Distal Radius Fractures in Adults

31/5/2014 Distal radius fractures in adults
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www.uptodate.com 2014 UpToDate
Author
David J Petron, MD
Section Editor
Patrice Eiff, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
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Distal radius fractures in adults
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2014. | This topic last updated: Nov 14, 2013.
INTRODUCTION The distal radius is the most common fracture site in the upper extremity. Such injuries account for
approximately one-sixth of fractures treated in US emergency departments [1]. The Colles fracture is the most common.
Familiarity with wrist anatomy and the natural history of major fracture types is essential for appropriate management of
distal radius fractures [2]. This topic review will discuss the evaluation and management of distal radius fractures in adults.
Other wrist injuries are discussed elsewhere. (See "Evaluation of the adult with acute wrist pain" and "Overview of carpal
fractures".)
EPIDEMIOLOGY AND RISK FACTORS A review of over 1.4 million US emergency department (ED) visits found that
hand and forearm fractures account for 1.5 percent of all visits [1]. Of these, fractures of the radius and/or ulna comprise the
largest portion (44 percent).
The majority of distal radius fractures occur as isolated injuries in two distinct populations: youth involved in sport who
sustain a relatively high-energy fall, and seniors with osteoporotic bone who sustain a low-energy fall.
Athletics The cause of wrist fractures among young people varies according to the local popularity of different physical
activities. A Scottish study of distal radius fractures related to sport found that football (ie, soccer) produced 50 percent of
fractures [3]. Play on artificial turf increased the likelihood of fracture by a factor of five. Skiing, dancing, and rugby caused
12, 9, and 7 percent of wrist fractures, respectively. More severe injuries occurred as a result of skiing, horseback riding, and
dancing.
The increasingly popular sport of snowboarding has a high rate of associated extremity fractures, including those of the
distal radius. Physicians at a Japanese hospital caring for more than 10 ski areas evaluated over 5000 snowboarders for
injuries [4]. They found most distal radius fractures occurred in patients in their twenties (82.3 percent) without extensive
snowboarding experience (42 percent novices; 48 percent intermediates). Ninety-four percent of patients had not received
professional instruction, and 87 percent were not wearing protective equipment. Although less likely to be injured, more
experienced snowboarders were more likely to sustain a complex intraarticular fracture.
Geriatric population Both age and gender play a role in the risk of distal radius fracture. At 50 years of age, a white
woman living in the United States or Northern Europe has approximately a 15 percent lifetime risk of a distal radius fracture;
a man in the same regions has a lifetime risk of just over 2 percent [5].
One large, prospective study of distal radius fractures among Caucasian women with osteoporosis, over the age of 65,
involved in low-energy falls, found three statistically significant, independent risk factors: decreased bone density at the
distal radius (RR = 1.8), a history of recurrent falls (RR = 1.6), and previous fracture after age 50 (RR = 1.3) [6]. For women
over 75 years of age, dementia was an additional risk factor. Use of oral estrogen was found to be protective, and
intraarticular fractures were more than twice as frequent in women with diabetes.

Among elderly men, distal radius fracture appears to be an early and sensitive marker of skeletal fragility [7]. More than any
other fracture type, distal radius fractures correlate with a higher absolute risk for hip fracture in men (among women spinal
compression fracture correlates more closely). A smaller study found shorter-than-expected life expectancy among patients
with distal radius fractures when compared with peers of comparable age, gender, and comorbidities [8]. After sustaining
this fracture, men were twice as likely to die as women with the same injury and did so almost twice as quickly. (See
"Epidemiology and etiology of osteoporosis in men".)
Although older patients sustaining low-energy distal radius fractures represent an important population for osteoporosis
screening and treatment, the opportunity is often squandered. One Canadian study evaluated osteoporosis follow-up and
treatment in a group of 156 patients who sustained a low-energy distal radius fracture [9]. They found that 32 percent of
patients were receiving osteoporosis treatment before their injury, but after fracturing their radius only 21 percent more
received osteoporosis screening, and only a few more began receiving a bisphosphonate or hormone replacement therapy.
(See "Prevention of osteoporosis" and "Screening for osteoporosis".)
ANATOMY The anatomy of the wrist is reviewed in detail separately. (See "Anatomy and basic biomechanics of the
wrist".)
MECHANISM OF INJURY The most common mechanism of distal radius fractures is Falling On an Out-Stretched Hand
(sometimes abbreviated as FOOSH), with the wrist in extension. Minimal force is needed to produce a distal radius fracture
in osteoporotic bone, and injury can occur after a fall from standing height or lower.
In healthy young patients, distal radius fractures often occur after violent injuries directly to the bone or by a compression
load driving the scaphoid or lunate into the distal radius, producing a "die-punch" fracture [2]. Such high-energy fractures are
more likely to be comminuted and intraarticular, and to occur in association with other significant injuries.
CLINICAL PRESENTATION AND PHYSICAL EXAMINATION The patient with a distal radius fracture usually describes
falling onto their outstretched hand or sustaining a blow to the wrist and complains of wrist pain, and possibly deformity. In
addition to standard inquiries about the mechanism of injury, the clinician should ask about any previous wrist injuries or
surgery, and any resultant abnormal anatomy [10]. Also important are medical conditions affecting the injured extremity,
such as carpal tunnel syndrome or peripheral vascular disease.
The clinician should inspect the injured extremity for swelling, deformity, and evidence of a possible open fracture. Swelling
may or may not have developed by the time of presentation. Obvious deformities, such as the classic "dinner-fork" deformity
(figure 1) associated with Colles' fractures, can occur, but the extremity may appear normal.
Examination includes an assessment of neurovascular status, including motor and sensory function of the median, radial,
and ulnar nerves. Particular attention should be paid to sensation in the thumb and index fingers because acute median
nerve compression is common, especially with severely displaced fractures. The clinician should assess circulation by
palpating the radial pulse and testing capillary refill of the nail beds and fingertips. (See 'Indications for orthopedic
consultation or referral' below.)
Range of motion of the wrist, including supination, pronation, flexion, and extension should be evaluated if possible. Ulnar
deviation with palpation of the anatomic snuffbox is important to ascertain the presence of a scaphoid fracture. Clinical
evaluation of a distal radioulnar joint (DRUJ) injury associated with a distal radius fracture is difficult. Ulnar-sided wrist pain
and tenderness may be present due to a DRUJ or ulnar styloid injury.
In order not to miss associated injuries, the clinician should examine the involved extremity in its entirety, particularly the
elbow and shoulder joints. A detailed description of the examination of the wrist and other joints is found elsewhere. (See
"Scaphoid fractures" and "Evaluation of the adult with acute wrist pain" and "Evaluation of elbow pain in adults".)
RADIOGRAPHIC FINDINGS When reading radiographs of distal radius fractures, clinicians should seek to answer four
important questions:
Is there loss of normal anatomy (eg, fracture displacement or angulation, loss of radial height)? (see 'Anatomic
landmarks and measurements' below).
Is there involvement of the radiocarpal or distal radioulnar joint?

If joints are involved, is there discontinuity of the articular surface (ie, articular step-off) or diastasis (ie, separation) of
the articular fragments?

Anatomic landmarks and measurements Accurate assessment of standard radiographs is essential for appropriate
management [11,12]. Radiographic evaluation of the distal radius includes true posterior-anterior (PA) and true lateral
projections. Oblique radiographs often are included as a supplemental view [13]. Each view contains a small number of
important landmarks and measurements for proper interpretation.
Posterior-anterior (PA) x-ray Landmarks on the PA projection include the radial and ulnar styloids, the distal
radioulnar joint (DRUJ), and the radiocarpal joint, including the proximal carpal bones. Important radiographic measurements
include radial inclination, radial height, and ulnar variance.
Lateral x-ray In a true lateral projection (image 3), the radius and ulna should be superimposed, and the pisiform
projected over the distal pole of the scaphoid. If the pisiform is found dorsal to the scaphoid, the patient is in relative
pronation; if found palmar, the patient is in relative supination. Normally, the lunate is seated within the fossa of the distal
radius, and the curvature of their articular surfaces should correspond. The central axis of the lunate should be collinear with
the central axis of the radius. Palmar migration is a sign of radiocarpal instability [13].
The most important measurement on a lateral projection is palmar tilt (ie, volar tilt). AP distance may also be helpful.
Classification Distal radius fractures can be described using either a fragment-specific classification [13] or the standard
Frykman classification. The Frykman classification system divides the fractures among four main groups based upon joint
involvement. Within each major grouping, fractures with even numbers involve a concomitant ulnar styloid fracture. Frykman
categories are:
Two common eponyms associated with distal radius fractures are Colles and Smith. Colles' fractures involve dorsal
Are high-risk features present (eg, severe comminution, articular step-off >2 mm, fracture-dislocation)? (see 'Indications
for orthopedic consultation or referral' below).
Radial inclination (image 1 and figure 2) is the angle between one line drawn perpendicular to the long axis of the
radius and a second line drawn between the distal tip of the radial styloid and the central reference point (CRP). The
CRP lies midway between the palmar ulnar corner and the dorsal ulnar corner of the distal radius (image 2). The
average angle is approximately 20 to 25 degrees, although there are slight gender differences (24.7 2.5 for women;
22.5 2.1 for men) [13]. The angle is often smaller with distal radius fractures.
Radial height (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of
the radial shaft: one through the distal tip of the radial styloid and the second through the CRP. Normal height averages
11.6 1.6 mm [13]. The measured height is often smaller with distal radius fractures.
Ulnar variance (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of
the radial shaft: one through the distal articular surface of the ulnar head and the second through the CRP. Normally,
the radial surface is distal to the ulnar surface by 1 to 2 mm (negative ulnar variance) [13]. When the ulnar surface is
distal to the radial surface (positive ulnar variance), the biomechanics of the wrist can be impaired, especially if the
distance is 5 mm greater than the contralateral wrist.
Palmar tilt (image 3 and figure 3) is the angle formed by the intersection of one line perpendicular to the longitudinal
axis of the radial shaft and a second line drawn through the apices of the palmar and the dorsal rims of the radius. The
normal palmar tilt on a standard lateral projection averages 11.2 4.6 degrees and does not differ between genders
[13]. A smaller palmar tilt as a result of fracture is a risk factor for subsequent pain and disability.
AP distance (image 3 and figure 3) lies between the apices of the dorsal and palmar rims of the radius. Normally, AP
distance should be slightly larger than the width of the lunate, and it averages 19.1 1.7 mm. It is significantly larger in
males (20.4 1.1) versus females (17.8 1.7) [13]. It can increase as a result of axial impaction injuries and suggests
articular step-off.
Types I/II: Completely extraarticular; complications are uncommon once anatomic alignment has been achieved (image
4A-C)
Types III/IV: Extend into the radiocarpal joint (image 5A-B)

Types V/VI: Extend into the distal radioulnar joint (DRUJ) (image 6)
Types VII/VIII: Involve both radiocarpal and DRUJ articular surfaces and are highly unstable (image 7)
displacement of the distal radius fragment (image 4A-C); Smith's fractures involve palmar displacement of the distal radius
fragment.
Fracture dislocations Two major types of radiocarpal fracture dislocations exist: Barton's and Hutchinson's.
Barton's fractures are separated into palmar and dorsal. They are best seen on lateral radiographs (image 8). Palmar
Barton's fractures occur when the palmar radiocarpal ligaments avulse a radial fragment and displace the radiocarpal unit
volarly. In a dorsal Barton's fracture, the dorsal radiocarpal ligaments avulse a radial fragment and displace the radiocarpal
unit dorsally. In both types, the distal radius fragment maintains articulation with the carpus, accounting for the dislocation
and instability. Closed reduction can be attempted, but these fractures are very unstable and reduction is usually lost.
Barton's fractures generally require operative fixation [14,15].
A second type of fracture dislocation carries the eponym of Hutchinson's fracture, and it is also called the chauffeur's
fracture (image 9). The typical mechanism is a direct blow to the radial styloid (such as might have occurred when the
starting crank of an early automobile suddenly reversed with a backfire striking the chauffeur's wrist), or a fall back onto an
outstretched hand held in ulnar deviation and supination. Such mechanisms cause the radioscaphocapitate ligament to
avulse a large fragment of the radial styloid. This injury frequently results in concomitant lunate dislocation or scapholunate
dissociation.
DIAGNOSIS Definitive diagnosis of a distal radius fracture is made on the basis of diagnostic imaging studies, typically
plain radiographs of the wrist. Radiographs are obtained when the diagnosis is suspected on the basis of a suggestive
history, often involving a fall onto an outstretched hand, and examination findings, including pain, tenderness, and possibly
deformity at the wrist.
DIFFERENTIAL DIAGNOSIS The mechanism most often responsible for distal radius fractures, fall onto an outstretched
hand, is associated with a number of other injuries that should be considered when evaluating patients with acute wrist pain
from direct trauma. These injuries include fractures of the scaphoid and other carpal bones, injury to the distal radioulnar
joint (DRUJ) or triangular fibrocartilage complex, and ligamentous injuries, which manifest differently depending upon the
involved ligaments (eg, lunate or perilunate dislocation, scapholunate dissociation). Scaphoid injuries are common and often
associated with tenderness in the anatomic snuffbox (picture 1).
Although clinical findings may vary somewhat depending upon the injury, there is substantial overlap in the presentations of
many of the injuries listed here. Furthermore, two or more injuries may occur simultaneously as a result of the same trauma.
Therefore, the only reliable method for distinguishing among injuries is diagnostic imaging, typically starting with plain
radiographs of the wrist. The diagnostic approach to patients with acute wrist pain and the diagnosis and management of
other major injuries that may be sustained by falling onto an outstretched wrist are discussed separately. (See "Scaphoid
fractures" and "Overview of carpal fractures" and "Evaluation of the adult with acute wrist pain".)
INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL Many distal radius fractures can be managed by
knowledgeable primary care clinicians. Conditions requiring emergent referral to an orthopedic surgeon include the following:
In cases of neurologic or vascular compromise, immediate closed reduction of any displaced fracture should be performed,
after providing analgesia, to attempt to alleviate symptoms. Persistent deficits despite reduction mandate emergent referral
to an appropriate surgeon, or transfer if such care is unavailable.
Unstable fractures and those at high risk for complications should also be referred to an orthopedic surgeon. The following
conditions warrant orthopedic referral:
Open fractures
Fractures associated with an acute neuropathy or compartment syndrome
Fractures associated with circulatory compromise in the hand (vascular surgical consultation may also be required in
this circumstance)
Palmarly displaced (eg, Smith's) fractures (see 'Classification' above)

Articular step-off greater than 2 mm
Large ulnar styloid fractures (ie, most or all of the styloid) with displaced fragments at the styloid base; these have an
increased risk of distal radioulnar joint (DRUJ) instability [16,17]

The parameters for instability are poorly defined in the literature and vary with patient age and functional demands. Clinicians
should be particularly concerned about patients who are physiologically young and have sustained high-energy, comminuted
injuries. The presence of the following conditions on initial radiographs suggests fracture instability and the need for referral
[20,21]:
Multiple scoring systems have been developed to predict instability in fractures of the distal radius [22-25]. However, these
formulas have tended to underestimate fracture instability, and their use is not recommended. Instead, we suggest referral
for any of the factors listed above.
INITIAL TREATMENT Recognition of emergent conditions and the decision of whether to perform a fracture reduction
comprise the most important steps in the acute management of distal radius fractures. If significant nerve injury (eg,
paralysis, severe weakness) or vascular compromise is present, immediate reduction of the displaced fracture, with
analgesia, is necessary to attempt to alleviate these symptoms. Persistent symptoms despite reduction mandate emergent
consultation with the appropriate surgical specialist. Compartment syndrome is an emergency requiring immediate surgical
release. (See 'Early complications' below.)
Should no emergent conditions exist, immediate reduction is not required, and appropriate treatment depends upon the type
of fracture.
Nondisplaced extra-articular fractures (Frykman types I/II) These fractures are relatively stable and can be treated
with a well-molded sugar tong, reverse sugar tong, or double sugar tong splint [26]. (See "Splinting of musculoskeletal
injuries", section on 'Sugar tong splints'.) The application of a circumferential cast in the acute setting increases the risk of
distal ischemia and carpal tunnel syndrome, and it should not be performed [19].
Proper positioning within the splint has the elbow flexed to 90 degrees and the arm in neutral position (ie, without forearm
supination or pronation, and without wrist flexion or extension). During the first several days following injury, the patient
should elevate the arm, apply ice to the fracture frequently (while keeping the splint dry), begin active range of motion of the
shoulder and fingers, and use analgesics as needed [3]. Opioids may be necessary; a short course of nonsteroidal anti-
inflammatory drugs (NSAIDs) may also be used.
Displaced fractures (Frykman types I-VIII) Displaced fractures with neurovascular compromise warrant an immediate
attempt at closed reduction (see 'Early complications' below). Immediate closed reduction by an experienced clinician is
appropriate, but not required, for displaced fractures without neurovascular compromise or radiographic evidence of instability
[1]. (See 'Radiographic findings' above.) If a clinician capable of performing a reduction is unavailable, the provider may
immobilize the fracture, provide appropriate analgesia, and discharge the patient, provided follow-up the next day for
reduction by an orthopedist has been arranged.
Criteria for adequate reduction in a patient with high functional demands include (see 'Classification' above):
Fracture dislocations (ie, Barton's or Hutchinson's) (see 'Fracture dislocations' above)
Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries [18,19] (Radial styloid
fractures are often associated with scapholunate injuries and such fractures are generally referred to an orthopedic
surgeon)
Fractures with significant displacement or comminution; these are unstable and likely to lose position even if initial
reduction is near-anatomic
Fractures likely to be unstable and unamenable to conservative treatment

Greater than 20 degrees of dorsal angulation
Fracture displacement in any direction greater than two-thirds the width of the radial shaft
Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)
Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)
Intraarticular component (especially involving the DRUJ)
Advanced osteoporosis
Substantial soft tissue swelling often accompanies displaced fractures, so splinting is recommended for postreduction
immobilization (see "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'). The application of a
circumferential cast in the acute setting increases the risk of distal ischemia and carpal tunnel syndrome, and it should not
be performed [19].
During the first several days following injury, the patient should elevate the arm, apply ice to the fracture frequently (while
keeping the splint dry), begin active range of motion of the shoulder and fingers, and use analgesics as needed [3]. Opioids
may be necessary; a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used.
FRACTURE REDUCTION BASICS In cases of neurologic or vascular compromise, immediate closed reduction of any
displaced fracture should be performed. Persistent deficits despite reduction mandate emergent referral to an appropriate
surgeon, or transfer if such care is unavailable (see 'Indications for orthopedic consultation or referral' above). Should no
emergent conditions exist, immediate reduction is not required. Adequate anesthesia must be obtained prior to reduction.
Hematoma block A hematoma block, with or without systemic opioids, provides adequate analgesia for reduction of
most displaced distal radius fractures. Hematoma blocks are safe and easy to perform.
First, the skin over and around the fracture site is prepared with an antiseptic solution (eg, chlorhexidine). Sterile technique
should be maintained throughout the procedure. Next, a 10 mL syringe is filled with 5 to 8 mL of one percent lidocaine
without epinephrine. A 22-gauge needle is attached to this syringe. The clinician then gently palpates the dorsum of the
wrist to locate the fracture step-off with one hand, and inserts the needle, also on the dorsal aspect of the wrist, with the
other. The needle is advanced directly into the fracture site. The clinician draws back continuously on the syringe while
advancing the needle. Aspiration is maintained until a flashback of blood confirms placement of the needle tip in the fracture
hematoma. The mixture of blood and lidocaine is then injected directly into the fracture site. Some clinicians perform
repeated aspirations and reinjections to disperse the anesthetic more completely before removing the needle.
Reduction techniques Traction/counter-traction is critical to reduction. This can be achieved with or without finger traps
(figure 4). The two approaches do not differ in the ultimate alignment attained or in the rate of failure to maintain reduction
[27].
Regardless of the method used to reduce the fracture, finger traps are a useful adjunct before the procedure is attempted.
Traction is applied by attaching the finger traps to the thumb, index, and middle fingers, while keeping the elbow flexed at 90
degrees and the forearm in neutral rotation. Five to 10 pounds (two to five kilograms) of downward traction is placed on the
distal humerus for at least five minutes before any reduction is attempted. This enables muscular relaxation and helps
distract the fracture fragments, bringing the radius closer to normal length.
Active reduction can be performed with the patient still in the finger traps. For Colles' type fractures, the examiner's thumbs
are placed on the dorsal aspect of the distal fracture fragment, while the fingers are placed on the palmar forearm just
proximal to the fracture line. While applying downward axial traction to the proximal fragment, the distal fragment is pushed
distally, palmarly, and ulnarly to eliminate the dorsal displacement and radial shortening.
A sugar tong, reverse-sugar tong, or double sugar tong splint is then applied and molded with the patient still in the finger
traps [2]. (See "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'.) A three-point contact molding
technique is used to help hold the reduction [28]. For Colles' type fractures, ideal immobilization for the first two weeks
consists of 15 degrees of palmar flexion, 10 to 15 degrees of ulnar deviation, and slight pronation [29].
Manual reduction can also be performed without finger traps, with the help of an assistant. The assistant provides counter-
traction by holding the elbow. The clinician then supinates the patient's forearm with one hand while applying longitudinal
traction to the distal fragment with the other hand and thumb. Next, the fracture is disimpacted by applying dorsal angulation
(ie, accentuating the fracture pattern). Finally, the reduction is completed by pronating the forearm and wrist, followed by the
application of some ulnar deviation, to correct the radial and dorsal angulation. The fracture is held in this position while a
splint is applied and molded in the fashion described immediately above.
FOLLOW-UP CARE Treatment of distal radius fractures varies according to the patient's health, functional needs, and the
injury sustained. Active patients with high functional needs require anatomic reductions, and they often need surgical
No dorsal tilt of the distal radial articular surface
Less than 5 mm of radial shortening
Less than 2 mm of displacement of fracture fragments
fixation.
The most fundamental decision is whether to treat conservatively or surgically. Clinicians should consider such medical
factors as bone quality, comorbidities, and functional demand. Fracture characteristics, associated injuries, risk of
complications, and clinician experience with fracture management are also relevant. As an example, a 16-year-old
skateboarder with a comminuted, displaced, intraarticular fracture requires surgical repair to achieve anatomic alignment; a
sedentary 80-year-old with an identical injury needs immobilization and occupational rehabilitation (see 'Geriatric
management' below). Finally, clinicians should inquire about patient preferences and social circumstances.
Conservative management with closed reduction and immobilization is appropriate for fractures that are reducible by closed
manipulation and will remain stable thereafter [29]. A systematic review found insufficient evidence to determine which
conservative treatments are most appropriate for common adult distal radius fractures [30]. Our recommendations below are
based upon the limited literature assessing treatment of these fractures and our clinical experience.
Nondisplaced extra-articular (Frykman types I/II) Patients are seen three to five days following injury to allow swelling
to subside. The clinician should remove the splint, assess neurovascular status, and obtain radiographs of the arm out of the
splint to confirm there is no loss of position.
If the fracture remains nondisplaced or minimally displaced, the clinician applies a short arm cast. The cast should extend
from the distal palmar crease to within 5 cm of the antecubital fossa, with the wrist in neutral position. Patients should be
seen in follow-up every two to three weeks thereafter until healing is complete. Radiographs are taken at the initial
postcasting visit, at two weeks, and then sometime between four and six weeks after injury to confirm proper alignment [2].
The patient's wrist and forearm should remain immobilized until there is evidence of radiographic healing or the fracture site
is nontender, generally four to six weeks postinjury. At this point, the patient can use a wrist brace in lieu of a cast.
Complete healing usually requires six to eight weeks.
For patients over 60 years of age, the period of immobilization should be kept to a minimum to avoid post-immobilization
stiffness. Early transition to a wrist splint may be helpful depending on fracture stability. In one randomized trial, patients
treated with a wrist splint were more satisfied and regained function sooner than patients immobilized in a cast [31].
Evidence guiding the appropriate period of fracture immobilization in the geriatric population is lacking. Nevertheless, we
think that older patients who meet the following criteria can be removed from their cast and placed in a wrist splint as early
as two to three weeks following injury:
Displaced (Frykman types I-VIII) Once reduction is achieved, we suggest patients remain in the initial sugar tong splint
for the following two to three weeks. The U-shaped part of the splint wraps around the elbow, thereby minimizing forearm
rotation and maintaining the desired pronation or supination, according to the fracture type. The sugar tong splint also
immobilizes the distal radioulnar joint (DRUJ), and splinted patients experience less pain than patients immobilized in a
short arm cast [29].
Radiographs are taken in the sugar tong splint on the third, seventh, and twelfth days following reduction. This enables the
clinician to detect quickly any loss of position and to assess the acceptability of any postreduction movement or residual
deformity. During the first two weeks, the initial splint should be adapted and molded as soft tissue swelling decreases. This
is achieved by wrapping the splint tighter with elastic bandages at each follow-up visit. Adequate tightness and molding
throughout the early postreduction period reduces the risk of secondary displacement [29].
At two to three weeks, the splint is changed to a short arm cast. Wrist immobilization continues in the cast for another three
to four weeks. The clinician must take care to maintain three point contact, and to avoid inadequate or excessively bulky
padding [29]. At each visit, the clinician should assess fracture site tenderness, swelling, elbow and hand motion, and
median nerve function. Radiographs should be obtained every two weeks and studied for signs of dorsal displacement,
palmar angulation, and radial shortening [2].
Extraarticular fracture of the distal radius
Minimal comminution present
Reduction was NOT necessary
Functional demands are few
Risk of fall or reinjury is low
Patients should be immobilized six to eight weeks, until there is evidence of radiographic healing and the fracture site is
nontender. At this point, the clinician can remove the cast and place the patient in a wrist brace. Complete healing generally
occurs within 8 to 12 weeks. The shortest possible period of immobilization is preferred for older patients; prolonged
immobilization can cause joint stiffness and significant loss of function [2].
Once the cast is removed, patients should begin active range-of-motion exercises. Physical therapy may be needed to
achieve acceptable motion, but most patients require only a single session of instruction [32]. Older patients and those with
more complicated fractures requiring prolonged immobilization may require more extensive rehabilitation.
Styloid fractures As described above, large ulnar styloid fractures (ie, most or all of the styloid is involved) with
displaced fragments at the styloid base should be referred to an orthopedic or hand surgeon, as they are associated with an
increased risk of distal radioulnar joint (DRUJ) instability [16,17,33,34]. Fractures of the tip of the ulnar styloid, distal to the
DRUJ, are generally considered stable and can be managed conservatively. Radial styloid fractures are often associated
with scapholunate injuries and such fractures are generally referred to an orthopedic or hand surgeon for possible surgical
management. (See 'Indications for orthopedic consultation or referral' above.)
Isolated nondisplaced fractures of the ulnar styloid that do not involve the DRUJ and are not associated with DRUJ instability
are uncommon, but can be managed conservatively in a short arm cast, as is done for nondisplaced radial fractures
generally. (See 'Nondisplaced extra-articular (Frykman types I/II)' above.)
Geriatric management
Fracture management Vigorous elderly patients with distal radius fractures should be referred for surgical treatment
as indicated. However, many older patients are best served by conservative fracture management and rehabilitation designed
to maximize function, despite the presence of significant deformity. One study of patients older than 70 years of age who
declined operative repair of their intraarticular distal radius fractures found 89 percent had a good or excellent functional
outcome, despite 26 percent having only a fair or poor anatomic result [35].
Another study of elderly patients with moderately displaced Colles' fractures randomized to reduction under Bier block and
immobilization or to immobilization alone found no functional difference between the two groups [36]. On average, two-thirds
of the dorsal angulation corrected by manipulation was lost by five weeks. The authors concluded that up to 30 degrees of
dorsal angulation and 5 mm of radial shortening may be accepted in selected elderly patients.
The limited utility of fracture reduction among low-functioning geriatric patients was confirmed in another study of 59 patients
with a mean age of 82 years. Of 60 fractures treated by closed reduction, 53 ultimately healed with significant deformity. Of
44 dorsally displaced fractures, reduction failed in seven cases initially, and 37 lost reduction during the following weeks of
immobilization. The authors concluded that reduction of fractures of the distal radius is of minimal value in old and frail,
dependent, or demented patients [37].
Osteoporosis also complicates management of older patients with fractures. Optimal clinical results of distal radius fractures
have been shown to correlate more closely with bone mineral density than with radiographic parameters [38]. Osteoporosis
contributes to fracture instability. We suggest patients with displaced fractures in osteoporotic bone be referred to an
experienced orthopedist. (See 'Indications for orthopedic consultation or referral' above.)
Regardless of management strategy, clinicians should minimize the length of time geriatric patients are immobilized
because of the risk of joint stiffness and consequent disability. (See "Frozen shoulder (adhesive capsulitis)".)
Osteoporosis evaluation Fracture in an elderly individual warrants an evaluation for osteoporosis. A history of a
fracture is an important risk factor for a subsequent fracture. Unfortunately, the majority of patients with vertebral, hip, and
distal radius fractures do not receive evaluation and treatment for underlying osteoporosis. As a result, these patients
frequently suffer additional fractures. Elderly patients with a history of fracture constitute a high-risk group that requires
additional evaluation and treatment. (See "Overview of the management of osteoporosis in postmenopausal women", section
on 'Medical intervention after fracture'.)
COMPLICATIONS
Early complications Median nerve injury, compartment syndrome, and vascular compromise (although the last two
rarely occur) are the most important early complications of distal radius fractures.
Acute carpal tunnel syndrome (ACTS) is found more frequently with severely comminuted or displaced fractures, patients
treated with multiple reductions, and those splinted in extreme wrist flexion (>15 degrees) [39]. The clinician must perform a
careful neurologic examination looking for signs of ACTS at the initial and first follow-up visits, and initial visits following any
remanipulation. Weakness or loss of thumb or index finger flexion is the most important finding. Carpal tunnel release is
indicated if symptoms progress, with or without reduction, or if surgical fixation is planned. Results are best if release is
performed urgently [39-41]. (See "Clinical manifestations and diagnosis of carpal tunnel syndrome".) A mild sensory deficit
consistent with median nerve contusion is often observed and generally is not caused by ACTS.
The interval from injury to development of compartment syndrome may range from 12 to 54 hours [42,43]. Increasing or
constant severe pain and pain elicited by passive extension of the fingers are important findings, but measurement of
elevated compartment pressures provides a definitive diagnosis. Emergent fasciotomy is required. A more detailed
discussion is found elsewhere. (See 'Complications of closed reduction and cast treatment' below.)
Vascular injuries are rare in closed fractures, but injury to the radial or ulnar artery has been reported in high-energy injuries
with significant fracture displacement. Perfusion often improves with reduction, but emergent vascular surgery evaluation is
necessary for any persistent impairment [44].
Injuries to carpal bones and carpal ligaments occasionally accompany distal radius fractures, and they should be suspected
in patients with persistent wrist pain despite acceptable alignment. A case series of 565 Colles' fractures revealed scaphoid
fractures were initially missed in 0.7 percent of cases and intercarpal ligament injuries in 0.9 percent [45]. Scaphoid
fractures in association with distal radius fractures should be treated with internal fixation [18]. Failure to identify and treat
scapholunate ligament injuries with acute pinning has been shown to adversely affect outcome [19]. Fracture lines that
involve the radial articular surface near the scapholunate ligament should raise suspicion of scapholunate ligament injury
(image 10). If initial radiographs show normal scapholunate distance but suspicion is high, we suggest placing a thumb
spica, in addition to appropriate wrist immobilization. (See "Scaphoid fractures".)
Complications of closed reduction and cast treatment Skin tearing can occur with over-vigorous manual reduction
and also with the use of older, metal finger traps. Skin rarely tears with the newer, cloth finger traps. If metal skin traps are
used, cloth tape can be placed over the fingers before they are hung to reduce skin injury [10].
Closed extremity fractures place patients at risk for compartment syndrome, although it is an uncommon complication of
distal radius fractures [45,46]. Patients with compartment syndrome complain of increasing or constant severe pain and
paresthesias. One potential warning sign may be increasing analgesic use. The clinician generally can palpate a firm, tense
forearm, and can elicit pain by passive extension of the fingers, thereby stretching the flexor tendons within the forearm
compartment. Measurement of elevated compartment pressures enables more accurate diagnosis. Normal pressure is less
than 5 mmHg; pressure exceeding 30 mmHg generally warrants emergent fasciotomy. Alterations in capillary refill, distal
pulses, and skin color are NOT reliable findings. Clinicians should warn patients about the symptoms of compartment
syndrome and consider it in patients who complain of severe pain in the days immediately following fracture reduction.
Reports exist of compartment syndrome following closed reduction under local hematoma block [47], but it is a rare
complication, and the role of the hematoma block has not been demonstrated [10]. Staphylococcus aureus osteomyelitis
following hematoma block has also been reported [48]. Attention to sterile technique and to the amount of local anesthetic
injected should minimize these complications.
Splinting the wrist in palmar flexion greater than 15 degrees increases the risk of ACTS [49] and complex regional pain
syndrome [50]. Careful splinting that allows full flexion and extension of the metacarpal phalangeal (MCP) joints is important
to prevent MCP joint contractures and proximal tendon adhesions [10].
Persistent sensory neuropathy following distal radius fracture can occur due to median nerve contusion at the time of injury
or reduction, but it correlates closely with fracture malunion [51]. Surgical treatment with osteotomy [52] and/or release of
the median nerve is indicated for persistent symptoms [53].
Tendon inflammation and rupture can occur with closed cast treatment. Rupture of the extensor pollicis longus (EPL) tendon
is most common, with an incidence of 0.3 percent [54] to 3 percent [55,56], and it occurs between two weeks and 11
months (average seven weeks) after injury [55]. Diagnosis is usually made after rupture, and treatment is surgical. EPL
rupture is more common with minimally displaced fractures. Tendonitis of the first dorsal compartment and of the extensor
carpi ulnaris can also be seen after distal radius fracture. This is usually responsive to steroid injection, but it must be
differentiated from triangular fibrocartilage tear or other ulnocarpal ligamentous injury [10].
Long-term outcomes/complications A number of variables related to patient characteristics, fracture type, and
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radiographic findings predispose patients to the development of osteoarthritis and disability. Major complications are
discussed below. The incidence of complex regional pain syndrome, another potential complication, may be reduced by
prophylactic vitamin C, and is discussed elsewhere. (See "Prevention and management of complex regional pain syndrome
in adults", section on 'Prevention'.)
Osteoarthritis Extraarticular fractures that are reduced to acceptable alignment rarely cause radiocarpal
osteoarthritis. For fractures with intraarticular extension, there is a significant association between residual displacement of
articular fragments at the time of bony union and the development of radiocarpal osteoarthritis [57]. In one case series, 100
percent of fractures with articular step-off of 2 mm or more developed radiographic evidence of osteoarthritis, compared with
only 11 percent of those that healed with a congruous joint [58]. A second series found that a step-off of only 1 mm
predisposed patients to radiocarpal osteoarthritis [59].
Residual disability Long-term disability has been correlated with a number of radiographic parameters and fracture
characteristics. One series found a close correlation between the degree of postinjury radial shortening and disability: 4
percent of patients with normal height had poor function, whereas 25 percent of patients with 3 to 5 mm of radial shortening
and 31 percent of patients with more than 5 mm of radial shortening had poor function [60]. (See 'Classification' above.)
Dorsal angulation alone influenced early but not 10-year function [61], but dorsal angulation of greater than 15 degrees
combined with more than 2 mm radial shortening compromised outcomes [62,63]. More than 10 degrees of dorsal tilt leads
to a dorsal carpal shift with compressive forces, causing pain and insecurity with gripping, even during everyday activities
[64]. Grip strength correlates inversely with the degree of osteoarthrosis [65]. (See 'Classification' above.)
Incongruency of the distal radioulnar joint (DRUJ) from residual dorsal angulation [66] or positive ulnar variance [67] has been
associated with wrist pain. Triangular fibrocartilage complex (TFCC) tears occur not infrequently with distal radius fractures
[68], and greater radial shortening and dorsal angulation is found in patients with TFCC tears (figure 5) [69]. A TFCC tear has
occurred if the distal radius is shortened by more than 2.7 mm. TFCC tears are described separately. (See "Evaluation of
the adult with subacute or chronic wrist pain", section on 'Triangular fibrocartilage complex injury'.)
The extent of fracture comminution and articular involvement correlates with loss of motion [64]. Range of motion loss after
immobilization should be treated with aggressive physical therapy, unless it is caused by bony malalignment, in which case
prolonged therapy is of no benefit [10].
Distal radius fractures frequently occur at work or under circumstances that allow for financial compensation. Injury
compensation was shown in one study to be the best predictor of pain and disability at six months [70]. Another author
found that patients with work-related injuries were more than four times less likely to return to work than those injured while
away from work [59]. Patients receiving compensation for their injuries are likely to have poorer outcomes regardless of the
anatomic result [10].
One important message to be gleaned from these data is that, with the exception of a subset of low-functioning geriatric
patients, clinicians should aggressively seek to achieve congruent joint reduction and to prevent excessive loss of radial
length or abnormal tilt of the radial articular surface.
Patient satisfaction The factors most responsible for patient satisfaction remain unclear. Some claim patient
satisfaction depends more on hand dominance and residual wrist pain than range of motion [71]. Others have found grip
power [72] and return of wrist function [73] most significant. A study of operative patients found satisfaction correlated better
with pain relief and grip strength than postoperative radiographic parameters [74].
RETURN TO SPORT OR WORK Return to work is determined by the severity of injury and the tasks involved. Patients
with sedentary jobs may return immediately; physical laborers may return to full duty only after they have regained near-
normal wrist motion and strength. It is reasonable for participants in contact sports also to delay return to play until they
have achieved near-normal motion and strength, and to wear a protective palmar splint during the first few weeks of play.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the
Basics. The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they
answer the four or five key questions a patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best
for patients who want in-depth information and are comfortable with some medical jargon.
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th th
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the
keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS
Basics topics (see "Patient information: Cast and splint care (The Basics)" and "Patient information: Common wrist
injuries (The Basics)")
Beyond the Basics topic (see "Patient information: Cast and splint care (Beyond the Basics)")
Distal radius fractures are extremely common. Fractures in younger patients are the result of high-energy trauma, often
during sports. Fractures in older patients are frequently the result of low-energy trauma to osteoporotic bone. The
typical mechanism for distal radius fracture is a Fall Onto an Out-Stretched Hand (FOOSH). (See 'Epidemiology and
risk factors' above and 'Mechanism of injury' above.)
Examination at the time of injury should include inspection for open fractures and deformity, assessment of wrist
motion (if possible), and evaluation for associated injuries, such as scaphoid fracture or scapholunate ligament injury.
The wrist may appear normal despite the presence of a fracture. In the days following injury or fracture manipulation,
clinicians should pay close attention to neurovascular status (particularly median nerve function) and beware of acute
compartment syndrome. (See 'Clinical presentation and physical examination' above.)
Diagnosis is typically made by x-ray. Clinicians should study the standard plain radiographs of the wrist, including
anterior-posterior (AP), lateral, and oblique views, looking for any loss of normal anatomy, the presence and degree of
joint involvement (including both radiocarpal and distal radioulnar joints), and the presence of any high-risk features (eg,
comminution, articular step-off >2 mm). Abnormal measurements of radial inclination, radial height, palmar tilt, or ulnar
variance suggest significant injury. (See 'Radiographic findings' above.)
Emergent orthopedic referral is required for the following conditions (see 'Indications for orthopedic consultation or
referral' above):
Open fractures
Acute compression neuropathy or compartment syndrome
Vascular compromise despite reduction (emergent vascular surgery referral may also be required in this
circumstance)
Unstable fractures and those at high risk for complications should be referred to an orthopedic surgeon. We
recommend that fractures associated with the following conditions be referred to a knowledgeable orthopedist (Grade
1B) (see 'Indications for orthopedic consultation or referral' above):
Palmar displacement
Radial articular step-off greater than 2 mm, or involvement of the articular surface of the distal radial ulnar joint
Large ulnar styloid fractures with displaced fragments at the styloid base
Greater than 20 degrees of dorsal angulation
Displacement in any direction greater than two-thirds the width of the radial shaft
Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)
Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)
Associated scaphoid fractures or scapholunate ligament injuries
Fracture-dislocations (see 'Fracture dislocations' above)
Advanced osteoporosis
Nondisplaced extraarticular fractures are relatively stable, and treatment is straightforward. We suggest the following
approach for acute management (Grade 2C) (see 'Initial treatment' above):

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REFERENCES
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Place the arm in a well-molded sugar tong, reverse sugar tong, or double sugar tong splint (NOT a circumferential
cast), with the arm in neutral position (ie, without forearm supination or pronation, and without wrist flexion or
extension). (See "Splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)
Elevate the arm.

Apply ice to the fracture frequently (while keeping the splint dry).
Begin active range of motion of the shoulder and fingers.
Use analgesics as needed. Opioids may be necessary; a short course of nonsteroidal anti-inflammatory drugs
(NSAIDs) may also be used.
Displaced fractures with neurovascular compromise warrant an immediate attempt at closed reduction. Immediate
closed reduction by an experienced clinician is appropriate, but not required, for displaced fractures without
neurovascular compromise or radiographic evidence of instability. (See 'Radiographic findings' above.)
If a clinician capable of performing a reduction is unavailable and there is no neurovascular compromise, the provider
may immobilize the fracture, provide appropriate analgesia, and discharge the patient, provided follow-up the next day
for reduction by an orthopedist has been arranged.
Our recommendations for postreduction care of displaced fractures do not differ from that of nondisplaced injuries
described immediately above. (See 'Initial treatment' above.)
Criteria for adequate reduction in a patient with high functional demands include:
No dorsal tilt of the distal radial articular surface

Less than 5 mm of radial shortening
Less than 2 mm of displacement of fracture fragments
Splints and casts should not place the wrist in palmar flexion greater than 15 degrees, and they should allow full
flexion and extension of the metacarpal phalangeal (MCP) joints to prevent complications.
A schedule for follow-up care, including timing of radiographs, is provided for both displaced and nondisplaced
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Vigorous elderly patients with distal radius fractures should be referred for surgical treatment as indicated. However,
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Complications from distal radius fractures fall into two main categories:
Early complications include acute carpal tunnel syndrome, vascular injury, and compartment syndrome. (See
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wrist pain or instability, and loss of motion. (See 'Long-term outcomes/complications' above.)
Poor functional outcome correlates with abnormal anatomy. With the exception of a subset of low-functioning geriatric
patients, clinicians should aggressively seek to achieve congruent joint reduction and to prevent excessive loss of
radial length or abnormal tilt of the radial articular surface. (See 'Long-term outcomes/complications' above.)

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Topic 219 Version 13.0
GRAPHICS
Colles' fracture
Due to the dorsal displacement of the distal fragment, Colles' type fractures are
often said to have a "dinner fork" appearance.
Graphic 78559 Version 1.0
Distal radius measurements: AP view
Three important measurements can be determined, using the AP view,
to assess the distal radius. Radial inclination is the angle between one
line drawn perpendicular to the long axis of the radius and a second
line from the tip of the radial styloid to the central reference point
(CRP). Radial height is the distance between two lines drawn
perpendicular to the long axis of the radius: one through the distal tip
of the radial styloid, the second through the CRP. Ulnar variance is
the distance between this second line through the CRP and a line
through the distal articular surface of the ulnar head. Measurements
are often abnormal when a fracture of the distal radius is present.
Courtesy of Erik L Schroeder, MD.
Distal radius anatomy, antero-posterior (AP) view
Measurements performed on the AP view include radial inclination, radial height, and
ulnar variance. Abnormal measurements are often found in the setting of distal
radius fracture.
Distal radius central reference point
The central reference point (CRP) lies midway between the palmar
ulnar corner and the dorsal ulnar corner of the distal radius. Use of
the CRP provides more accurate measurements of radial inclination,
radial height, and ulnar variance.
Distal radius measurements: Lateral view
In a true lateral projection, the radius and ulna should be
superimposed, and the pisiform projected over the distal pole of the
scaphoid (white arrow). Normally, the lunate is seated within the
fossa of the distal radius, and the curvature of their articular surfaces
should correspond. Palmar migration is a sign of radiocarpal instability.
Palmar tilt is the angle formed by the intersection of one line
perpendicular to the longitudinal axis of the radial shaft and a second
line drawn through the apices of the palmar and the dorsal rims of the
radius. AP distance can also be measured.
Distal radius anatomy, lateral view
Measurements performed on lateral radiographs include volar tilt and AP distance.
Note the normal linear alignment of the capitate, lunate, and radius. Also, note how
the curvature of the articular surfaces of these bones corresponds.
Frykman I radius fracture AP view
This x-ray, taken of a 23-year-old snowboarder after she fell back
onto her outstretched left hand, shows a Frykman I distal radius
fracture. The x-ray shows several abnormalities including a significant
loss of radial height, decreased radial inclination, and positive ulnar
variance. Also, several fracture lines are present (black arrows),
indicating comminution.
Frykman I radius fracture lateral view
On the lateral x-ray of the same fracture, the dorsal angulation of the
distal fragment is apparent. Such fractures are often referred to by
the eponym Colles'. Note this is not a true lateral: the images of the
radius and ulna are not superimposed, and the pisiform (black arrow)
is seen dorsal to the distal pole of the scaphoid.
Frykman I radius fracture oblique view
The oblique view of the same fracture highlights the loss of radial
height.
Frykman IV radius fracture AP view
This fracture occurred in a 73-year-old osteoporotic woman following
a low-energy fall onto her outstretched right hand. Due to the
extension of the fracture into the radiocarpal joint and the distal ulnar
injury (white arrow), this fracture is categorized as a Frykman IV.
Most notable on this image is the displacement of the distal radial
fragment (red arrow) and the loss of radial height. Other injuries are
present, most notably a scaphoid fracture (black arrow).
Frykman IV radius fracture lateral view
The lateral x-ray of the same injury demonstrates significant dorsal
displacement and angulation of the distal radial fragment.
X-ray of Frykman Type VI fracture of distal
radioulnar joint and ulnar styloid
This anteroposterior plain radiograph of the left wrist shows a distal
radial fracture involving the distal radioulnar joint (arrowhead) and a
transverse ulnar styloid fracture (arrow).
A-P: anteroposterior.
Xray of Frykman Type VII radioulnar and
radiocarpal fracture
This anteroposterior plain radiograph of the wrist shows a radioulnar
fracture (arrow), and a fracture into the radiocarpal joint
(arrowhead).
A-P: anteroposterior.
Plain x-ray of Bartons fracture dislocation of wrist
The patient is a 40-year-old man who presented with wrist pain following a fall on an
outstretched hand, and found to have a Barton's fracture/dislocation. Image A is an AP
radiograph of the right wrist demonstrating an intraarticular fracture of the distal radius
(arrow). Image B is a lateral radiograph demonstrating an intraarticular radial fracture with
dorsally-displaced radial bone fragments (arrow) and dorsal dislocation of the carpal bones
with respect to the radius (arrowhead), consistent with a Barton's fracture/dislocation.
AP: anteroposterior.
Courtesy of Aaron Harman, MD.
X-ray of Hutchinson's radiocarpal fracture
This anteroposterior plain x-ray of the right hand shows an intra-
articular fracture through the radial styloid process (arrow) with
minimal displacement.

Palpation of the scaphoid in anatomic snuffbox
A good method for evaluating the body of the scaphoid is to gently
bring the patients wrist into ulnar deviation and slight volar flexion,
and then, palpate the anatomic snuffbox. The snuffbox lies between
the extensor pollicis longus tendon medially and extensor pollicis brevis
and abductor pollicis longus tendons laterally.
Courtesy of Kevin Burroughs, MD.
Finger trap fixture
Regardless of whether they are used in reduction, finger traps are a
useful adjunct before the procedure. Traction is applied by attaching
the finger traps to the thumb, index, and middle fingers, while keeping
the elbow flexed at 90 degrees and the forearm in neutral rotation.
Downward traction, using weights, is placed on the distal humerus for
at least five minutes before any reduction attempt. This enables
muscular relaxation and helps distract the fracture fragments, bringing
the radius closer to normal length.
Scapholunate dissociation
This anteroposterior radiograph of the wrist shows a >3 mm
separation (black arrow) between the scaphoid and lunate (Terry
Thomas sign) that indicates a scapholunate dissociation (tear). This
patient also had a distal radius fracture.
Courtesy of Kevin E Burroughs, MD.
Triangular fibrocartilage complex
Reproduced with permission from: Nagle DJ. Arthroscopically assisted triangular
fibrocartilage complex dbridement and ulnar shortening. In: Operative Techniques in
Orthopaedic Surgery, Wiesel SW (Ed), Philadelphia: Lippincott Williams & Wilkins, 2010.
Copyright 2010 Lippincott Williams & Wilkins.
http://www.lww.com
Di scl osures: David J Petron, MD Nothing to disclose. Patrice Eiff, MD Nothing to disclose. Jonathan Grayzel, MD, FAAEM Employee
of UpToDate, Inc.
Contributor disclosures are reviewed f or conf licts of interest by the editorial group. When f ound, these are addressed by vetting through
a multi-level review process, and through requirements f or ref erences to be provided to support the content. Appropriately ref erenced
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Distal Radius Fractures in Adults

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31/5/2014 Distal radius fractures in adults

31/5/2014 Distal radius fractures in adults

Is there involvement of the radiocarpal or distal radioulnar joint?

31/5/2014 Distal radius fractures in adults

Types III/IV: Extend into the radiocarpal joint (image 5A-B)

Palmarly displaced (eg, Smith's) fractures (see 'Classification' above)

31/5/2014 Distal radius fractures in adults

Fractures likely to be unstable and unamenable to conservative treatment

31/5/2014 Distal radius fractures in adults

Elevate the arm.

No dorsal tilt of the distal radial articular surface

31/5/2014 Distal radius fractures in adults

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