Assessment and management of acute distal radius fractures
by Zoe Little

Scenario: called to A&E to assess a 64 year old woman who fell on her outstretched hand - no other injuries

History:

Age
Handedness
Occupation
Hobbies/level of function – may be important in deciding definitive treatment plan
Time/date of injury
Mechanism
Altered sensation or motor function distal to the injury
Any other injuries

Past medical/surgical history:

Including previous wrist/forearm problems/surgery
Medication/drugs and allergies

Examination:

Deformity
Ecchymosis
Tenderness
Painful range of motion
Thorough neurovascular assessment, with particular attention to the median nerve

Investigations:

PA and lateral x-rays of the wrist: examine the radiological relationships and consider contralateral views for comparison

Lateral x-ray

• Measure volar (palmar) tilt (average 11-12 degrees)

Postero-Anterior x-ray

• Measure radial length (average 11mm)
• Measure radial inclination (average 23 degrees)
• Look for any intra-articular involvement

Look for associated injuries:

• Widening of the scapholunate interval (suggestive of scapholunate ligament injury)
• Interruption of Gilula’s lines (carpal instability)
• Consider CT to further demonstrate the extent of any intra-articular involvement
  

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Classification

Descriptive:

Open vs closed
Displacement
Angulation
Comminution
Loss of radial length

Frykman:

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Eponymous fractures

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Management

Aim to restore anatomy and regain function - displaced fractures should undergo closed reduction in the emergency department.
Dependent upon fracture pattern and patient factors

Non-operative treatment

Closed reduction (if displaced) and cast immobilisation for 6 weeks

Indications:

• Undisplaced and minimally displaced fractures
• Displaced fractures which have been reduced to achieve:

            Radial length - within 5mm of the contralateral wrist
            Palmar (volar) tilt - up to 5o dorsal angulation
            Radial inclination - less than 5o loss
            Intra-articular step - less than 2mm

Techniques

Closed reduction (dorsally angulated fracture):

                        Stages
Perform a haematoma block

• Identify the fracture site by palpation (dorsally)
• Prepare a syringe with 8-12ml 1% lidocaine (depending on patient’s weight) and attach a 23G needle
• Apply chlorhexidine spray and allow to dry - do not contaminate the cleaned area
• Insert the needle into the fracture site and aspirate until a flash from the fracture haematoma is seen in the needle
• Infiltrate the haematoma with the appropriate dose of lidocaine
• Allow 5-10 minutes for onset of anaesthesia

        Equipment required
Gloves
Blunt fill or 21G needle to draw up
23G needle to administer block
10ml syringe
1% lidocaine - 2mg/kg (0.2ml/kg)
Chlorhexidine spray
Adhesive dressing

An assistant is required - to apply counter-traction and apply backslab whist traction and reduction are maintained

Reduction
Hyperextend the distal fragment, then apply traction to reduce the distal fragment onto the proximal fragment

Apply backslab
Apply a well moulded backslab with the wrist in slight flexion (<15o)

Check x-ray
Repeat AP and lateral radiographs

Operative treatment
Options:
Percutaneous pinning
External fixation
Open reduction and internal fixation (dorsal or volar plating)

Indications:

• Radial shortening >5mm
• Dorsal angulation >5o
• Loss of radial inclination >5o
• Displaced intra-articular fracture (step>2mm)
• Volar or dorsal comminution
• Unstable fracture pattern (e.g. Smith’s fracture)
• Loss of reduction following non-operative treatment