ORIGINAL ARTICLE

Fracture Geometry In Distal Radius As A Predictor Of Concomitant Injuries: Proposing A

Metaphyseal Danger Zone Sign'
Bhaskar Borgohain1, Praveen Tittal2
Abstract:
Background: Analysis of fracture pattern reveals the amount of energy imparted to the extremity and
alerts the surgeons to higher risk pattern of injury. Comminuted fractures occur when the deforming
force is a combination of compression, bending and torsion usually signifying a high energy injury in
non-osteoporotic bone and a high likelihood of severe associated loco-regional soft tissue injury.
Method: The authors present nine consecutive cases of high energy distal radius fractures in relatively
younger patients, which were associated with severe comminution with or without an open wound in
the metaphyseal area. Results: These cases of distal radius fractures were roughly falling into the AOASIF type C fractures or Fernandez type V fractures that signify high energy injuries. All these cases
were associated with other significant skeletal or non-skeletal injuries; either loco-regional or remote.
Conclusion: The author propounds that severe comminution in the metaphyseal or metadiaphyseal area
in distal radius fractures in relatively younger individuals is an independent risk factor for associated
injuries.
Keywords:
Fracture geometry; distal radius; concomitant injuries
Introduction:
Analysis of fracture pattern reveals the amount of energy imparted to the extremity and alerts the
surgeons to higher risk pattern of injury 1. Comminuted fractures occur when the deforming force is a
combination of compression, bending and torsion 2. Comminution of bone usually signifies that there is
severe associated loco-regional soft tissue injury. In osteopenic bone however, comminution may result
from low energy trauma and less soft tissue injury 3. The mechanics of the fall plays important role in
whether a fracture will occur and which bone will fracture.
Address for Correspondence:
1. Bhaskar Borgohain
Asst. Professor and in-charge, Department of Orthopaedics & Trauma,
North-Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, (NEIGRIHMS) Shillong,
793018.
Phone : +91 0364 2538097
Fax : +91 0364 25380209
E-mail : bhaskarborg@gmail.com
2. Department of orthopaedics,
Maulana Azad Medical College, New Delhi

J.Orthopaedics | 2010| Vol 7 | Issue 2 | e10

The orientation of the fall and location of the impact determine the type of fracture, and whether a
fracture occurs depends on the energy of the fall (distance to impact and weight of the moving parts)
and how much of that energy is absorbed by protective responses, the impact surface and soft tissues
overerlying the bone 4. Bones break when the forces applied to them exceed their strength. The
direction of impact is as important as that of the amount of force itself.5 It is difficult to know how much
energy is absorbed by protective responses, the impact surface and soft tissues over the bone (covering)
before the fracture happens. We feel that due to protective responses that attempts to prevent vital
organ from injuries; the upper limbs & the body move in unaccustomed directions or positions and
when the bone finally gives way (fractures) that is the end of protection, so far provided by the upper
limb before loss of weight bearing/transmitting ability of the limb. At this very point of failure the same
protective process risks injury to other bones and organs. From a series of cases presenting to the
casualty department, we propose that specific fracture geometry of distal radius in younger individual
not only predicts energy imparted on the tissue but also may predict existence of associated locoregional and even remote injuries.
Materials and Methods:
The Case series
These cases were noted and recorded over two and a half year period in a tertiary care hospital. The
first two cases need elaboration. Case no. 1, was a neglected and heavily contaminated open fracture of
distal radius in 45 year old village lady who fell down from a tree (Fig 1.) She had a contusion in lower
arm which was treated so far as soft tissue injury. A second fracture was a grossly displaced ipsilateral
surgical neck of humerus proved in X-ray after admission (Fig 2).
Case
No.

Age

Fracture

Wound

1.

(Years)
45

(AO)
C3

(Gustilo)
Gr. I

2.

50

C3

Gr. II

3.
4.

30
11

C2
C2

None
None

5.

19

C2

None

6.

45

C2

None

7.
8.
9.

25
22
40

C2
C3
C3

None
Gr.I
Gr.I

Mode of
injury

Associated injury

Fall from
height
MVA

# Surgical neck
humerus
Death due to other
injury?
2nd MC base #
EDH@

Fall
Fall from
height
Fall from
height
Fall in
stairs
MVA
MVA
MVA

Inferior Pubic
ramus #
Dental injury $
Sup. Pubic ramus #
Left 5th rib #
Splenic injury ***

@ Extradural haematoma
$ Needing tooth extraction
*** With minimum fluid in peritoneum;responded to conservative treatment.

J.Orthopaedics | 2010| Vol 7 | Issue 2 | e11

Figure 1: Case no.1 with metaphyseal extension of fracture line with gross displacement.
In Case no. 2, this deaf and dumb patient met road side accident. She had a fracture with unusual
comminution (Fig 3). She was conscious and apparently there were no elements of other associated
injury as per history from her attendants and also on examination. The fracture was stabilized by
external fixator under local anaesthesia. Immediate postoperative condition was uneventful, but after 4
hours she became unconscious and had a cardiac arrest. The possibility of cardiac contusion, pericardial
temponade, head injury or major visceral injury couldn t be ruled out since autopsy was denied by
relatives.

Figure 2: Case no. showing the concomitant missed proximal surgical neck humerus fracture

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Figure 3: Unusual fracture line in metaphysic in a young adult that doesn t precisely fall into any
common classification

Figure 4: Another case where comminution is not extensive but fracture line running into high
metaphysis.
Discussion :
These consecutive nine cases of distal radius fractures were associated with extension of comminution
in the high metaphyseal area with or without comminution in the epiphyseal area. The metaphyseal
extension of fracture line was not always seen in AP view but may be seen in lateral/oblique view
radiograph only. Osteoporosis was not radiologically apparent in any case. All these cases were
associated with other significant skeletal or non-skeletal injuries. These fractures were roughly falling
into the type C fractures (especially C3 Type) in AO-ASIF and in Universal classification of Sarmiento
(Fernandez type V fractures) and they signify high energy injuries.
From this series of cases we propose that fracture geometry of distal radius in younger individual
predicts associated loco-regional or remote injuries. Our thinking and observation are based on the fact
that effective protective reflexes cushion the impact of a fall in active individuals. Isolated fractures of
distal radius are classically seen in osteoporotic (but fit) individuals. But fracture of distal end radius
with associated ipsilateral limb injuries are increasingly found in young active adult partly due to higher
incidence of high energy trauma and increased participation in sports and similar outdoor activities 6.
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Younger individuals are usually non-osteoporosis and injuries are high energy type. In elderly, the
effective protective reflexes to cushion the impact of a fall are obtunded corresponding to their age and
that is why the incidence of hip fractures are more common than distal radius fractures in elderly, which
is attributed to increased frailty and decreased protective response (e.g. rapid reflexive elbow
extension) during a tendency to fall 6.
Theoretically, the longer the length of metaphyseal comminution, greater is the likelihood of higher
energy and higher protective resistance imparted by the bone of the injured individual and greater is the
likelihood of impact to the surface of collision at the end point of failure (fracture). Similarly the viscera
and limbs are also likely to get injured at the same time due to the magnitude of trauma and proximity to
the direction of force line of fire . The AO-ASIF classification of DER fractures appreciates the extent
or length of metaphyseal comminution though they recognize articular comminution in more details
since it is more important for DRUJ.
Though many associated injuries in distal radius fractures are well-described in the literature namely
injury to the DRUJ, triangular fibro cartilage (TFCC), carpal & carpal ligament injuries, median nerve
injury, radial head fracture etc 7-10; no mention is found in these literature about remote injuries that we
have noticed in our cases. The degree of articular comminution has no correlation with incidence of local
injuries like TFCC injury 10. It is well known that orthopedic injuries can mask the presence of lifethreatening visceral injuries 11. An open fracture is also known to dramatize clinical presentation and
lead to missed concomitant injuries.
Associated injuries are important in treatment and for rehabilitation. We couldn t find any literature
mentioning remote injuries in distal radius fractures. Scapular fractures are associated with chest
injuries, clavicle fractures, rib fractures, tibial fractures, spleen & liver injuries 12. But femoral fractures
on the other hand are reportedly associated with other life-threatening injuries 11.

Figure 5: The proposed metaphyseal danger zone sign. The dark line depicting the fracture progression
line. (DRUJ: Distal Radio-ulnar Joint.)

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Based on these considerations, we propose that metaphyseal comminution and extension of fracture
line approximately 3 cm beyond the DRUJ may suggest possibility of another unsuspected/ occult injury;
remote or loco-regional. Therefore in young patients this area may be called Metaphyseal danger zone
(Fig.5). If this finding is present we should actively look for another missed injury. This may be
especially true in patients who are non-cooperative or who have altered sensorium due to alcohol, drugs
or head injuries with a wrist radiograph showing such fractures or if there is an open wound. Statistical
analysis in a large number of randomly selected cases is needed to further this observational analysis.
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This is a peer reviewed paper
Please cite as: Bhaskar Borgohain: Fracture geometry in distal radius as a predictor of concomitant
injuries: proposing a metaphyseal danger zone sign'

J.Orthopaedics 2010;7(2)e10

URL: http://www.jortho.org/2010/7/2/e