RADIAL FRACTURE

Distal radius fractures
occur through the distal
metaphysis of the radius
May involve articular
surface
frequently involving the
ulnar styloid
Most often result from a fall
on the outstretched hand.
forced extension of the
carpus,
impact loading of the
distal radius.
Associated injuries may
accompany distal radius
fractures.

Diagnosis: Diagnostic Tests and

Examination
General physical exam of the patient,
including an evaluation of the injured
joint, and a joint above and below
Radiographs of the injured wrist
Radiographs of other areas, if
symptoms warrant.
CT scan of the distal radius in
selected instances.

Radiographic Assessment

radial inclination
volar tilt
radial length
Any intra-articular gap or step

Radial length

radial length was

measured on the
posteroanterior view as the
distance between 2 lines
drawn perpendicular to the
long axis to the radius: one
line was drawn at the level
of the radial styloid tip and
the other line was drawn at
the ulnar border of the
radius articular surface.

Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800

Radial Inclination
Radial inclination was
measured on the
posteroanterior view by
determining the angle
between a line
tangential to the distal
radial articular surface
and a line perpendicular
to the shaft of the radius

Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800

Volar tilt/Palmar tilt

Palmar tilt was measured

by the angle between the
plane of the distal
articular surface as seen
on the lateral x-ray and
the plane perpendicular
to the longitudinal axis of
the radius

Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800

Ulnar variance
Vertical distance between
a) a line drawn parallel to
the proximal surface of the
lunate facet of the distal
radius and
b) a line parallel to the
articular surface of the
ulnar head.
Usually negative variance
(e.g. -1 mm) or neutral
variance

Computed Tomography
Indications:
Intra-articular fxs with multiple
fragments
centrally impacted fragments
DRUJ incongruity
19 consecutive fx, CT had
better sensitivity for
intraarticular frag
et al: J Hand Surg, 1997
management change in 5Cole
pts

DISTAL RADIAL FRACTURE

Classied by:
presence or absence
of intra-articular
involvement,
degree of
comminution,
dorsal vs. volar
displacement,
involvement of the
distal radioulnar
joint.

Classication of
Distal Radius Fractures
Ideal system should
describe:
Type of injury
Severity
Evaluation
Treatment
Prognosis

Common Classications

Gartland/Werley
Frykman
Weber (AO/ASIF)
Melone
Column theory
Fernandez
(mechanism)

Frykman Classication
Extraarticular

Radio-carpal joint

Radio-ulnar joint

Both joints

Same pattern as
odd numbers,
except ulnar
styloid also
fractured

The AO/ASIF classication as proposed by MLLER

Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture

The treatment of fractures at the

distal Radius
The treatment of fractures at
the distal end of the radius
has certainly evolved since
Abraham Colles provided
the rst description to the
English speaking community in 1814

Determination of the best treatment option

The fracture pattern,
The degree of
displacement,
The stability of the
fracture,
The age and physical
demands of the patient.

Those patients with low

demand activities may
be best served with
nonoperative
techniques.
High demand patients,
however, may require
surgical xation to allow
early range of motion
and to prevent stiffness, which could be
detrimental for certain
activities.

Treatment Goals

Preserve hand and wrist function

Realign normal osseous anatomy
promote bony healing
Avoid complications
Allow early nger and elbow ROM

A stable fracture is one that is acceptably aligned

after reduction effort and where the likelihood of
displacement is small
Cumulative risk factors for
the loss of reduc-tion have
been identied as
age over 60,
greater than 20 dorsal
angulation,
5 mm radial shortening,
dorsal comminution,
ulna fracture, and
intra-articular radiocarpal
involvement

Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review.
J Hand Surg 2008;33A:421429

Unstable Distal Radius

Fracture

Instability is dened as the

inability of a fracture to
resist displacement after it
has been manipulated into
an anatomic position

Lafontaine et al suggested 5
factors that indicated
instability:
1. initial dorsal angulation
greater than 20,
2. dorsal comminution,
3. radiocarpal intraarticular
involvement,
4. associated ulna fractures,
5. age greater than 60
years.

Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury

1989;20:208 210.

Important radiographic
parameter
Anatomic studies
have determined
average values for
these important
radiographic
parameters:
radial inclination
(23),
palmar tilt (11),
radial length (12 mm)
Friberg S, Lundstrm B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol
Diagn 1976; 17:249 256.

The standard of treatment

for fractures of the distal radius

The standard of treatment for most fractures of the

distal radius remains closed reduction and
immobilization.
Surgical intervention should be considered when
an acceptable reduction cannot be achieved or
maintained by closed means.

CLOSED REDUCTION AND CAST IMMOBILIZATION

Closed reduction and

immobilization in a plaster
cast remains an accepted
method of treatment for
most sta-ble distal radius
fractures and for all non
displaced fractures

CLOSED REDUCTION AND PINNING

Closed reduction and

percutaneous pin xation
are best suited for
fractures without
articular involvement and
also without substantial
metaphyseal
comminution.

CLOSED REDUCTION AND PINNING

A variety of pinning
methods have been
described;
The most popular is
oblique radial styloid to
proximal ulnar cortex,
as well as placement of
the pins through the
fracture site.

A prospective, randomized trial

encountered markedly inferior
clinical and radiological results
for percutaneous pinning compared
with
locked volar plating,
even for extra-articular distal radius
frac-tures.
McFadyen I, Field J, McCann P, Ward J, Nicol S, Curwen C.
Should unstable extra-articular distal radial fractures be treated with xed-angle volar-locked plates or
percutaneous Kirschner wires? A pro-spective randomised controlled trial. Injury 2010;42:162166.

EXTERNAL FIXATION

It employs ligamentotaxis to
improve the length and
alignment of the fracture.

Bridging external fracture

xation refers to a surgical
effort that bridges the radius
fracture and gains purchase
distal to the radiocarpal joint.
Nonbridging external xation
uses pins in the distal radial
fragment and pins proximal
to the fracture with-out
bridging the radiocarpal
joint.

External xation:
The treatment of choice
for distal radius fractures
in the 1980s

Types of External Fixation

Spanning
Dynamic
Clyburne
Agee
Pennig

Static
AO
Ace

Non-spanning

Hoffman 2
Cobra
Zimmer
AO

Bridging external xation

A spanning xator is one which

xes distal radius fractures by
spanning the carpus; I.e.,
xation into radius and
metacarpals

Nonbridging external
xation

A non-spanning xator is
one which xes distal radius
fracture by securing pins in
the radius alone, proximal
to and distal to the fracture
site.
In this instance, frag-ments
are reduced by direct
manipulation. The nonbridging method requires a
sizeable extra-articular
distal fracture fragment

DORSAL PLATES
Radius fractures with metaphyseal comminution typi-cally collapse in a dorsal
direction and a dorsal ap-proach will provide excellent articular surface
visual-ization and allow for buttressing of these fragments.
Disadvantages are that the plate is placed under the extensor tendons, which
may lead to extensor tendon irritation and rupture.

Synovitis was noted to occur where the extensor

tendon glide directly over the plate and screws.
After plate removal, the tendon has visible
attritional changes.

Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*

J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

VOLAR FIXED-ANGLE PLATES

A more traditional
approach involves
proximal plate
xation before the
fracture is reduced,
and the distal
screws are subsequently placed to
maintain the
reduction effort

The lift-off method places the distal screws rst and then uses the
plate to correct the dorsal mal-alignment of the fracture.
Johannes Schneppendahl, MD, JoachimWindolf, MD, Robert A. Kaufmann, MD. J Hand Surg 2012;37A:17181725.

The Surgical Technique

The fracture surgery perform with the patient
under regional anesthesia.
Image intensication is crucial during surgery
and is accomplished with a surgeonoperated mini-C-arm fluoroscopy unit.
Parenteral antibiotics are given at least thirty
minutes before the commencement of
surgery.
Pneumatic tourniquet control is used.

Anterior approach
Incision line over the
flexor carpi radialis
tendon.

The flexor carpi radialis

tendon sheath is opened
(arrow).

Kevin C. Chung and Elizabeth A. Petruska

J Bone Joint Surg Am. 2007;89:256-266.

Anterior approach

The incision is made along

the radial border of the flexor
carpi radialis tendon to
ensure that the palmar
cutaneous branch of the
median nerve (displayed
over a dark blue background)
is protected.
The index nger of the
surgeon is swept under the
flexor pollicis longus tendon
in an ulnar direction.

Anterior approach
Retractors are placed
gently to expose the
pronator quadratus
(arrow).

An L-shaped incision (dark

lines) is made to elevate
the pronator quadratus.

The Surgical Technique

It is useful to place a needle

into the radiocarpal joint
to identify the most distal
rim of the radius.
Manipulative reduction is
performed to realign the
volar cortical fracture
lines.
Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*
J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

The Surgical Technique

A smooth
Kirschner wire
is placed from
the radial
styloid across
the fracture
line to achieve
provisional
xation of the
fracture.
Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*
J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

The Surgical Technique

Retractors are placed to
provide full exposure
prior to plate
application.

The distal row of locking

screws is placed near
the subchondral bone
of the distal fragment.
Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*
J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

The Surgical Technique

The position of the plate and
distal screws is conrmed
with use of fluoroscopy.
The proximal limb of the plate
purposely lies off the
diaphysis by 10 to facilitate
further reduction of the distal
fragment when the proximal
limb is secured to the bone.
Volar tilt of the distal fragment is
achieved by tightening the
proximal screws. The
provisional Kirschner wire is
removed before the screws
are
fully
Jesse
B.tightened.
Jupiter, MD, M. Marent-Huber, and the LCP Study Group*
J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

The nal anatomic reduction and plate and screw

placement are conrmed with use of intraoperative
fluoroscopy.

Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*

J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

Insert plate and screw

The rst consideration, insert the rst screw in subchondral bone.
It is strongly recomended to use Image Intensier

All screw had been inserted

Pronator Quadratus sutured back to its place

Complications of Volar Plate Fixation for

Managing Distal Radius Fracture

Postoperative lateral radiograph (A) and

intraoperative photograph (B) of a
patient who presented with extensor pollicis
longus rupture 2 months after volar plate
xation of a distal radius fracture. In panel B,
the screw tip can be seen in the third
extensor compartment (arrow).

The exposure to the dorsal aspect of the radius. The retinaculum

is opened over the third extensor compartment, elevating the
extensor pollicis longus.

Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*

J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

Case Presentation

Summary
The standard of treatment for most fractures of the
distal radius remains closed reduction and
immobilization.
Surgical intervention should be considered when
an acceptable reduction cannot be achieved or
maintained by closed means.

Thank you