Colles' Frx

- See:
- Distal Radius Frx Menu:
- Intra-Articular Fractures of the Distal Radius:
- General Discussion:
- frx was described by Abraham Colles in 1814, originally described as low energy extra
articular
frx of distal radius occuring in elderly individuals;
- frx is typically dorsally displaced and angulated;
- mechanism:
- fracture is also caused by a forced dorsiflexion of the wrist;
- occurs in pts > 50 years of age who fall on out stretched hand;
- dorsal surface undergoes compression while volar surface undergoes tension;
- classification:
- Frykman Classification
- Melone Classification
- Universal Classification
- associated injuries:
- TFCC tear
- according to the report by Richards et al 1997 et, TFCC tears occurred in 53% of
extra-articular
distal radius fractures vs 35% of intra-articular fractures;
- Physical Exam and Evaluation:

- Radiographic Findings:
- x-ray appearance is that of a dorsally angulated fracture of distal radial metaphysis
(2-3 cm proximal to wrist joint), w/ or w/o associated frx of ulnar styloid;
- initial frx line is almost always on volar side & is single line;
- determination of stability:
- intra-articular component:
- radial shortening:
- dorsal angulation:
- radial inclination:
- distal radioulnar subluxation and/or ulnar styloid frx
- in stable extra-articular fractures, there will often be frx extension into the DRUJ,
which is the most likely source of symptoms;
- scapholunate dissociation:
- ref: Scapho-Lunate Diastasis: A Component of Fractures of the Distal Radius.
Mudgal-CS. Jones-WA. J Hand Surg. 1990. 15-B. pp 503-505.
- comminution:
- dorsal surface is frequently comminuted;

- if comminution extends volar to midaxial plane of radius, then cast immobilization will
frequently fail;
- expect increase in comminution w/ incr in amount of dorsiflexion;
- high-loading angles, (70-90 deg), have much more comminution than low
loading angles of 20 to 40 deg;
- as noted in the study by Trumble et al 1998, external fixation provided clear
advantages in specific situations;
- in older patients, pain relief, grip strength, and ROM were significantly better
when external fixation was used;
- in younger patients, external fixation provided consistently better results when
there was comminution in 2 or more cortices;
- references:
- An effective treatment of comminuted fractures of the distal radius.
- Intrafocal (Kapandji) pinning of distal radius fractures with and without external
fixation.
TE Trumble et al. J. Hand Surg. Vol 23-A. No 3. May 1998. p 381.
- Treatment:
- Colles Fracture Reduction: (see: position of immobilization);
- Percutaneous Pinning
- External Fixators for Distal Radius Fractures:
- ORIF of Intra-Articular Distal Radius Fractures:
- Late Complications:
- extensor pollicis longus rupture:
- RSD
- often RSD following colles fractures will result from over distraction of an external
fixator;
- in the presentation by D Stoffelen and PL Broos (15 th Annual Meeting of the
Orthopaedic Trauma Association 1999), the authors found
use of calcitonin to be helpful in treating this disorder;
- loss of reduction and secondary deformity;
- median nerve compression;
- malunion:
- distal radioulnar joint injury;
- extension of Colles frx into the RU joint has a worse prognosis;
- in stable extra-articular fractures, there will often be frx extension into the DRUJ, which
is the most likely source of symptoms;
- patients may note:
- weak grip;
- localized pain;
- loss of supination;
- ref: The Distal Radio-Ulnar Joint in Colle's Fracture. GS Roysam. JBJS 75-B, 1993. p
58-60.

- Refernces

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Fractures of the Radius:

- Proximal Radial Fractures:
- Radial Head Frx:
- Radial Neck Frx:
- Distal Radius Fractures:
- radiographs:
- radial inclination
- radial length
- palmar slope:
- fracture types
- barton's fracture - dorsal
- barton's fracture - volar
- chauffeur's fracture
- colles fracture
- intra-articular fractures of distal radius:
- malunion
- pediatric distal radius fracture:
- smith's fracture
- classification:
- frykman classification
- melone classification
- universal classification
- treatment:
- closed reduction
- percutaneous pinning
- external fixators for distal radius fractures:
- ORIF of distal radius fractures
- references
- Radial Shaft Fractures:
- Both Bone Fractures:
- Galeazzi's Fracture:
- Radial Shaft Fractures: Discussion:
- Surgical Approach for Radial Shaft Fractures:
Dorsal Approach (Thompson) :
Henry Approach to the Radius (anterior approach);

Growth plate activity in the upper extremity.

Hand and wrist function after external fixation of unstable distal radial fractures.
Fractures of the distal end of the radius in young adults: a 30-year follow-up.

Remodeling of angulated distal forearm fractures in children.

Pattern of forearm fractures in children.
Year Book: Fractures of the Lower End of the Radius Anteriorly Displaced Treated by Plating.
Congenital proximal radio-ulnar synostosis. Natural history and functional assessment.
Intra-articular fractures of the distal end of the radius in young adults.
Angulated radial neck fractures in children. A prospective study of percutaneous reduction.

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Radial Neck Fracture:

- See:
- Radial Head Frx;
- Pediatric Elbow Injuries
- Discussion:
- radial neck frx are more common in children, whereas frx of radial head occur primarily in
adults;
- site of frx in childhood is either thru physis w/ metaphyseal fragment (type II physeal injury),
or thru neck proper (3-4 mm distal to epiphyseal plate);
- most cases are Salter-Harris type II fractures (90%);
- in children, proximal radial epiphysis is cartilaginous & is more prone to fracture than
hard articular surface of radial head;
- may have angulation or lateral translation of radial head to a variable degree (Jeffrey type
I);
- this frx occurs on average at age of 10 yrs, after ossification center of the proximal radial
epiphysis appears;
- ossification center of the upper epiphysis of the radius appears at fifth yr & fuses w/
body between ages of 16 and 18 years;
- mechanism:
- results from a hard fall on an extended & supinated outstretched hand;
- force is transmitted thru shaft of radius, & momentum of body drives capitellum against
lateral half of radial head,
tilting & displacing it laterally;
- direction of tilting of displaced head relative to shaft of radius depends upon the rotational
attitude of radius at time of injury;
- if the forearm is fully supinated, the displacement is lateral;
- if the forearm is in neutral mid position, it is posteiror;
- total displacement, especially in posterior direction, may occur following spontaneous
relocation of an elbow dislocation;
- associated Injuries:

- capitulum fracture
- dislocation of distal RU joint;
- valgus instability (MCL avulsion);
- rupture of triceps tendon;
- fracture of olecranon or upper shaft of the ulna;
- compression force may frx lateral humeral condyle;
- Physical Exam:
- carefully assess the function of the posterior interosseous nerve;

- Radiographic Features:
- before age 4, normal lateral (valgus) sloping of radial neck may be
misinterpreted
as representing an injury;
- upto 15 deg of valgus may be normal;
- notch at lateral aspect of proximal radial metaphysis may be seen in older
children
and should not be confused with injury;
- note that the radial neck may lie in 15 deg of valgus;
- note that the physis of the proximal radius is widened on the lateral side;
- technique:
- anteriorposterior, lateral (look for fat pad sign)
- consider radiocapitellar view;
- forearm in neutral rotation & the x-ray tube angle 45 deg. cephalad
- type I frx:
- may be difficult to identify;
- posterior fat pad sign should suggest further oblique views, including radial head
capitellum view;
- Salter Harris II:
- type II frx is most common type of radial head & neck frxs in children;
- look for positive posterior fat pad signs, but note that this fracture type can be extraarticular,
and therefore a fat pad sign may not be seen;
- subtle anterior or posterior displacement of the radial head or shaft, as determined
by use of radiocapitellar line;
- Accetable Reduction:
- younger child:
- < 10 deg of residual neck angulation will correct w/ growth;
- upto 30 deg of residual angulation can be accepted;
- angulation is > 30 deg
- closed manipulative reduction or percutaneous pin to manipulate frx;
- age > than 10 yrs:
- poor results w/ angulation > 30 deg, or translocation > 3 mm;
- inability to reduce angulation < 45 deg, requires ORIF
- crossed K-wire fixation of the proximal radius is preferred;
- inability to pronate and supinate the forearm more than 60 deg, is another sign that that
the reduction is not adequate;
- Treatment Algorithm Based on Displacement:
- minimally displaced frx:

- immobilize elbow (in 90 deg of flexion & neutral forearm rotation) in posterior splint for 1-2
weeks, then active ROM;
- child > 10 years: correct tilting of radial head to less than 15 deg by closed reduction;
- moderately displaced Frx:
- w/ frx tilting of between 30 & 60 deg perform closed reduction under GEA;
- 45 deg of angulation is acceptable, if passive supination and pronation is 60-70 deg in
both directions;
- reduction maneuver;
- elbow is completely extended & forearm is then fully supinated;
- determine direction of displacement of radial head;
- firm digital pressure is applied to acheive reduction;
- displaced frx:
- may require open reduction;
- closed manipulative reduction is attempted under GET
- manipulation should achieve < 30 deg of angulation to be acceptable;
- attempt reduction by applying a valgus stress and simultaneous direct manipulation
w/ the surgeon's thumbs;
- percutaneous K-wire manipulation may be attempted before resorting to open
reduction;
- pronating the forearm moves the posterior interosseous nerve away from the
radial head;
- oblique K-wires offer the best fixation in this age group;
- w/ residual angulation > 45 deg after reduction, consider ORIF;
- when frx is diagnosed late, deformity of radial head tilting can be corrected by open up
wedge osteotomy with a bone grafting;

- Specific Treatment Methods:

- ORIF of radial neck frx in adults:
- see: posterolateral approach:
- consider insertion of an AO 2.0 mm miniplate
- following fixation, test for MCL instability which is commonly found in adults;
- radial head excision in children:
- in children radial head should not be excised because of resulting growth disturbance &
deformity of wrist & elbow;
- excision of radial head in children is disastrous, w/ uniformly poor results due to cubitus
valgus, proximal migration
of radius, & synostosis.
- Complications:
- malunion results from failure either to achieve adequate reduction or to maintain reduction;
- malunion may also result from premature fusion of upper radial epiphysis occurs
frequently displaced fractures;
- this will cause shortening of the radius and increased cubitus valgus, depending on
pt's age & degree of cartilagenous damage;
- non union:
- in the study by PM Waters et al, the authors conducted a retrospective review of 9 cases
of radial neck nonunion in an
effort to identify risk factors for nonunion and to evaluate treatment options;
- 9 patients, average age 8.2 years, sustained displaced Salter-Harris type II fractures
of the radial neck, with average angulation of 83 and average displacement of
83%,
and elbow dislocation or additional fracture in eight of nine patients;

- initial treatment with open reduction achieved anatomical alignment of the fracture
fragments
in 7 of the 9 patients;
- initial reduction was lost and radial neck nonunion developed in all patients;
- nonunion was treated with observation, radial head and neck excision, or ORIF with
bone graft,
depending on the level of pain, deformity, and functional deficit;
- healing of the nonunion did not necessarily lead to improvement of clinical
symptoms;
- severity of initial fracture displacement and inadequate fixation technique
contributed to radial neck nonunion;
- ref: Radial Neck Fracture Nonunion in Children. Peter M. Waters, JPO 2001;21:570576
- avascular necrosis:
- may occur in upto 10 %, and is more common with operative intervention;

Angulated radial neck fractures in children. A prospective study of percutaneous reduction

Fractures of the radial head and neck in children.
Radial growth and function of the forearm after excision of the radial head. A study of growing
macaque monkeys.
Fracture-separation of the distal humeral epiphysis in young children.
Management of radial neck fractures in children: a retrospective analysis of one hundred
patients.
Observations concerning radial neck fractures in children.
Fowles JV, Kassab MT: J Pediatr Orthop 1986;6:51.
Percutaneous reduction of displaced radial neck fractures in children.
SM Berstein et al. J. Pediatric Orthopaedics. Vol 13. 1993. p 85-88.
Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning.
JP Metaizeau et al. J. Pediatric Orthopedics. Vol 13. 1993. p 355-360.
New reduction technique for severely displaced pediatric radial neck fractures.

Radiographic Findings of Distal Radius Frx:

- See:
- Radiology of the Wrist
- Distal Radius Fx

- Discussion:
- radiographic measurements:
- articular step off: most important determinant of outcome;
- radial shortening second most determinant of outcome;
- dorsal angulation
- radial inclination
- unstable vs stable frx;
- stable frx are usually extra articular w/ mild to moderate displacement, & when reduced
do not redisplace to the original deformity;
- in stable extra-articular fractures, there will often be frx extension into the DRUJ, which is
the most likely source of symptoms;
- intra-articular frx:
- displacement can be measured by applying a series of circular templates to the
curvature of the greatest remaining
articular surface of the distal radius;
- depressed areas off of the circle template are measured for step off;
- comminution:
- if comminution extends volar to midaxial plane of radius, then cast immobilization will
frequently fail;
- as noted by Trumble et al 1998, in younger patients, external fixation provided
consistently better
results when there was comminution in 2 or more cortices or when there was
comminution of one
surface which was greater than 50% of the metaphyseal diameter;
- in older patients, external fixation provided better results if there was comminution in
only one cortex;
- references:
- An effective treatment of comminuted fractures of the distal radius.
- Intrafocal (Kapandji) pinning of distal radius fractures with and without external
fixation.
TE Trumble et al. J. Hand Surg. Vol 23-A. No 3. May 1998. p 381.
- rotational alignment:
- in the study by Tornetta et al (15 th Annual Meeting of the Orthopaedic Trauma
Association, 1999), the authors point out that
there can be up to 38 deg of mal-rotation can be present before a step off can be
appreciated on the lateral view;
- PA views were even less sensitive for determining malrotation;
- it was determined that over pronation of the distal fragment was associated with a
more volar position of the ulna
on a true lateral view (where as it is normally slightly dorsal on a true lateral view);
- classification:
- Frykman Classification
- Melone Classification
- Universal Classification

- Routine Views:
- PA View
- radial inclination
- radial length: (ulnar variance)
- radial ulnar joints:
- distal radioulnar joint should measure approximately 2 mm;
- if there is a of a radio-ulnar joint disruption consider CT scan;
- lateral view
- fat pads: (in the case of occult injury)
- dorsal tilt:
- look for dorsal tilt of the lunate (DISI deformity);
- misc: consider use of a 20-25 deg tilted lateral to better profile the radial articular surface;
- ref: Tilted lateral radiographs in the evaluation of intra-articular distal radius fractures.
DW Lundy MD et al. J. Hand Surgery. Vol 24-A. 1999. p 249.
- Specialized Studies:
- Ulnar Deviation PA View;
- Pronated Olblique (STT joint)
- Ulnar Deviation Lateral View:
- normally ulnar deviation will cause the lunate to dorsiflex and shift volarly, and the radioluno-capitate
alignment resembles a DISI pattern;
- volar shift of the lunate helps maintain the normal co-linear relationship of the radius
and the capitate;
- w/ mid carpal ulnar instability, the lunate will dorsiflex,
but will not have normal palmar translation;
- hence, the longitudinal axis of the capitate lies above the axis of the radius;
- this "zig zag" deformity would be expected to cause symptoms following distal radial
fractures even if the loss of volar tilt was minimal;
- CT scan: can help assess the step off of intra-articular fractures and comminution;

Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters.
Computerized tomographic evaluation of acute distal radial fractures.
Colles fracture: does the anatomical result affect the final function
Colles' fracture. How should its displacement be measured and how should it be immobilized.
Factors affecting the outcome of Colles' fracture: an anatomical and functional study.
Radiographic evaluation of osseous displacement following intra-articular fractures of the
distal radius: reliability of plain radiography versus computed tomography.

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Radial Inclination of Distal Radius Frx

- Discussion:
- mean radial inclination was 24 degrees (range, 19 to 29 degrees);
- measured on PA view, & describes relative angle of distal radial articular surface to
a line perpendicular to long axis of the radius;
- this angle normally measures between 16 and 28 deg, av = 20;
- measured on AP & is represented by < formed by line drawn from tip of radial styloid to
ulnar corner of articular surface of distal end of radius & line drawn perpendicular
to longitudinal axis of the radius;
- avgerage radial inclination is 22 to 23 deg (some say 16 to 28 deg);
- loss of radial inclination will increase load across the lunate;
- Acceptable Reduction:
- radial tilt greater than 10-15 deg;
- loss of radial inclination will be more likely to result in pain when there is concomitant loss of
dorsal inclination;
- Restoration of Radial Inclination:
- radial-ulnar translation of hand on forearm is may be used in realigning distal radial fragment
on the radial shaft;
- w/ ulnar translation, the 1st and 2nd extensor compartment tendons and their associated
retinaculum create a radial soft tissue hinge;
- this allows ligamentotaxis w/ ulnar translation to restore the ulnar tilt;

Distal Radial Frx: Radial Length:

- Distal Radial Length:
- shortening results from extensive comminution and impaction of frx fragments into the
metaphysis;
- shortening of radius is more disabling than an angulatory deformity of the distal radius (ie,
dorsal tilt or loss or radial inclination);
- radial shortening following distal radial frx may lead to acquired positive ulnar variance, ulnar
impaction syndrome, and instability;
- patients will often have significant loss of pronation and suprination;
- some authors, in fact, note that radial shortening is only important in so much that it
reflects a change in ulnar variance;
- usually a change of more than 3 mm of ulnar variance will lead to symptoms;
- radiographic measurement:
- for precise measurement, a true lateral radiograph of both wrists should be obtained
inorder to compare the
radial lengths of the injured and the non injured wrists;

10

- mark two lines perpendicular to long axis of the radius;

- first line intersects tip of radial styloid;
- second line intersects distal articular surface of ulnar head;
- distance between two lines, is called radial length should be 11 to 12 mm;
- acceptable reduction:
- normal length of radius averages 9-12 mm;
- shortening of upto 3-5 mm can be associated w/ a satisfactory result, as long as there is
an accurate articular restoration,
however, the surgeon should strive to achieve less than 2 mm of shortening;
- greater than 10 mm of shortening is often associated w/ symptoms, including
involvement of distal RU joint
- management:
- when radial shortening is due to comminution, then external fixation is the most
reliable method of restoring length;

Correction of Post-Traumatic Wrist Deformity in Adults by Osteotomy, Bone Grafting, and Internal
Fixation.
DL Fernandex MD. JBJS Vol 64-A, No 8, Oct 1982. p 1164-1178.
Classification of distal radius fractures.
S. Solgaard. Acta Orthop Scand. Vol 56. p 249-252. 1985.
Fractures of the distal end of the radius in young adults: a 30-year follow-up.
Minor axial shortening of the radius affects outcome of Colles' fracture treatment.
Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation.
TE Trumble et al. J. Hand Surg. Vol 23-A. No 3. May 1998. p 381.

Distal Radius Frx: Dorsal Angulation:

- See:
- Reduction of Dorsal Angulation:
- Discussion:
- measured on lateral, from angle created between articular surface
of distal radius & line perpendicular to long axis of radius;
- normal volar tilt measures between 0 to 22 degrees (mean 11 to 14.5 deg);
- rare individuals may even have a dorsal tilt (which for them is normal);
- dorsal tilt decreases moment arm of finger extensors, making wrist less efficienct;
- w/ dorsal tilt deformity, there will be significant transfer of load onto ulna;

11

- normally 82% of compressive load across the wrist is borne by radio-carpal

joint, and 18% is borne thru the ulnocarpal joint;
- w/ a 45-deg dorsal angulation deformity, 65 % of axial load across carpus
is directed onto ulna;
- remaining loads on radius will be concentrated on dorsal aspect of
scaphoid fossa;
- Acceptable Reduction:
- most orthopaedist will generally not accept any angulation past neurtal;
- consider obtaining a lateral radiograph of the opposite wrist for comparison;
- note that some patients may be predisposed to ulnar mid carpal instability,
and hence, even an "acceptable reduction" w/ 5 deg volar tilt may cause symptoms;
- note whether there is abnormal dorsal tilt of the lunate;
- as pointed out by Jupiter JBJS 1991: dorsal tilt greater than 20 deg will often
become symptomatic w/ pain at radiocarpal articulation, as well as in
limited grip strength, if angulation is not reduced;
- when radial shortening occurs w/ dorsal tilt, there may be dysfunction of the
distal R-U joint, manifested by limited rotation of forearm & impingement
of ulna on radius;
- Assoicatted Findings in Acute Injury:
- see unstable distal radial frx;
- in younger patients w/ distal radius frx, mid-carpal instability may be found in
association w/ excessive dorsal tilt;
- look for dorsal tilt of the lunate (DISI deformity);
- comminution:
- dorsal surface is frequently comminuted;
- if comminution extends volar to midaxial plane of radius, then cast
immobilization will frequently fail;
- expect increase in comminution w/ incr in amount of dorsiflexion;
- high-loading angles, (70-90 deg), have much more comminution
than low loading angles of 20 to 40 deg;
- Effects of Chronic Dorsal Tilt:
- in chronic cases, a malunion w/ excessive dorsal tilt may lead to ulnar mid carpal instability;
- w/ healed fractures, symptotomatic dorsal angulation greater than 20 deg
can be managed w/ a corrective opening wedge radial osteotomy;

Dorsal Barton's Fracture / Dorsal Shearing Frx:

- Discussion:
- distal radius fracture w/ dislocation of radiocarpal joint;
- most common frx dislocation of the wrist joint;
- comminuted frx of distal radius may involve either anterior or posterior cortex and
may extend into the wrist joint;
- frx dislocation or subluxation in which the rim of distal radius,
dorsally or volarly is displaced with the hand and carpus;
- it often occurs along with a radial styloid frx;
- it differs from Colles' or Smith's Fracture in that the dislocation is the
most striking radiographic finding;
- in most cases, marginal frag is smaller than in anterior injury & often involves

12

medial aspect where EPL crosses distal radius;

- Radiographs:
- 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;

Anterior and posterior marginal fracture-dislocations of the distal radius. An analysis of the
results of treatment.
Barton's fractures - reverse Barton's fractures: Confusing eponyms.
GH Thompson and TT Grant. CORR. Vol 122, 1977. p 210-221.
Barton's Fractures.
JC de Oliveira. JBJS Vol 55-A, 1973. p 586-594.

Volar Barton's Fractures:

- Discussion:
- characterized by frx of volar margin of the carpal surface of the radius which is associated w/
subluxation of radiocarpal joint;
- similar to Smith's type III;
- comminuted frx of distal radius may involve either anterior or posterior cortex and may
extend into the wrist joint;
- both involve volar dislocation of carpus assoc w/ intra articular distal radius component;
- frx dislocation or subluxation in which the rim of distal radius, dorsally or volarly is
displaced with the hand and carpus;
- it differs from Colles' or Smith's Fracture in that the dislocation is the most striking
radiographic finding;
- volar Barton's is more common than dorsal Barton frxs;
- mechanism:
- usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and
tension failure of volar lip of radius;
- strong volar radiocarpal ligaments avulse the volar lip of the radius from the
metaphysis;
- Radiographs:

13

- frx cleft extends proximally in coronal plane in oblique direction, so that free fragment is
wedge shaped;
- carpus is displaced volarly & proximally w/ articular fragment;
- w/ volar Barton's frx, it is critical to note whether there is more ulnar or radial sided
comminution (since this will affect the choice of surgical approach);
- if necessary, order a CT scan to better define the anatomy;
- Non Operative Treatment:
- most of these fractures will require operative treatment;
- if non operative treatment is attempt, be sure to immobilize the wrist palmar flexed which will
tip the carpi away from the fractured volar surface;
- ORIF and Surgical Approach for Anteriorly Displaced Frx:
- ORIF is required for all displaced volar articular lip fractures;
- even with initial acceptable reduction (w/ wrist in extension), recurrance of palmar
subluxation is common;
- strong proximal pull of the extrinsic wrist and digital flexors and extensors makes closed
reduction difficult and predisposes joint to redisplacement;
- implants:
- volar plates are well tolerated, and seldom need to be removed;
- small T plate on the volar aspect;
- plate is bent in mid portion to effect prebending effect;
- ensure that the distal margin of the plate does not encroach on the articular surface
(using flouro);
- slight dorsal articular penetration may be allowable;
- begin w/ a proximal screw (3.5 cortical) placed into the distal side of the oval hole, which
will have
the effect of moving the plate distally (which then applies compression to the
periarticular fragments);
- subsequently, insert the distal screw (4.0 cancellous) only if it is needed;

Barton's Fractures.
JC de Oliveira. JBJS Vol 55-A, 1973. p 586-594.
Anterior and posterior marginal fracture-dislocations of the distal
radius. An analysis of the results of treatment.
Barton's fractures - reverse Barton's fractures: Confusing eponyms.
GH Thompson and TT Grant. CORR. Vol 122, 1977. p 210-221.

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14

Chauffeur's Fracture: Radial Styloid Fractures:

- Discussion:
- radial styloid frxs most commonly occur from tension forces sustained
during ulnar deviation and supination of the wrist;
- strong radiocarpal ligament, particularly radioscaphocapitate ligament, avulse
radial styloid from metaphysis of the radius;
- ligamentous attachments maintains alignment radial styloid to carpus,
but styloid may be markedly displaced from the rest of radius;
- brachioradialis & extrinsic wrist & finger flexors & extensors
exert powerful displacing force on carpus/radial styloid complex;
- frx of styloid are frequently accompanied by dislocations of lunate;
- Associated Injuries:
- Scapholunate Dissociation:
- Transstyloid Perilunar Dislocation:
- Dorsal Barton's:
- Radiographs:
- while styloid is best visualized radiographically in partially pronated view,
identification of scapholunatae diastasis requires supinated view;
- evaluation of radial styloid frxs should always include supinated view
so that SLD can be ruled out; (see x-ray findings)
- Surgical Fixation: (see percutaneous fixation)
- fixation of radial styloid begins at tip, which is best approached via
small incision along margin of 1st dorsal compartment (APL, EPB);
- although K wire or cannulated lag screw fixation can be achieved
percutaneously, it is advisable to make small incision;
- remember that the the radial styloid lies slightly volar to the mid axis
of the radius, and therefore the wire should be directed slightly
dorsally as well as ulnarly and proximally;
- reduction is secured w/ either K wire or lag screw;
- 3 indications formal ORIF; (See: ORIF of Distal Radius Frx:)
- rotational displacement in axial or coronal plane may prove
difficult to overcome, or hematomas may interfere w/ reduction;
- interposed tissue (FCR, or rarely wrist extensors);
- metaphyseal defect after reduction which requires bone grafting;
use of either a small drill guide or tissue protector to protect
dorsal sensory radial nerve;
- evaluation of reduction:
- articular reduction is best evaluated by radiocarpal arthrotomy between
second & fourth dorsal compartments, just distal to Lister's tubercle;
- when bone grafting is necessary, placement is usually required in the
area between the first and second dorsal compartments;
- K wire fixation devices should pass perpendicular to the fracture
site, enter the tip of the radial styloid, and exit proximal to distal RU joint;
- stabilization of styloid w/ K wires alone is hazardous, becuase medial, single
cortex fixation is often insufficient to prevent redisplacement;
- as an alternative, two cancellous screws (4.0 mm cancellous) or
3.5 mm cortex screws or 3.5 mm cannulated screws;
- butress plate is more reliable (2.7 mm condylar plate);

15

----------------------------------The Chaufeur's Fracture: Simple or Complex?

RH Helm and MA Tonkin.
J. Hand Surg. 17-B, 1992. p 156-159.

Intra-Articular Frx of the Distal Radius:

- See:
- Distral Radius Frx Menu
- Dorsal Barton's Frx
- Volar Barton's Frx:
- Unstable Distal Radial Frx;
- Discussion:
- mechanism:
- distal radius articular frx principally result from the die punch mechanism of injury that
leads to consistent patterns
of articular disruption and often with w/ radiographic signs of instability (most often
DISI deformity);
- effects of articular incongruity:
- articular involvement in low-energy frx in older, post-menopausal women has little effect
on the generally favorable outcome in these pts;
- in younger patients, these fractures are often result of high energy trauma and may be
associated w/ carpal instability, and/or disruption of distal RU joint;
- as noted by Kirk and Jupiter, 91% of wrists that had greater than 1 mm of incongruity
developed DJD and
100% of wrists that had more than 2 mm of incongruity develop DJD after an avg
6.7 years;
- as noted by Catalano et al 1997, residual joint incongruenty will lead to radiographic
DJD in about 75% of wrists at an average of 7 years,
however, this radiographic appearance does not necessarily correlate with
functional status;
- associated injuries:
- TFCC tear
- according to the report by Richards et al 1997 et, TFCC tears occurred in 53% of
extra-articular distal radius fractures vs 35% of intra-articular fractures;
- scapholunate dissociation:
- as noted by Richards et al 1997, 21% of patients with intra-articular distal radius frx
will have SLD;
- classification:
- frykman classification
- melone classification
- universal classification

16

- Radiographs:
- in the study by Cole et al 1997, the arc method read off of reformated CT images provided
the most reliable method for quantitating articular step off;

- Treatment:
- for patients w/ high energy, shearing, two-part radiocarpal frx-dislocation, (Dorsal or Volar
Barton's Frx)
restoration of articular congruity is required to optimize hand and wrist function and
prevent post-traumatic arthritis;
- percutaneous pinning
- external fixation:
- references:
- Plaster cast versus external fixation for unstable intraarticular Colles' fractures.
- External fixation for intra-articular fractures of the distal radius.
- The surgical treatment of severe comminuted intraarticular fractures of the distal
radius with the small AO external fixation device. A prospective three-and-one-half-year follow-up
study.
- ORIF of distal radius fractures
- references:
- The operative treatment of intraarticular fractures of the distal radius.
- Open reduction and internal fixation of comminuted, intraarticular fractures of the
distal radius.
- Limited open reduction of the lunate facet in comminuted intra-articular fractures of
the distal radius.
- Open reduction and internal fixation of displaced, comminuted intra-articular
fractures of the distal end of the radius.
- Case Example:

Treatment of Distal Radius Frx Malunion:

- Discussion:
- often patients will note pain weeks to months after the cast is removed;
- w/ excessive dorsal tilt, will often develop a symptomatic ulnar mid-carpal instability (or
carpus adaptive DISI);
- in the report by Taleisnik and Watson 1984, the average amount of dorsal tilt which
caused significant
symptoms was 23 deg, however, in one case a patient had symptoms w/ 8 deg of
volar tilt;

17

- Exam:
- w/ excessive dorsal tilt, look for:
- symptoms may include tenderness over lunocapitate and triquetrohamate joints;
- a painful audible snap often results from active ulnar deviation w/ forearm pronation;
- some loss of palmar flexion is usually present;
- grip strength is usually decreased by 50%;
- w/ excessive radial shortening or loss of radial inclination would be more likely to affect
the RU joint (limiting pronation and supination);
- Radiographs:
- PA View
- Radial Inclination
- Radial Length:
- Lateral View
- Fat Pads: (in the case of occult injury)
- Palmar Slope:
- look for dorsal tilt of the lunate (DISI deformity);
- excessive dorsal tilt is associated w/ ulnar mid carpal instability (or carpus adaptive
DISI);
- Opening Wedge Osteotomy:
- preoperative consdierations:
- this procedure is mainly indicated in young active patients;
- ensure that the fracture is fully healed before the osteotomy is performed;
- if the osteotomy is performed before the frx is fully healed, the distal radius may refracture
as the osteotomy is created;
- radiographs of the opposite wrist should be taken inorder to help judge how much
correction is necessary;
- surgical technique:
- dorsal approach to the distal radius;
- distal radius is approached between the 2nd and 4th compartments;
- EPL tendon is mobilized;
- subperiosteal dissection will maximize the amount of soft tissue between the
extensor tendons and the plate;
- in the saggital plane, a K wire is inserted perpendicular to the radial surface, at a point
several cm
proximal to the osteotomy site;
- preparing for the osteotomy:
- a second K wire is inserted just proximal to the radial articular surface, at an angle
subtended by it and
the first wire which equals the amount of deformity in the saggital plane;
- finally a third K wire is inserted parallel to the joint line;
- this ensures that the osteotomy is parallel to the joint line;
- consider using flouro to confirm this, or place a wire thru the joint capsule along the
articular surface of the radius;
- Lister's tubercle is removed to produce a more flat surface for the plate;
- osteotomy site is marked 2.5 cm proximal to the wrist joint;
- Homan retractors are inserted to protect the volar soft tissues;
- osteotomy:
- osteotomy is made just proximal to the sigmoid notch;

18

- in the AP plane, the osteotomy is made at right angles to the radial shaft (as opposed to
making it parallel to the radial inclination);
- the later cut may not allow enough room for distal screw fixation;
- in the lateral plane, the osteotomy is made parallel to the dorsal tilt;
- osteotomy is created on the dorsal and radial aspects of the distal radius, which allows
lengthening and re-creation
of volar tilt (against the intact volar and ulnar periosteal hinge);
- the osteotomy is spread open w/ laminar spreaders until the K wires are parallel;
- on the radial side of osteotomy, the amount of opening should equal the templated
radial length deficit;
- if present, correct any supination deformity of the distal fragment;
- fitting the bone graft:
- laminar spreads hold the osteotomy apart while calipers are used to measure the bony
defect;
- radiographs are taken to confirm the correction;
- bone graft is harvested to fit the required dimensions;
- a hall burr can be used to gently shape the bone graft;
- typically the graft will be triangular on the lateral view, and will be trapezoidal on the AP
view;
- a plate can be used to secure the graft, but if additional fixation is needed, a lag screw
can be inserted from
the radial styloid to the ulnar cortex of the distal radius;
- assessment of RU joint: (see RU joint)
- these patients will often have an ulnar impaction syndrome;
- following opening wedge osteotomy, check passive supination and pronation;
- w/ a significant deficit, consider Bower's arthroplasty;
- some authors will choose a Darrach procedure;

Pediatric Distal Radius Fracture:

- Discussion:
- children's frx are rarely intra-articular;
- common types:
- physeal frx:
- torus fracture:
- green stick frx
- both bone forearm frx:
- galeazzi's frx
- distal radius fracture:
- w/ bayonete opposition, the child should receive general anesthesia with closed
reduction and pin fixation;
- if closed reduction is still not possible, then insert a 1 mm K wire percutaneously
into the
fracture site and use it "lever" the fracture into a reduced position;
- ref: Completely displaced distal radius fractures with intact ulnas in children.

19

DR Roy. Orthopedics. Vol 12. 1989. 1089-1092.

- associated injuries:
- condylar and supracondylar frx;
- Anesthesia:
- note that in children, the term "IV sedation" should be changed to "IV anesthesia," since any
amount of IV sedatives are potentially dangerous;
- determine when the child last ate;
- realize that a painful fracture can cause a gastric ileus, and therefore, waiting 8 hours before
administering IV anesthetics does not at all guarentee that the child's stomach will be
empty;
- Reduction:
- distal both bones forearm frx:
- pure traction may actually make it more difficult to oppose the frx ends due to tightening
of the overlying periosteum (like a chinese finger trap);
- the distal radius is hyperextended and the distal fragment is pushed distally until the
dorsal cortex is out to length;
- the distal fragment is then "hinged over" the frx site;
- if closed reduction is still not possible, then insert a 1 mm K wire percutaneously into the
fracture site and use it "lever" the fracture into a reduced position;
- references:
- Closed reduction of fractures of the proximal radius in children.
B Kaufman et al. JBJS. 71-B. 1989. p 66-67.
- Acceptable Reduction:
- accetable reduction in both bone forearm frx:
- references:
- Remodelling after distal forearm fractures in children. II. The final orientation of the distal
and proximal epiphyseal plates of the radius.
- Remodelling after distal forearm fractures in children. III. Correction of residual
angulation in fractures of the radius.
- Remodeling of angulated distal forearm fractures in children.
- Remodeling of angulated distal forearm fractures in children.
- Translation of the radius as a predictor of outcome in distal radial fractures of children.
- Complications:
- references:
- Compartmental syndrome complicating Salter-Harris type II distal radius fracture.
- Growth disturbance of the distal radial epiphysis after trauma: operative treatment by
corrective radial osteotomy.
- Redisplacement after closed reduction of forearm fractures in children.

Pattern of forearm fractures in children.

20

Use of pins and plaster in the treatment of unstable pediatric forearm fractures.
Team physician #5. Salter-Harris type I fracture of the distal radius due to weightlifting.
The Management of Isolated Distal Radius Fractures in Children.
Gibbons C., Woods DA, Pailthorpe J. Pediatric Orthopaedics 1994. 14: 207-210.

Main Menu Home Page

Smith's Fracture:
- See:
- Barton's Fracture:
- Discussion:
- extra - articular palmarly displaced distal radius frx;
- volar angulation of frx is referred to as "Garden Spade" deformity
(reversed Colles Fracture);
- hand & wrist are displaced forward or volarly w/ respect to forearm;
- frx may be extra articular, intra articular, or be part of frx dislocation of wrist;
- Mechanism:
- backward fall on the palm of an outstreched hand causing pronation of
upper extremity while the hand is fixed to the ground;
- Classification:
- Type I: extra articular;
- Type II: crosses into the dorsal articlar surface;
- Type III: enters radiocarpal joint
- Volar Barton's Fracture = Smith's type III
- both involve volar dislocation of carpus assoc w/ intra articular
distal radius component;
- Reduction:
- frx should be closed reduced by reversing frx deformity w/ longitudinal traction
& applying as long arm cast w/ forearm in supination & wrist in neutral;
- Non Operative Rx:
- if closed reduction is attempted, the wrist should remain in extension;
- Surgical Treatment:
- ORIF (or External Fixators) is treatment of choice for volar displaced
fractures, esp intra articular types II and III;
- Ex fix for open Smith's frx is acceptable for wound considerations;
- Reduction w/ flouro & supplementary K wires may be needed for Smith's
type II frxs, to insure anatomic alignment of radiocarpal joint;
- Smith's Type III: Barton's Fracture:
- volarly displaced frx of Smith's or volar Barton's type is approached thru
volar incision and appication of a buttress plate;
- displaced volar spike (Melone type III) may also require volar approach;
- incision is made thru proximally extended carpal tunnel incision,
w/ reflection of pronator quadratus from radius;
- plate is contoured to fit metaphyseal curvature, & distal frag screws are
rarely indicated;

21

- during open reduction of distal radius, surgeon needs to examine

articular surface reduction of radioscaphoid, radiolunate, and
distal radioulnar joints, and treat each appropriately;
- there is little indication for primary excision of distal ulna;
Main Menu Home Page

Frykman Classification of Distal Radius Frx:

Fracture
Extra articular
Intra articular involving radiocarpal joint
Intra articular involving distal RU joint
Intra articular involving both radiocarpal &
distal radioulnar joints

Distal Ulnar Fracture:

Absent Present
I
II
III
IV
V
VI
VI
VIII

- Discussion:
- Frykman classification considers involvement of radiocarpal & RU joint,
in addition to presnce or absence of frx of ulnar styloid process;
- classification does not include extent or direction of initial displacement,
dorsal comminution, or shortening of the distal fragment;
- hence, it is less useful in evaluating outcome of treatment;

Fracture of the Distal Radius Including Sequelae--Shoulder-Hand-Finger Syndrome, Disturbance

in the Distal
Radio-Ulnar Joint and Impairment of Nerve Function. A Clinical and Experimental Study.
Frykman, Gosta:
Acta Orthop. Scandinavica, Supplementum 108, 1967.

Main Menu Home Page

Melone Classification for Distal Radius Fractures:

- Components: Shaft, Radial Styloid, and Dorsal Medial and Palmar Medial Parts;
- Type I:
- colles frx equiv: undisplaced and minimally comminuted;

22

- Type II:
- die punch frx: unstable w/ moderate to severe displacement;
- similar to Mayo class II: displaced frx involving radioscaphoid joint;
- radioscaphoid joint frx: involves more than radial styloid (Chauffeur frx)
fracture) and has significant dorsal angulation and radial shortening;
- requires stabilization provided by external fixators, along w/
percutaneous pins, to maintain an accurate reduction;
- Type IIb (irreducible)
- this is a double die punch frx which is an irreducible injury;
- dorsal medial component fragmentation;
- persistent radiocarpal incongruity > than 2 mm;
- radial shortening > 3 - 5 mm;
- dorsal tilting & displacement > of 10 deg
- radiocarpal step off > 5 mm (on a lateral view);
- requires open treatment for restoration of articular congruity;
- requires ORIF of radiocarpal articular surface, supplementary external fixation,
and iliac bone grafting;
- Type III:
- is die punch or lunate load fracture, and is often irreducible by traction alone;
- involves additional frx from shaft of radius that projects into flexor compartment;
- Mayo equivolent: are displaced involving the radiolunate joint;
- this may require fixation w/ small screws or wires in conjunction with closed or
limited open articular surgery;
- Type IV:
- transverse split of articular surfaces w/ rotational displacement;
- Mayo eqivolent is a displaced frx involving both radioscaphoid & lunate joints,
and the sigmoid fossa of the distal radius;
- is often a more comminuted frx involving all of major joint articular surfaces,
& almost always includes frx component into distal radioulnar joint;
-------------------------------------------Intra-articular fractures of the distal end of the radius in young adults.
Distal Radius Fractures: Patterns of articular fragmentation.
CP Melone Jr.
Orthop Clin North Am. Vol 24, 1993. p 239-253.

Universal Classification of Dorsal Displaced Radius

Fractures;

- Type I: extra articular, undisplaced;

- Type II: extra articular, displaced;

23

- Type III intra articular, undisplaced;

- Type IV: intra articular, displaced;
----------------------------------------

Closed Reduction of Distal Radius Fractures:

- Discussion:
- closed reduction & immobilization in plaster cast remains accepted method of treatment for
majority of stable distal radius frx;
- unstable fractures will often lose reduction in the cast and will slip back to the prereduction position;
- patients should be examined for carpal tunnel symptoms before and after reduction;
- carpal tunnel symptoms that do not resolve following reduction will require carpal tunnel
release;
- Technique:
- anesthesia: (see: anesthesia menu)
- hematoma block w/ lidocaine;
- w/ hematoma block surgeon should look for "flash back" of blood from hematoma,
prior to injection;
- references:
- Regional anesthesia preferable for Colles' fracture. Controlled comparison with local
anesthesia.
- Neurological complications of dynamic reduction of Colles' fractures without
anesthesia compared with traditional manipulation after local infiltration anesthesia.
- methods of reduction:
- Jones method: involves increasing deformity, applying traction, and immobilizing hand &
wrist in reduced position;
- placing hand & wrist in too much flexion (Cotton-Loder position) leads to median
nerve compression & stiff fingers;
- Bohler advocated longitudinal traction followed by extension and realignment;
- alternatively, consider hyper-extending the distal fragment, and then translating it distally
(while in
the extended position) until it can be "hooked over" the proximal fragment;
- subsequently, the distal fragment can be flexed (or hinged) over the proximal shaft
fragment;
- closed reduction of distal radius fractures is facilitated by having an assistant provide
counter
traction (above the elbow) while the surgeon controls the distal fragment w/ both hands
(both
thumbs over the dorsal surface of the distal fragment);
- flouroscopy:
- it allows a quick, gentle, and complete reduction;
- prepare are by prewrapping the arm w/ sheet cotton and have the plaster or fibroglass
ready;
- if flouroscopy is not available, then do not pre-wrap the extremity w/ cotton;
- it will be necessary to palpate the landmarks (outer shaped of radius, radial styloid,
and
Lister's tubercle, in order to judge the success of the reduction;
- casting:

24

- generally, the surgeon will use a pre-measured double sugar sugar tong splint, which is 68 layers in thickness;
- more than 8 layers of plaster can cause full thickness burns:
- references: Setting temperatures of synthetic casts.
- position of immobilization:
- references:
- Functional bracing of Colles' fractures: a prospective study of immobilization in
supination vs. pronation.
- The treatment of Colles' fracture. Immobilisation with the wrist dorsiflexed.
- Colles' fracture. How should its displacement be measured and how should it be
immobilized.
- Brace treatment of Colles' fracture.
- Forearm fractures in children. Cast treatment with the elbow extended.
- follow up:
- radiographs:
- repeat radiographs are required weekly for 2-3 weeks to ensure that there is maintenance
of the reduction;
- a fracture reduction that slips should be considered to be unstable and probably require
fixation with (pins, or ex fix ect.)
- there is some evidence that remanipulation following fracture displacement in cast is not
effective for these fractures;
- ultimately, whether or not a patient is satisfied with the results of non operative treatment
depends heavily on their personal expectations, non dominant side, and functional status;
- hence, younger patients w/ involvement of dominant side, moderately high functional
demands, and high expections for outcome may not be satisfied with non operative care;
- references:
- The value of remanipulating Colles fractures. MM McQueen et al. JBJS Vol 68-B.
1986. p 232-233.
- Closed reduction of axial compression in Colles fracture is hardly possible. A.
Schmalholz. Acta Orthop Scand. Vol 60. 1989. p 57-59.
- Redisplaced unstable fractures of the distal radius: a prospective randomized
comparison of four methods of treatment.
McQueen, MM. et al. JBJS. Vol 78-B. 1996.p 404-409.
- Fractures of the distal radius in low-demand elderly patients: closed reduction of no
value in 53 of 60 wrists.
- Comparative Studies:
- in the report by SA Earnshaw et al, the authors compared closed treatment of Colles
fractures using a finger trap reduction
technique as compared to manual reduction techniques;
- no significant differences were found between the alignment of the fractures in the two
treatment groups at any time;
- with dorsal tilt of <10 and radial shortening of <5 mm considered acceptable, the two
techniques both produced an 87% rate of satisfactory reductions;
- percentages of fractures in an acceptable alignment were only 57% and 50% at one
week after finger-trap traction and manual manipulation, respectively,
and only 27% and 32% at five weeks;
- although closed reduction was successful for the majority of fractures, most redisplaced
substantially during the period of cast immobilization;
- Closed Reduction of Colles Fractures: Comparison of Manual Manipulation and Finger-Trap
Traction. A Prospective, Randomized Study
S.A. Earnshaw, DM, FRCS The Journal of Bone and Joint Surgery (American) 84:354358 (2002)
- Plaster cast versus external fixation for unstable intraarticular Colles' fractures.

25

- External fixation or plaster for severely displaced comminuted Colles' fractures A

prospective study of anatomical and functional results.
- Displaced distal radius fractures. A comparative study of early results following external
fixation, functional bracing in supination, or dorsal plaster immobilization.
- Displaced distal radius fractures. A comparative study of early results following external
fixation, functional bracing in supination, or dorsal plaster immobilization.
- External fixation or plaster cast for severely displaced Colles' fractures Prospective 1-year
study of 46 patients.
- External fixation or plaster cast for severely displaced Colles' fractures Prospective 1-year
study of 46 patients.
- Cast or external fixation for fracture of the distal radius. A prospective study of 126 cases.
- A prospective randomized trial of external fixation and plaster cast immobilization in the
treatment of distal radial fractures.

Colles' fracture. How should its displacement be measured and how should it be immobilized.
Brace treatment of Colles' fracture.
Forearm fractures in children. Cast treatment with the elbow extended.
Long-term results of conservative treatment of fractures of the distal radius.
Outcome following non operative treatment of displaced distal radius fractures in low demand
patients older than 60 years. BT Young MD et al. J. Hand Surg.. Vol 25-A. p 19-28.
Predictors of early and late instability following conservative treatment of extra-articular distal
radius fractures.

Distal Radius Frx: Percutaneous Pinning:

- See:
- Distal Radius Frx Menu:
- External Fixators for Distal Radius Frx
- Intra-Articular Fractures of the Distal Radius:
- Unstable Distal Radius Frx
- Radiographs:
- r/o concomitant scapholunate dissociation;

- Anatomic Considerations:
- die punch fragment:

26

- following fixation of the radial styloid fragment, the remaining depressed articular
fragments are elevated and reduced;
- reduction is facilitated w/ traction, direct pressure, or with use of a small incision and
application of pointed reduction clamps;
- if reduction can not be performed closed, then a limited open reduction can be
performed;
- wires can be inserted transverse across the subchondral portion of the distal radial
articlular surface, either thru the ulna
and across the RU joint, or directed transversely thru the radial cortex to lie just under
the subchondral surface;
- metaphyseal comminution:
- w/ high energy frxs or w/ metaphyseal comminution, consider combination of external
fixation and bone grafting inorder to
prevent late collapse of the articular reduction;
- Outcome Studies:
- while the wrist is in this position, percutaneous K wires are inserted, and then the
distraction is released and the wrist is taken out of flexion;
- in the study by CE Dunning et al, the authors investigated the changes in fracture
stability when using supplemental
radial styloid pinning in combination with external fixation;
- 8 previously frozen cadaveric upper extremities were mounted in a computercontrolled wrist-loading apparatus;
- this device was used to generate finger and forearm motions through loading
relevant tendons.
- unstable extra-articular distal radius fracture was simulated by removing a dorsal
wedge
from the distal radius metaphysis;
- electromagnetic tracking system measured fragment motion following randomized
application
of a Hoffman external fixator, a Hoffman external fixator with 2 supplemental
radial styloid
pins, and a dorsal 3.5-mm AO plate;
- addition of radial styloid pins to a construct stabilized by an external fixator
significantly
improved fragment stability, approaching that achieved with the dorsal AO plate;
- in the report by Scott W. Wolfe et al, the authors simulated unstable extra-articular distal
radius fractures
were created in 7 fresh-frozen cadaveric upper extremities and stabilized using 4
different external fixators;
- physiologic muscle tension across the wrist was simulated by application of 40-N
load distributed among the wrist tendons;
- fracture stability was reassessed for each of the constructs after augmentation of
the fracture fragments
with a single dorsal transfixion K-wire;
- K-wire augmentation demonstrated a significant reduction in motion of the distal
radial fragment of at least 40% in all 3 rotational planes;
- for flexion/extension, the reduction in motion was from 4.5 to 2.6.
- for radial/ulnar deviation, the range of motion decreased from 3.0 to 1.5.
- rotational motion declined from an average of 3.2 to 1.2.
- addition of the single dorsal transfixion K-wire significantly improved stability of each
of the 4 fixators in at least 1 of the 3 planes in which motion was measured;
- data supported the concept of K-wire augmentation for increasing stability of an
unstable extra-

27

articular distal radius fracture regardless of the type of external fixator that is
used;
- references:
- Intraarticular fractures of the distal radius: a cadaveric study to determine if
ligamentotaxis restores radiopalmar tilt.
- Severe fractures of the distal radius: effect of amount and duration of external
fixator distraction on outcome.
- Biomechanical analysis of pin placement and pin size for external fixation of
distal radius fractures.
- Supplemental pinning improves the stability of external fixation in distal radius
fractures during simulated finger and forearm motion
Cynthia E. Dunning. J Hand Surg 1999;24A:992-1000
- A biomechanical comparison of different wrist external fixators with and without
K-wire augmentation
Scott W. Wolfe J Hand Surg 1999;24A:516-524
- Specific Techniques:
- which ever technique is used, it is essential to hold the fracture closed reduced as possible
while the pins are inserted inorder
that there is minimal skin traction against the pins;
- consider positioning the distal forearm on a stack of towels which allows the wrist be
maximally palmar flexed which helps with the reduction, which facilitates pin
insertion (hand and thumb are moved out of the way), and which allows easy flouroscopy
since the distal forearm rests parallel to the ground on the towels;
- extra-focal pinning techniques:
- Kapandji's Technique:
- dorsal pin placement:
- single dorsal transfixion K-wire yields the greatest reduction in fragment motion in the
flexion/extension plane;
- single 0.065-inch (1.6 mm) K-wire is used to augment fixation;
- wire is drilled at a 45 angle in the sagittal plane from the dorsal lip of the distal radius,
across the osteotomy site and through the volar cortex (dorsal transfixion wire);
- starting point is positioned just distal to Lister's tubercle;
- ref: Dorsal pin placement and external fixation for correction of dorsal tilt in fractures of
the distal radius.
Braun RM, Gellman H. J Hand Surg 1994;19A:653-655.
- trans-ulnar technique:
- ulnar-radial pinning with fixation of the DRUJ
- K wires are placed thru distal ulna into the reduced distal radius;
- technique avoid dorsal sensory branch of radial nerve;
- there is enhance stability with this technique since there is bicortical pin placement thru
the ulna;
- disadvantage: need to immobilize R-U joint w/ long arm cast;
- references:
- DePalma: (JBJS, 1952; 34A: 651-662)
- The history and evolution of percutaneous pinning of displaced distal radius
fractures. Rayhack, JM. Orthop. Clin. North Am. 24: 287-300. 1993.
- Trans-ulnar percutaneous pinning of displaced distal radius fractures: a preliminary
report. Rayhack, JM. J. Orthop. Trauma. 3: 107. 1989.
- Bone Grafting: (see bone graft harvest techniques);

28

- elevation of impacted fracture fragments often results in a metaphyseal fracture defect;

- bone grafting via a limited incision over the frx site fills in the fracture site defect and helps
prevent fracture collapse;
- the bone graft attempts to hold the reduction in place, and in a sense helps take the place of
external fixation;
- it is often easier to perform percutaneous pinning and bone grafting at 10 days from injury
since this allows the frx site to become slightly sticky;
- references:
- Augmentation of distal radius fracture fixation with Coralline hydroxyapatite bone graft
substitute.
SW Wolfe et al. J. Hand Surgery. Vol 24-A. No 4. July 1999. p 816.
- Assessment of Reduction: Is external fixation necessary?
- in an unstable distal radius frx w/ inadquate reduction consider the addition of external
fixation + K wires;
- as noted in the study by Trumble et al 1998, external fixation provided clear advantages in
specific situations;
- in older patients, pain relief, grip strength, and ROM were significantly better when
external fixation was used;
- in younger patients, external fixation provided consistently better results when there was
comminution in 2 or more cortices or
when there was comminution of one surface which was greater than 50% of the
metaphyseal diameter;
- in their study, restoration of radial length was more important than dorsal tilt or radial tilt,
and external fixation
afforded better restoration of length than pinning and casting;
- Compications:
- RSD may result from pin injury to the superficial radial sensory nerve;
- RSD is avoided by making small incisions over the pin insertion site and by spreading
with a hemostat;
- if a surgical assistant is available, then he/she can help maintain the reduction while the
surgeon
uses a soft tissue protector to prevent the radial nerve from winding around the pin;
- if an assistant is not available consider applying a lubricant (K-Y) to the pin;
- this 40 year old patient underwent application of a external fixator prior to insertion of pins;
- note that prior to pin insertion, the external fixator was distracted to help maintain the
reduction, but at the
end of the case, the distraction was released and the reduction was rechecked w/
flouro;
- it is essential that the MP joints achieve full flexion at the end of the case, as
overdistraction can lead to MP join clawing;

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