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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



Picture
Picture
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

Classification

Descriptive:

Open vs closed
Displacement
Angulation
Comminution
Loss of radial length

Frykman:


Picture

Eponymous fractures

Picture

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
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