M u s c u l o s k e l e t a l I m a g i n g R ev i ew

Porrino et al.
Management of Fractures of the Distal Radius

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Musculoskeletal Imaging
Review

Fractures of the Distal

Radius: Postmanagement
Radiographic Characterization
Jack A. Porrino1
Ezekiel Maloney
Kurt Scherer
Hyojeong Mulcahy
Alice S. Ha
Christopher Allan

OBJECTIVE. The purpose of this article is to describe the management options available
for the treatment of the distal radius fracture as well as potential associated complications.
CONCLUSION. There are a wide variety of currently accepted and used treatment options for fractures of the distal radius, ranging from closed reduction with casting to various
forms of invasive surgical management. The radiologist must be familiar with these various
forms of management to recognize complications when present on follow-up radiographs.

Porrino JA, Maloney E, Mulcahy H, Scherer K,

Ha AS, Allan C

racture of the distal radius is common, and there are a variety of

treatment options. In this article,
we focus on the myriad of currently accepted treatment options, their radiographic appearance, and unexpected outcomes.
In the young adult, the goal of treatment of
fracture of the distal radius involves restoring
radiocarpal and distal radioulnar joint articular congruity as well as restoration and maintenance of radial length [1]. The restoration of
articular congruity and radial length is considered important for pain relief, wrist motion,
and grip strength in this population, all markers of functional outcome [2]. Of the many surgical options available, none has shown superior functional outcome relative to another [35].
The decision to treat in a closed fashion, or
alternatively by way of one of many surgical
options, is predicated on the concept of instability. A fracture of the distal radius is considered unstable, by definition, if it is unable to
resist displacement after anatomic reduction
[6, 7]. Predictors of instability can be identified on the prereduction radiograph and have
been discussed in detail elsewhere [2, 59].
In the pediatric population, anatomic reduction is not required because significant bone
turnover results in excellent outcome and a
low rate of complication [10]. For the elderly, studies have shown no change in functional outcome in those managed surgically versus
those managed without surgical intervention,
regardless of the radiographic or anatomic discrepancies [4, 1012]. Despite these similar
functional outcomes, the use of internal fixation in the elderly continues to rise [13].

Keywords: distal radius fracture, dorsal plate, external

fixator device, hardware failure, volar plate
DOI:10.2214/AJR.13.12141
Received October 28, 2013; accepted after revision
February 18, 2014.
1

All authors: Department of Radiology, University of

Washington Medical Center-Roosevelt, Box 354755, 4245
Roosevelt Way NE, Seattle, WA 98105. Address
correspondence to J. A. Porrino, Jr. (jporrino@uw.edu).

This article is available for credit.

AJR 2014; 203:846853
0361803X/14/2034846
American Roentgen Ray Society

846

There are many potential complications

after fracture of the distal radius. Some occur despite management, whereas others
have a predilection for specific forms of
treatment. Complications include loss of reduction, malunion, soft-tissue and osseous
infection, tendon irritation, neuropathy or
nerve injury, compartment syndrome, complex regional pain syndrome, and hardware
failure [14, 15].
In this article, we review the treatment approaches available and provide corresponding imaging examples of the expected and
unexpected outcomes. Those complications
most commonly attributable to an individual
management strategy are discussed.
Treatment Options
Closed Reduction and Casting
In the young adult population, the nondisplaced extra- or intraarticular fracture
can be treated nonoperatively. Alternatively, the clinician must use a series of clinical, physical examination, and radiographic
findings in an attempt to predict whether the
displaced distal radius fracture will be stable after closed reduction [1, 9].
Closed reduction and casting are common
in the pediatric population, for whom anatomic
reduction is not necessary [10]. In the elderly,
closed reduction and casting can be used despite the radiographic appearance of the fracture because functional outcome appears to be
independent of articular congruity [4, 1012].
Once a decision has been made to proceed with closed manipulation and casting,
frequent clinical and radiographic follow-up

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Management of Fractures of the Distal Radius

is necessary to assess for loss of reduction
when relevant, presence of healing, and other
potential complications [9, 14] (Fig. 1).
Rupture of the extensor pollicis longus
(EPL) tendon has been observed with nondisplaced fractures of the distal radius, with an
incidence as high as 3% (Fig. 2). Rupture usually occurs within the first 2 months from the
time of fracture, with a purported mechanism
of decreased vascularity of the tendon at the
level of the Lister tubercle. Because this complication is not specifically attributable to any
one form of treatment, it can occur with conservative, closed reduction and casting [9, 14].
Complex regional pain syndrome (Fig. 3),
compartment syndrome, skin tearing during
reduction, carpal tunnel syndrome, and stiffness are also potential complications of closed
reduction and casting [12, 14].
Closed Reduction With Percutaneous Pinning
Closed reduction followed by percutaneous
pinning with Kirschner wires (Fig. 4) is reportedly an optimal strategy when fractures are extraarticular and exhibit persistent displacement
after reduction. The presence of intraarticular
radiocarpal joint extension does not preclude
use of this treatment when this component of
the fracture is nondisplaced [1, 8].
Placement of Kirschner wires through the
fracture site is referred to as intrafocal pinning. With intrafocal pinning, pins enter the
fracture site and are then levered from proximal to distal to reduce the distal fragment
and finally advanced into the cortex of the
shaft proximal to the fracture, stabilizing the
reduction. Specifically, pins are used to correct radial inclination and dorsal tilt [1, 8].
When distraction is required to sustain fracture reduction, it can be achieved with either
external or internal accessory fixation hardware. At our institution, an internal radiocarpal
joint-spanning bridge plate is frequently used
for supplemental osseous stabilization (Fig. 5).
The bridging plate is removed at 3 months [1].
Wound or pin track infection related to pins
left outside of the skin is a potential risk involved with this treatment (Fig. 6). Burying the
Kirschner wires below the skin reduces the rate
of infection; however, a second procedure is required for removal. Additionally, injury to the
superficial radial nerve is a potential complication seen with this management [1, 8].
External Fixation Device
The external fixator device consists of a
scaffold created by longitudinal bars that provide stability in combination with pins that

fixate the bone fragments and attach to the

longitudinal bars. The external fixator can
be augmented through the use of Kirschner
wires, providing improved stability [3].
External fixator devices are most popular with fractures that are excessively comminuted, making open reduction and internal fixation challenging. These devices can
be used as a temporizing agent or definitive
management. There are two forms of external fixators: those spanning the radiocarpal
joint, referred to as bridging fixators (Fig.
7) and those that traverse only the fracture
site, or nonbridging fixators. The latter require a large stable distal fracture fragment
to gain purchase, whereas the former are
limited by resultant wrist stiffness [3, 8].
External fixator devices exist with an internal gear mechanism that not only provides
longitudinal distraction but also provides
translation of the hand in the volar direction.
This results in deliberate volar displacement
of the capitate followed by the lunate and
eventually the desired outcome of volar tilt of
the distal fracture fragment. This concept is
called ligamentotaxis [3]. Potential complications of the external fixator device include
hardware failure, superficial radial nerve injury, complex regional pain syndrome (which
has been attributed to overdistraction of the
carpus), carpal tunnel syndrome, pin track infection, and rarely osteomyelitis [3, 8, 14].
Plate Fixation
Surgical plates provide secure fixation
without protruding wires or pins and permit early exercise. Plate selection is largely
based on fracture configuration and clinician
preference. Potential drawbacks include operative trauma; nerve injury; tendon rupture;
compartment syndrome; infection; and hardware complications such as bending, breaking, and screw pullout [2, 14, 1618] (Fig. 8).
Compression plating has been used in the
past to maintain anatomic reduction, requiring double cortex fixation. Recently, locking plates have been introduced, in which the
locking screws mate with the threaded plateholds, creating a fixed-angle construct and
eliminating the need for double-cortex fixation. The locking plate decreases the potential for motion of screws in the cortex and loss
of purchase of small fracture fragments [19].
Dorsal plate fixationAs a rule, structural
support should be provided along the same cortex as the major site of collapse, and with distal radius fractures, collapse typically occurs in
a dorsal direction. This theory influenced ear-

ly use of the dorsal plate, which seemed most

logical (Fig. 9). However, owing to a paucity of
soft tissues separating bone from tendon within
this region, tendon irritation or rupture became
an increasingly recognized complication, most
notably involving the extensor pollicis longus.
As a result, the need for hardware removal is
higher than that for the volar applied plate [8,
16, 18, 20]. Today, dorsal plate fixation is often
reserved for fracture patterns not amenable to a
volar approach [8, 18].
Volar plate fixationAn increase in soft
tissue separating bone from tendon makes tendon irritation or rupture much less common
after volar plate placement relative to the dorsal plate. This increased soft tissue permits the
presence of thicker and stronger plates that are
capable of maintaining reduction of dorsal as
well as volar fractures. The concave contour
of the volar surface of the distal radius enables
easier fracture realignment relative to the convex dorsal surface. Finally, blood supply to distal radius fracture fragments is predominately along the dorsal surface and can be avoided
with a volar approach [8, 16, 18, 21] (Fig. 9).
When the volar plate is placed too far distal,
beyond the watershed line (Figs. 9 and 10), defined as the distal border of the concave surface
of the volar radius (or the most volar aspect of
the distal radius), there is a risk for flexor tendon irritation because the tendons are no longer protected by the pronator quadratus muscle. Additional caution must be taken by the
surgeon to avoid intraarticular placement of a
screw. The surgeon must also avoid penetrating
the dorsal cortex with the volar applied screws,
which may result in extensor tendon irritation
(Fig. 10). Carpal tunnel syndrome and complex regional pain syndrome have been reported with volar applied plates [12, 17, 18].
Fragment-specific internal fixation
Fragment-specific hardware includes interfragmentary compression screws, custom-designed wire forms, and low-profile
anatomically contoured plate constructs (Fig.
11). In theory, this treatment option provides
stability of reduction while avoiding soft-tissue complications by requiring only a limited
open surgical approach [2, 8].
The three-column division of the distal radius devised by Rikli and Regazzoni [22] is
used to guide placement of this hardware. In
this concept, the radius is divided into a lateral radial and intermediate radial column, the
line of demarcation being where the scaphoid
and lunate articulate with the articular surface of the radius and impart forces onto the
distal radial articular surface. A third medi-

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al column is composed of the ulna, triangular

fibrocartilage, and distal radioulnar joint [16,
2022] (Fig. 11). Tendon irritation and rupture remain potential complications that can
necessitate hardware removal [2].
Alternative and Future Forms of Management
The flexible stainless steel curved intramedullary implant Wrist Rocket WRX (Sonoma Orthopedic Products) provides distal
radius fracture fixation with decreased disruption of the soft tissues (Fig. 12). This, in
theory, permits early range of motion and decreased soft-tissue complications. The device
has locking cortical screws and proximal and
distal grippers to engage the intramedullary
cortex for rigid fixation while a buttress peg
supports the subchondral bone [19].
A study by Jupiter [11] addressed the future treatment of distal radius fractures and
emerging therapies. Percutaneous techniques,
including injectable calcium phosphate bone
cement as well as percutaneous expandable
balloons made of tantalum metal that accept
screws, appear promising. Jupiter predicts injectable orthobiologics that rapidly enhance
the development of callus, permitting the use
of only a splint for the management of distal
radius fractures, may become a reality. The
severely disrupted intraarticular distal radius fracture may soon be repaired with metal
hemiarthroplasty that resurfaces the distal aspect of the radius [11].
Conclusion
Numerous treatment options are used for
the management of fractures of the distal radius. The radiologist must be familiar with

848

their expected and unexpected imaging appearances to provide optimal patient care.
References
1. Weil WM, Trumble TE. Treatment of distal radius
fractures with intrafocal (Kapandji) pinning and
supplemental skeletal stabilization. Hand Clin
2005; 21:317328
2. Bae DS, Koris MJ. Fragment-specific internal
fixation of distal radius fractures. Hand Clin
2005; 21:355362
3. Bindra RR. Biomechanics and biology of external
fixation of distal radius fractures. Hand Clin
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4. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC.
A systematic review of outcomes and complications of treating unstable distal radius fractures in
the elderly. J Hand Surg Am 2011; 36:824835
5. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung
KC. A meta-analysis of outcomes of external fixation
versus plate osteosynthesis for unstable distal radius
fractures. J Hand Surg Am 2005; 30:11851199
6. Slutsky DJ. Predicting the outcome of distal radius fractures. Hand Clin 2005; 21:289294
7. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J
Hand Surg Am 2004; 29:11281138
8. Henry MH. Distal radius fractures: current concepts. J Hand Surg Am 2008; 33:12151227
9. Fernandez DL. Closed manipulation and casting of
distal radius fractures. Hand Clin 2005; 21:307316
10. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin
2012; 28:113125
11. Jupiter J. Future treatment and research directions in
distal radius fracture. Hand Clin 2012; 28:245248
12. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical

and radiologic outcomes of unstable Colles type

distal radius fractures in patients older than 70
years: nonoperative treatment versus volar locking plating. J Orthop Trauma 2009; 23:237242
13. Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to Medicare for the
treatment of distal radius fracture in the elderly. J
Hand Surg Am 2011; 36:12821287
14. Gutow AP. Avoidance and treatment of complications of distal radius fractures. Hand Clin 2005;
21:295305
15. McKay SD, MacDermid JC, Roth JH, Richards
RS. Assessment of complications of distal radius
fractures and development of a complication
checklist. J Hand Surg Am 2001; 26:916922
16. Freeland AE, Luber KT. Biomechanics and biology of plate fixation of distal radius fractures.
Hand Clin 2005; 21:329339
17. Arora R, Lutz M, Hennerbichler A, Krappinger D,
Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with
a palmar locking-plate. J Orthop Trauma 2007;
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18. Toros T, Sgn TS, zaksar K. Complications of
distal radius locking plates. Injury 2013;
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19. Petscavage JM, Ha AS, Khorashadi L, Perrich K,
Chew FS. New and improved orthopedic hardware for the 21st century. Part 1. Upper extremity.
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20. Tavakolian JD, Jupiter JB. Dorsal plating for distal radius fractures. Hand Clin 2005; 21:341346
21. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21:347354
22. Rikli DA, Regazzoni P. Fractures of the distal end
of the radius treated by internal fixation and early
function: a preliminary report of 20 cases. J Bone
Joint Surg Br 1996; 78:588592

Fig. 1Loss of reduction in 88-year-old woman.

Patient underwent closed reduction of distal radius
fracture followed by interval loss of reduction.
Dashed and solid lines indicate radial length. Dotted
line demonstrates ulnar variance.
A, Frontal radiograph after reduction shows near
anatomic alignment of distal radius fracture.
B, Follow-up radiograph obtained 3 months later
shows loss of reduction. Note radial shortening
(dashed line in relation to solid line) and ulnar-positive
variance (dotted line).

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Management of Fractures of the Distal Radius

Fig. 2Rupture of extensor pollicis longus
(EPL) after distal radius fracture (Smith
fracture) in 47-year-old man following
motorcycle accident. There was also distal
radioulnar joint (DRUJ) dislocation. Injury
was initially stabilized with volar plate, but
there was refractory DRUJ instability and
EPL rupture. Patient subsequently underwent
operative pinning of DRUJ and tendon transfer
of extensor indicis proprius (EIP) to EPL.
AC, Initial lateral radiograph (A),
postoperative lateral radiograph with DRUJ
instability (B), and intraoperative photograph
(C) of ruptured EPL (arrowheads, C) in its bed
scarred and stretched over operative retractor
as well as harvested EIP (arrow, C) pulled into
preparatory position for suturing into distal EPL
as tendon transfer.

Fig. 3Complex regional pain syndrome in 63-year-old man who presented with
chronic pain in his right wrist 6 months after closed reduction of distal radius
fracture. Follow-up radiographs were unremarkable. Representative image in
delayed phase from three-phase bone scan shows increased uptake in distal right
upper extremity (evident on all three phases), consistent with complex regional
pain syndrome.

Fig. 419-year-old woman with distal radius fracture

fixed by percutaneous pins. Frontal radiograph
shows closed reduction with percutaneous pinning.
Incidentally noted is fracture of ulnar styloid.

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Fig. 5Internal radiocarpal joint-spanning bridge plate in 61-year-old man with distal radius fracture.
A and B, Frontal (A) and lateral (B) radiographs show distal radius fracture fixed by radiocarpal
joint spanning bridge plate.

A
Fig. 6Pin tract infection in 25-year-old woman after operative reduction of intraarticular distal radius
fracture, including percutaneous pin fixation of unstable distal radioulnar joint.
A and B, Frontal radiographs show interval migration of pin with surrounding osteolysis between 6-week (A)
and 13-week (B) postoperative studies. Patient subsequently underwent operative incision and drainage of
associated soft-tissue wound and removal of all hardware.

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B
Fig. 7Bridging external fixator
device in 23-year-old man with
distal radius fracture. Frontal
radiograph shows bridging external
fixator device with a series of lowprofile plates and screws fixing
distal radius fracture. Incidentally
noted is percutaneous pin fixation
of fractures involving ulnar styloid
and first metacarpal.

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Management of Fractures of the Distal Radius

Fig. 8Surgical plate and screw complications.

A, Lateral radiograph of wrist in 48-year-old woman shows distal radius fracture fixed by volar
plate and screws. Arrowhead shows screw backing out.
B, Oblique radiograph of wrist in 67-year-old woman shows distal radius fracture fixed by
plate and screws. Arrowheads show fractured screw.
C and D, Frontal radiograph (C) in 72-year-old man after fracture of distal radius. Radiograph
after volar plate and screw fixation complicated by osteomyelitis (D) shows increased
lucency at site of previous fracture and periosteal reaction around volar plate. Patient
underwent operative removal of hardware. Gross purulence, erosion, and devitalized bone
were found extending into marrow cavity around screws.

Fig. 9Dorsal and volar plate fixation.

A and B, Frontal (A) and lateral (B)
radiographs in 23-year-old man
show distal radius fracture fixed by
dorsal plate and screws.
(Fig. 9 continues on next page)

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Fig. 9 (continued) Dorsal and volar plate fixation.

C and D, Frontal (C) and lateral (D) radiographs in 54-year-old
woman show distal radius fracture fixed by volar plate and
screws. Arrow in D indicates watershed line.

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Fig. 10Volar screw through dorsal cortex in 36-year-old man who presented with chronic wrist
pain 1 month after volar plate fixation of distal radius fracture at outside institution.
A, Radiograph appeared unremarkable, and CT was performed because of clinical signs of
extensor tendon irritation.
B, Sagittal CT image reveals protrusion of one of distal screws (arrowhead) into extensor tendon
compartment, accounting for patients symptoms. Patient subsequently underwent operative revision.

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Management of Fractures of the Distal Radius

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Fig. 11Fragment-specific internal fixation with

Rikli and Regazzoni [22] divisions in 60-year-old man
6 weeks after fracture of distal radius. (Reprinted
from [19])
A and B, Frontal (A) and lateral (B) radiographs show
radial column pin plate and volar locking compression
plate fixing revised fracture of radial styloid (lateral
column) as well as volar buttress pin fixing revised
volar ulnar-sided fracture of distal radius (intermediate
column). Radius is divided into three columns (lines,
A) in accordance with Rikli and Regazzoni description.
There is lateral radial and intermediate radial column,
line of demarcation being where scaphoid and
lunate articulate with articular surface of radius.
Third, medial column, is composed of ulna, triangular
fibrocartilage, and distal radioulnar joint.

Fig. 1237-year-old man with myotonic dystrophy

after fall and resultant distal radius fracture.
(Reprinted from [19])
A and B, Intraoperative fluoroscopic image (A) shows
minimally invasive placement of Wrist Rocket WRX
(Sonoma Orthopedic Products). Postoperative image
(B) shows entirety of construct.

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