Distal Radial Fractures

Definition/Description

The radius is the larger of the two bones in the forearm and lies in a radial position. The distal end of the radius is defined as the area three centimeters proximal to the radiocarpal joint, where the radius meets the lunate and scaphoid bones of the wrist. Distal radius fractures are It usually results from a fall with the arms extended [1]. Most distal radius fractures are closed injuries in which the overlying skin remains intact [2][3]. The radius is the most commonly fractured bone in the arm.

For centuries, this fracture was classified as a wrist dislocation, but this description remained vague. It was redefined as a fracture by the Irish surgeon and anatomist Abraham Colles in 1814 and was subsequently named Colles’ fracture [4].

Clinically Relevant Anatomy

The wrist joint (also known as the radiocarpal joint) is a synovial joint of the upper extremity that marks the transition zone between the forearm and hand.

The wrist joint is formed distally by the proximal row of carpal bones (except the pisiform bone);

• os scaphoid
• os lunate
• os triquete

The wrist joint is formed by the distal radius and the articular disc proximally.

Multiplanar wrist motion is based on three joints:

• radioscaphoid
• radiolunate
• distal radioulnar joints

The ulna is not part of the wrist joint — it joins the radius at two places, the superior and inferior radioulnar joints. 80% of the axial load is supported by the distal radius and 20% by the ulna. A fibrocartilaginous disk called the articular disc is located in the on the upper surface of the ulna. This disc prevents the ulna from articulating with the carpal bone. Together, the carpal bones form a convex surface that connects with the radius and the concave surface of the articular disc.

There are several known ligaments that attach to the distal radius. These usually remain intact during the distal radius fracture. Compared with the dorsal ligament, the volar ligament is stronger and stabilizes the radiocarpal joint [5].

Epidemiology /Aetiology

Distal radius fractures are among the most common fractures of the upper extremity in adults, accounting for one-sixth of all fractures in the emergency department. It is mainly seen in elderly Caucasians [2][3][6][7][8]. Usually a history of a fall or similar trauma upper body. Pain and swelling in the forearm or wrist are common. Bruising and deformity of the wrist or forearm may also occur [9].

In women, the incidence of distal radius fractures increases with age starting at age 40. Men have a much higher incidence of distal radius fractures before age 40. Distal radius fractures in young adults are often the result of high-energy trauma, such as a fall from a height in a motor vehicle accident or sports participation [10]. In older adults, they are usually the result of low energy or moderate trauma, such as a fall from a standing height. This may reflect more fragile bones due to osteoporosis in older adults [2][11].

[12]

Characteristics/Clinical Presentation

Distal radius fractures can be classified according to their clinical presentation and typical deformities. Dorsal displacement, dorsal angulation, dorsal comminution, and radial shortening can all be used to describe the fracture presentation. Classification based on fracture pattern, e.g. Intra-articular (disrupted articular surface) or extra-articular (radial articular surface intact) can also be used. [2] [13]

The classification of intra-articular fractures

• Type Ι: stable, without comminution
• Type II: Unstable stamped dorsal or volar side; ΙΙa: Reducible ΙΙb: Irreducible
• Type II: Spike fracture; contusion of volar structures
• Type IV: Split fracture; medial complex fracture with separate displacement of dorsal and volar fragments
• Type V: Explosive fracture; severe communication with major soft tissue injury

2. Classification of extra-articular fractures

• Type A: extra-articular
• Type A1: The extra-articular ulna is intact
• Type A2: Extra-articular integrity of the ulna
• Type A3: Multiple extra-articular radial fractures [14]

Types of Fractures

Colles Fracture

Colles fractures are usually seen as the result of a fall with the hand outstretched and result in extra- or intra-articular displacement of the dorsal side of the fractured radius:

• Intra-articular fractures are often seen in younger age groups secondary to higher energy
• More than 90% of distal radius fractures are Colles fractures [14]

Smith’s Fracture

This is a reverse Colles’, with the forearm pinned in supination resulting in volar displacement due to the fall on the flexed wrist [14]

Barton’s Fracture

This is an intra-articular fracture with subluxation or dislocation of the carpal bone. In the Frykman classification system, half of the eight grades of distal radius fractures include involvement of the ulnar styloid process.

Complications are common and varied. They can be the result of injury or treatment and are associated with poorer outcomes. These can include:[15]

• upper extremity stiffness
• Carpal tunnel syndrome or medial nerve involvement
• malunion
• carpal instability
• DRUJ dysfunction
• Dupuytren’s disease
• radiocarpal arthritis
• tendon/ligament injuries
• post-traumatic osteoarthritis
• compartment syndrome
• Infection (mainly open fractures) [14][15]
• Complex regional pain syndrome [7][16][17][18]

Differential Diagnosis

Because the mechanism of injury for distal radius fractures is usually a high-energy traumatic event, radiographs should be taken to confirm the diagnosis and ensure that surrounding tissues are intact. Other injuries that cause radial pain may include TFCC tears or perforations Galeazzi fracture (fracture to distal 2/3 of radius) scaphoid fracture or radiocarpal ligament injury.

• Malunions – Malunions of the distal radius are the most common complication, affecting up to 17% of patients. A physical therapist can assess the impact of a malunion by performing a detailed physical examination to determine if surgery is appropriate, including preoperative medical history, location and pain severity and loss of function [13][18].
• Compartment Syndrome – This complication affects only 1% of patients. If compartment syndrome is suspected, immediately elevate for observation and loosen the cast [18].
• Complex Regional Pain Syndrome (CRPS) – This complication is observed in 8-35% of patients [18]. CRPS should be suspected when pain limitation and swelling of the ROM are disproportionate to the injury. Changes in skin temperature and sweating may also occur. For good functionality Early identification and a multidisciplinary approach to treatment are critical to outcome in this patient population. This approach should include psychiatric and physical/occupational therapy interventions to address pain and functional limitations.
• Dupuytren’s Disease – Patient presents with mild contracture of the palm along the fourth and fifth rays within six months of distal radius fracture. The severity of the contracture determines the course of treatment [18].
• Neuropathology – Neuropathy may appear acutely or throughout treatment. The median nerve is most common (4%), but 1% of patients have ulnar or radial involvement [7]. A physical therapist may need to refer the patient to an orthopedic surgeon [18].
• Acute carpal tunnel syndrome – Physical therapists must be able to recognize acute carpal tunnel syndrome, as delays in treatment are associated with poor outcomes, incomplete recovery, or prolonged functional recovery [7][18].
• Tendon complications – Physiotherapists should be prepared to refer patients to surgery in the event of tendon complications secondary to inflammatory irritation or impingement rupture [18].
• Capsular contracture – Even with physical therapy, some patients are unable to regain full rotation of the forearm due to distal radioulnar capsule contracture. Dorsal contractures limit pronation, volar contractures limit supination, and both may occur simultaneously. DRUJ capsule resection may be Consider [16] if functional ROM is not restored.

Diagnostic Procedures

Radiographic parameters are used to examine anatomical abnormalities.

There are a number of classification systems that describe distal radius fractures. The classification system should follow the following two principles:

• Classification should prescribe treatment
• Classification should indicate long-term functional outcomes of treatment or be associated with these expected outcomes [14]

Outcome Measures

A Distal Radius Fracture Complication Checklist and Score Sheet were developed to improve prospective data collection[19]. The checklist includes a breakdown of all DRF challenges with each graded according to severity (Mild = 1 Moderate = 2 Severe = 3). All remaining scores are then calculated. The the categories of the questionnaire are

• nerve complications
• bone/joint complications
• tendon complications

Self-Report Outcome Measures

• Visual Analogue Scale (VAS) to evaluate pain[20].
• Disabilities of the Arm Shoulder and Hand questionnaire (DASH)[20][21].
• Patient Fingerprint Analysis (PRWE)[20][21]
• The Michigan Alcohol Outcome Questionnaire (MHQ) is a specific alcohol outcome divided into six scales:
  1. overall hand function
  2. activities of daily living
  3. pain
  4. work performance
  5. aesthetics
  6. patient satisfaction with hand function

Physical Outcome Measures

• ROM of the elbow with a goniometer [20].
• Grip Strength is an important outcome determinant because it is an important function of daily activities[21] it can be measured with a dynamometer[20]. A hand held dynamometer or a Jamar hydraulic hand dynamometer can be used.

Examination

Physical therapists should perform a comprehensive physical examination that includes subjective and contextual information.

• Subjective exam includes any information provided by the patient such as pain experience limitations of ROM of the elbow and functional limitations.[7]
• Objective testing includes assessment of finger and digit ROM grip and forearm strength bone and soft-tissue abnormalities skin integrity and associated muscles.[7] Be aware that the opposite side may be an unreliable countermeasure.[21]

Health care providers should evaluate muscle integrity in the presence of persistent pain associated with suspected wrist instability as soon as possible in order to avoid poor function and delayed strength. The specifics of fractures and high-energy injuries are complex indicating involvement of the intercarpal ligament[16].

To confirm the diagnosis, x-rays can detect tumor migration as well as the number of bone fragments[1].

Medical Management

Non-surgical Treatment

If the fracture is in an acceptable position a plaster cast can be applied until the bone heals. When the fracture is displaced the fragment is repositioned (reduced) followed by the application of a cast or dressing. The cast will be replaced two to three weeks after implantation when the inflammation subsides and then removed after six weeks of reduction assuming an acceptable cure rate has occurred. After this physical therapy can begin to improve the function of the injured wrist[1].

Surgical Treatment

If the displacement is so large that reduction is insufficient to maintain an acceptable bone position, surgical intervention is necessary.

Orthopedic surgeons often recommend surgical repair of distal fractures for healthy, active individuals[22]. The diversity of reduction and stabilization strategies becomes clear when considering the five Cochrane review series focusing exclusively on this topic. The methods of production including: 1) closed reduction and percutaneous pinning either extra-focal or intra-focal 2) bridging external fixation with or without supplemental Kirschner-wire fixation 3) dorsal plating 4) fragment-specific fixation 5) open reduction and internal fixation a volar plate by classic Henry method 6) a combination of these methods[2][3][13][17][18][22][23]. According to Bushnell and Bynum (2007) surgical “complications include edema hematoma stiffness infection neurovascular injury loss of fixation recurrent malunion nonunion or delayed union instability tendon irritation or fracture osteoarthritis residual ulnar-side pain median neuropathy complex regional pain syndrome and complications around the bone-graft harvest site.[13]

Radiographic image of external fixator

• External Fixation – External fixation is usually a minimally invasive closed technique in which metal pins or screws are driven into the bone through small incisions in the skin. These pins can then be placed in a plaster cast externally or in an external fixator frame.[2] [3] In compared with the standard immobilization procedure, external fixation of distal radius fractures reduces redisplacement and provides better anatomic results. However, the current evidence for positive functional outcomes from external fixation is weak and is also associated with a high risk of complications such as pin site infections and radial nerve injuries.
• Internal fixation – Internal fixation requires open surgery where the fractured bone is exposed. Dorsal volar or screwed T-plates can be used.[13] However since open surgery is invasive and demanding there is an increased risk of infection and soft tissue damage and hence this type of fixation is usually reserved for more severe injuries.[17]

[24]

• Bone Grafts – When distal radial fractures are reduced, bony voids often occur and can be reduced by placement of bone grafts or bone graft substitutes. Autogenous bone material obtained from the patient themselves or allogenous bone material from cadavers or living donors can be used as a filler to reduce osteoporosis.[25] However, there is a risk of complications including infectious nerve injury or pain at the donor site and there is little evidence that bone grafts can improve anatomy or function improve.[26] Bone graft is required in most procedures except for wedge comparison.[13]

Radiographic image of internal fixator plate

• Percutaneous Pinning – Another method of reducing and stabilizing fractures is percutaneous pinning which involves a string of pins or wires placed through the skin and into the bone.[13] [23] This process is usually less invasive and the fracture is thrown down a a pin inserted into the bone is used to fix the distal radial fragment. Current indications for the optimal pinning route and duration of insertion are uncertain such that the risk of complications likely outweighs the therapeutic benefits of pinning.
• Closed reduction – In closed reduction, a different maneuver is used to reposition displaced radial fragments while the arm is in traction. Different methods include manual reset, where two people pull in opposite directions to create and maintain longitudinal traction, and mechanical Methods of reduction include the use of “finger traps”. However, there is insufficient evidence on the effectiveness of different closed reduction methods used to treat distal radius fractures. [18]

Percutaneous pinning radiograph

• Arthroscopic Assisted Reduction – This technique has many advantages over open reduction. In addition to being less invasive, it allows direct visualization and reduction of joint displacement, giving the opportunity to diagnose and treat associated ligament injuries, removal of joint Cartilage fragments and lavage of the radiocarpal joint. The main limitations of arthroscopic reduction are due to the limited number of surgeons who have undergone longer and more difficult procedures and the potential for compartment syndrome or acute carpal tunnel syndrome effusions [22]

Physical Therapy Management

Current physical therapy management of distal radius fractures includes postoperative or immobilization [27]. The treatment of distal radius fractures is controversial and requires further research. There is a great need for multiple treatment options, and there is no gold standard. Optimal treatment must be determined based on the type of fracture assessed on x-rays after provisional reduction.

There are several treatment positions for distal radius fractures. The choice depends on [1]:

• Nature of fracture
• Age of patient
• Activity level of patient
• Surgeon’s personal preference

Education

Using self-management methods can help foster positive health behaviors during recovery. Self-management programs can provide benefits in terms of participants’ knowledge of symptom management self-efficacy and health status. These programs are often offered to people with chronic conditions disease [28].

Pain Management

Ice elevation and over-the-counter medications for pain relief are often sufficient to relieve pain from this type of injury [1].

Rehabilitation

Kay et al. [8] found that for adults with casts and/or post-immobilization of distal radius fractures, a rehabilitation program consisting of advice and exercises led by a physical therapist provided some improvement compared to no physical therapy intervention. Additional benefits [29]. These benefits improved pain compared to The control group at weeks 3 and 6 had reduced activity restriction compared to the control group at week 3 and had higher levels of satisfaction compared with the control group. There were no differences between the two groups in wrist AROM or grip strength recovery [29].

Michlovitz et al. [30] published the results of a survey of physical therapists, occupational therapists, and certified hand therapists to identify common practices in the rehabilitation of patients with DRF.

During immobilisation:

Fewer than 10% of DRF cases are referred for treatment at this stage. Priorities during immobilization include management of edema and finger stiffness and patient education. Home exercise programs for shoulder-elbow and finger ROM are often offered. hot/cold mode Can be used for pain management. Compression wraps and retrograde massage can be used to treat edema. In 50% of cases, rest splints are used for support and protection. [30]

After immobilisation:

90% of the therapists surveyed included heat/cold therapy and ROM exercises during this phase. 80% used compression wraps and retrograde mobility massage for joint and soft tissue mobilization. Almost 90% also use strengthening exercises to improve strength in both and function. Static or dynamic splinting (or both) can be used to address joint stiffness [30].

Smith et al [31] summarized the following postoperative rehabilitation techniques.

Plating on the dorsal side of the external fixation Plating on the fixed angle of the palm 1. Early pain and edema control1. Early edema control 1. Immediate AROM2 of edema control wrist and unaffected joints. Fixed site care2. Rest Static Wrist Splint 2. Rest Static Wrist Splint with 30° Extension 3. Uninvolved Direct AROM Difficulty rotating the forearm joint Wrist AROM impossible3. Direct AROM unaffected joints.3. After bone healing: Wrist active/active-assisted/passive ROM progression; protective static wrist splint only; static progressive splint rarely shown 4. Irritant desensitization protocol Radial sensory nerve or CRPS (if indicated)4. Guard the first wrist AROM4. Progressive activity and ADLs5. After removal of immobilization hardware: active/active-assisted/passive ROM of wrist and forearm; focus on finger flexion, wrist extension, ulnar deviation and supination; during static progressive splinting Indicated; progressive activity and ADLs5. After bone healing: active/active-assisted/passive wrist ROM with emphasis on active wrist flexion; preload and release extensor tendon program; use static progressive splinting as needed6. Progressive Activities and Daily Activities

Recovery

Because distal radius fractures are so different and have a variety of treatment options, recovery is different for everyone. It may be necessary to consult with the treating surgeon to determine when various activities can resume. [1]

In the first two months after surgery, patients report severe pain with exercise and severe disability in activities of daily living, as assessed by validated and reliable outcome measures such as the Patient Wrist Evaluation (PRWE) and the Arm, Shoulder and Hand disability Questionnaire (DASH) [35] These self-reported deficits were reflected in decreased ROM and decreased grip strength measures, with strength more correlated with functional capacity. Most patients achieve most of their recovery within the first six months. A small percentage of patients will Regardless of the treatment regimen [7] [35] [36], persistent pain and disability are experienced within a year of injury, especially when moving from a sitting to standing position and when bearing weight. Patients with atypical recovery from distal radius fractures require treatment modification and goal setting Improve functional levels.

Key Research

Handoll et al conducted eight Cochrane reviews of distal radius fractures. Not enough data to draw conclusions. This may be due to poor study design and the heterogeneity of distal radius fractures themselves.

• Different methods of external fixation for the treatment of distal radius fractures in adults [3]
• External fixation and conservative treatment of distal radius fractures in adults [2]
• Internal fixation and comparison of different fixation methods for adult distal radius fractures [17]
• Closed reduction approach in the treatment of distal radius fractures in adults [18]
• Percutaneous fixation for distal radius fractures in adults [23]
• Bone grafts and substitutes for the treatment of distal radius fractures in adults [26]
• Conservative intervention for the treatment of distal radius fractures in adults [37]
• Rehabilitation of distal radius fractures in adults [38]

In a randomized controlled trial, Kay et al. [27] supported physical therapy interventions, despite the study’s many limitations. [8] While no significant differences in grip strength and wrist extension were found among the experimental groups, it is important to note some minor All measures improved significantly compared to the control group. These include the benefits of activity pain and satisfaction.

Clinical Bottom Line

Because distal radius fractures are one of the most common injuries in orthopedics, it is important that a physical therapist understands risk factors and treatment options. Although further research is needed to determine appropriate postoperative management, recommendations are based on Current evidence suggests that patients should be referred regularly to a physiotherapist for an education and exercise program.