Journal of the Accident and Medical Practitioners Association (JAMPA) 2004; Vol. 1 (No. 2)
 Accident and Medical Practitioners Association, New Zealand
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Intra-articular Fractures of the Distal Radius
Minimising the Requirement for Surgery and Long-term Disability
S.J. Hoskin, MBChB, BMedSci
Nelson Hospital, Nelson
About the author:
Dr Stephen Hoskin, MBChB, BMedSci, is a second-year house surgeon at Nelson Hospital,
Nelson. He most enjoys paediatrics, emergency medicine, and general practice. Dr Hoskin is
planning to become a rural GP but also intends to work in developing countries.
Address for correspondence: Dr Stephen Hoskin, MBChB, BMedSci, Nelson Hospital,
Private Bag 18, Nelson.
E-mail: stephen@hoskin.net.nz
Issues this article will address
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The importance of identifying and appropriately managing intra-articular fractures
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Steps that can be taken to maximise the chances of a good functional outcome
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The need for appropriate patient education to reduce the risk of subsequent fracture
movement
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Salient Points
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Intra-articular fractures of the distal radius have higher rates of complications than
extra-articular fractures.
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Several radiographic parameters are useful in assessing distal radiographic fractures:
radial tilt, palmar tilt, radial height, radial width, articular step-off, articular gap.
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The most important prognostic factors are those relating to joint congruity: articular
step-off and articular gap.
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Radiographs should be examined to check for signs of other injuries such as radioulna dislocation, carpal fracture and carpal dislocation.
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Manual techniques should be used to restore normal anatomy, re-reducing the fracture
if joint congruity, among other parameters, is not achieved.
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Good plaster technique and patient education should be undertaken to reduce the risk
of subsequent fracture movement.
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Any intra-articular fracture is unstable and requires orthopaedic follow-up within 10
days.
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Key words: Fractures · Intra-articular fractures · Radius fractures · Management ·
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Complications
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Introduction
Fractures of the distal radius are the most common type of fracture seen in emergency
departments, accounting for 15% of all fractures seen.[1] They are usually defined as “those
occurring within three centimetres of the radiocarpal joint of the radius”,[2] and are most
commonly seen in females over the age of 40 years. In young people, the fracture is typically
the result of high-energy trauma such as falling down stairs. In older adults, the bone is more
fragile and fractures occur with low-energy trauma such as falling from standing height.
In the UK, the one-year incidence of fractures of the distal radius is 9 per 10,000 men and 37
per 10,000 women. In the USA or Northern Europe, a white woman aged 50 years has a 15%
lifetime risk of distal radius fracture, while a man has a lifetime risk of just over 2%.[2,3]
These figures correlate roughly with New Zealand data where the Accident Compensation
Corporation (ACC) registered around 3800 new cases of “hand/wrist” fractures over the 12month period to June 2003 at a cost of over NZ$10 million.[4]
Intra-articular fractures are an important subgroup of distal radius fractures. They are more
likely to require surgical intervention and have a higher rate of complications. This article
discusses measures that can be taken in the acute setting to reduce the likelihood of adverse
outcomes and maximise long-term function.
CASE DESCRIPTION
A 41-year-old male presented to Nelson Hospital emergency department after slipping on
a rock and falling about 2.5 metres onto his right arm. The arm was painful and swollen
over the wrist. He was otherwise fit and well and did not smoke.
On examination, there was marked swelling over the distal radius and wrist with some
dinner-fork appearance. Neurovascular function was intact. Plain digital radiography
revealed a comminuted oblique intra-articular fracture of the distal radius with
approximately 35° of dorsal angulation of the distal segment. There was an avulsion of the
ulna styloid (Figure 1).
Figure 1. Radiograph prior to reduction. (click here to view figure)
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A Bier’s block was applied and the distal radius was manually reduced by applying
traction and then pressure in the palmar direction to correct the angulation. The wrist was
held in ulnar deviation in the neutral position while a plaster cast was applied. Postreduction radiography showed a near-anatomical position of the fracture (Figure 2).
Figure 2. Radiograph post-reduction. (click here to view figure)
As the patient was due to leave the Nelson area, he was given a hard copy of his x-rays
and arrangements were made for him to see an orthopaedic surgeon in his home city.
At follow-up one week after the injury, a plain x-ray showed the fracture was unmoved
and at two weeks after injury the fracture was still in a good position. At this stage, the
plan for the patient was to have another x-ray at four weeks post-injury. If the fracture
remained in position, the cast would be removed after a total of six weeks.
Emergency Management Considerations
Diagnosis
Intra-articular fractures are not easily distinguished on clinical grounds. Plain radiography is
required to identify whether the fracture extends into the articular surface of the distal radius.
Care should be taken to note the extra-articular features of the fracture and look for
associated pathology such as radio-ulna dislocation, ulna-styloid dislocation, ulna fracture,
scaphoid fracture, and carpal (e.g. scapho-lunate) dislocation.
Radiological parameters to note are the radial tilt (inclination), palmar (volar) tilt, radial
height, and radial width. The methods to determine these parameters have been described in a
review by Rodriguez-Merchan,[5] as follows:
“The radial inclination is measured on the PA view and describes an angle between
a line along the distal radial articular surface and the long axis of the radius,
normally 23° to 24°. The volar tilt is measured on the lateral view as the angle
between the line representing the distal radial articular surface and a line
perpendicular to the long axis of the radius, normally 11° to 12°.
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The radial height is measured on the PA view as the difference in length between
the radius and ulna. This is calculated by drawing two lines perpendicular to the
long axis of the radius, one tangent to the tip of the radial styloid, and the other
tangent to the flat surface of the ulnar head. The normal distance between the two
lines is 9 to 12 mm. The radial width is measured on the PA view and is the distance
between the longitudinal axis in the center of the radius and the most lateral (radial)
point of the radial styloid process.”[5]
An easier way to measure radial length is to compare the adjacent distal surfaces of the radius
and ulna. The ulna is usually 0 to 3 mm shorter than the radius. However, there is normal
anatomical variation, such as having a slightly longer ulna, in which case comparison
radiographs with the other wrist may be required to determine whether the anatomy is newly
deranged.
These radiological parameters are estimated just as reliably using digital radiographs as using
celluloid radiographs.[6] The main prognostic indicator is joint congruity, which is revealed
by the articular step-off or gap. A step-off equal to or greater than 2 mm is associated with
long-term pain, arthritis and loss of function.[1,5,7,8] The problem with plain radiography is
that it can under- or overestimate the degree of step-off or articular comminution.
Conventional tomography and computer-assisted tomography are both more precise than
plain radiography at estimating degree of articular step-off .[1] In the future, conventional
tomography will be superseded by multidimensional CT.
Treatment
The aim of treatment is to restore anatomy back to as near-normal as possible. Almost all
fractures of the distal radius will benefit from an attempt at reduction. The main benefit of
restoring normal anatomy is improving functional outcome.[5,8] Additional benefits include
a better cosmetic result and potentially avoiding surgery with its associated risks and costs.
Early reduction can also reduce pain and swelling and may be required to relieve vascular
compromise or nerve impingement.
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No particular technique of manual reduction is better than any other. A technique whereby
non-anaesthetised patients provide their own counter traction has even been trialed. There
was short-lived, greater pain but the anatomical results of reduction were no different to
traditional, two-person methods.[3] Once the fracture has been reduced, the thumb should be
pulled while the plaster is applied and allowed to set. Pulling the thumb maintains traction
and puts the wrist into ulna deviation, which provides ligamentous traction around the distal
radius. Having the wrist slightly flexed or extended probably provides additional ligamentotaxis and improves the outcome.[9]
The plaster should apply pressure at three points around the fracture. Particular care should
be taken to ensure the palmar aspect is well moulded. Excessive padding provides inadequate
support around the fracture, increasing the likelihood of redisplacement. Below elbow casting
is adequate. Neurovascular function should be re-examined after plastering.
Follow-up x-rays should be obtained to ensure the fracture has been reduced. The most
important area is the articular surface of the distal radius. If the step-off is greater than 2 mm,
the fracture requires surgical correction. The main extra-articular criteria are the palmar tilt,
radial inclination, and radial height.[5,7] Dorsal angulation greater than 10° reduces the range
of motion and worsens dorsal intercalated segment instability. Radial shortening distorts
radio-ulnar kinematics and distorts the triangular fibrocartilage.[5] If the bony anatomy can
be improved, the plaster can be removed and the fracture re-reduced. If a repeat x-ray after
replastering shows no improvement, the patient should be referred to an orthopaedic surgeon.
Patient Education
Patients should be made aware of the nature of their injury and that the fracture involves the
joint and is, therefore, unstable. By maintaining normal anatomy, their chances of regaining a
functional, pain-free wrist are maximised. Encourage strict plaster care such as avoiding
water and early changing if the plaster becomes loose. Discourage activities such as heavy
lifting or falling that put the wrist at risk of excessive force.
Patients should also be made aware of possible early complications such as compartment
syndrome, what symptoms and signs to look out for, and what to do if they occur, i.e. see a
doctor immediately. The patient also needs to be aware that the fracture may require surgery
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to improve the outcome. Discuss possible complications such as arthritis to give an extra
incentive to provide good initial care (Table 1). Surgery carries additional risks of infection,
radial nerve dysfunction, and anaesthetic complications, but subjective outcome scores at
long-term follow-up are no worse than for conservative treatment.[2,8]
Table 1. Complications of intra-articular fractures of the distal radius [1,2,5,7,8] (click
here to view table)
Any fracture provides the opportunity for health promotion to smokers. Smoking increases
the time required for a fracture to heal. Given this fact, along with the practical difficulty of
smoking with a cast on, the day of fracture is a great time to give up. It may also be
appropriate to commence treatment for osteoporosis in patients at risk. These patients include
postmenopausal women, people who have fractured with minimal trauma, and those whose
radiographs demonstrate low bone density.
Follow-up
Intra-articular fractures are unstable. Even if good anatomical positioning is achieved with
manual reduction, patients must be followed closely, preferably by an orthopaedic surgeon.
In an analysis of eight trials, redisplacement requiring surgery was necessary in one-sixth of
distal radius fractures treated conservatively.[2] Redisplacement and subsequent deformity
after cast treatment is more likely if there is “dorsal or volar comminution, severe dorsal
angulation and incomplete reduction”.[5] Repeat imaging is therefore required, sometimes
using standard or computer-assisted tomography.
For fractures that require surgical correction, surgery is technically easier if done within 10 to
14 days of injury. After this time, bony fragments lose their definition and become harder to
piece back together. Fractures that require surgery despite manual reduction should therefore
be followed-up as soon as practical. For fractures where near-normal anatomy is restored,
repeat imaging is usually done each week initially, so follow-up at one week is a suitable
time.
In summary, intra-articular fractures of the distal radius are potentially debilitating. There are
several techniques the emergency clinician can use to minimise the likelihood of surgery or
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the occurrence of long-term disability. These include identifying intra-articular fractures
early, using good reduction and plastering technique, providing patient education, and early
orthopaedic follow-up.
References
1. Freedman DM, Dowdle J, Glickel SZ, Singson R, Okezie T. Tomography versus
computed tomography for assessing step off in intraarticular distal radial fractures.
Clinical Orthop 1999;361:199-204.
2. Handoll HHG, Madhok R. Surgical interventions for treating distal radial fractures in
adults. The Cochrane Library, Issue 2. Chichester, UK: John Wiley & Sons; 2004.
3. Handoll HHG, Madhok R. Closed reduction methods for treating distal radial fractures in
adults. The Cochrane Library, Issue 2. Chichester, UK: John Wiley & Sons; 2004.
4. Accident Compensation Corporation (ACC). Injury statistics 2004. Available from:
http://www.acc.co.nz/about-acc/acc-injury-statistics/2-all-entitlement-claims/diagnosisby-injury-site.html. Accessed July, 2004.
5. Rodriguez-Merchan EC. Management of comminuted fractures of the distal radius in the
adult. Conservative or surgical? Clinical Orthop 1998;353:53-62.
6. Bozentka DJ, Beredjiklian PK, Westawski D, Steinberg DR. Digital radiographs in the
assessment of distal radius fracture parameters. Clinical Orthop 2002;397:409-13.
7. Lipton HA, Wollstein R. Operative treatment of intraarticular distal radial fractures.
Clinical Orthop 1996;327:110-24.
8. Fernandez JJ, Gruen GS, Herndon JH. Outcome of distal radius fractures using the short
form 36 health survey. Clinical Orthop 1997;341:36-41.
9. Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in
Adults. The Cochrane Library, Issue 2. Chichester, UK: John Wiley & Sons; 2004.
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Table 1
Table 1. Complications of intra-articular fractures of the distal radius [1,2,5,7,8]
Short-term complications
Long-term complications
Concomitant injuries to soft tissue,
Loss of range of motiona
tendon, nerve, vessels
Reduced grip strength
Vascular compromise
Arthritisb
Carpal tunnel syndrome
Pain
Extensor pollicis longus rupture
Mid-carpal instability
Compartment syndrome
Reflex sympathetic dystrophy
Malunion
a
Loss of range of motion is slightly less after open reduction and internal fixation
(ORIF).
b
Arthritis develops in 86-100% of patients if the step-off is 2 mm or greater, 25% if the
step-off is less than 2 mm, and approximately 50% after open reduction and internal
fixation. Post-ORIF arthritis is mostly mild.[1,7]
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