Distal Radius Fracture
Classification systems
- Melone (four-part concept of the articular surface)
Mechanism
Most commonly a fall on the outstretched hand with the wrist extended, driving an axial and dorsally directed load through the carpus into the metaphysis. Low-energy falls dominate in osteoporotic elderly patients; high-energy road traffic or sporting injuries in young adults produce more comminution, articular splitting and associated carpal or soft-tissue injury. A fall onto a flexed wrist produces the volar-displacement pattern instead.
Age considerations
- Paediatric
- Physis is the weak link, so the same fall more often yields a torus/buckle or a Salter-Harris II separation rather than a comminuted metaphyseal break. Remodelling potential in the plane of wrist motion is generous, so more residual angulation is accepted; repeated forceful manipulation risks growth arrest and is discouraged.
- Young adult
- Implies higher energy. Restoration of radial length, inclination and volar tilt matters for long-term grip and forearm rotation, so articular step and displacement are tolerated poorly and operative restoration is considered readily. Look actively for associated scaphoid, distal radioulnar joint and interosseous ligament injury.
- Elderly
- Frequently a fragility fracture and a sentinel event for bone health assessment. Functional demand, hand dominance, cognition and independence weigh more heavily than radiographic perfection; several patients with modest malunion still achieve satisfactory function. Early mobilisation and fall-risk review are as important as the fracture itself.
Management options
Closed reduction and below-elbow cast immobilisationshowhide
Indication
Extra-articular or minimally displaced patterns that are stable after reduction, and lower-demand patients in whom acceptable alignment parameters are met.
Implant design notes
No implant. A well-moulded three-point cast with the wrist in neutral to slight flexion and ulnar deviation; extreme flexion positions are avoided because they raise carpal tunnel pressure.
Approach
Non-operative. Haematoma block or sedation, longitudinal traction to disimpact, then reduction manoeuvre reversing the deforming force, followed by moulding.
Steps overview
- Confirm neurovascular status and document median nerve function before manipulation
- Achieve anaesthesia with a haematoma block or procedural sedation
- Apply sustained longitudinal traction to disimpact the metaphyseal fragment
- Reverse the deformity with a directed manoeuvre and translate the distal fragment back
- Mould a below-elbow slab with three-point pressure while traction is maintained
- Check reduction radiographs in two planes before completing the cast
- Review at one and two weeks for loss of position; begin finger and shoulder motion immediately
Notes
Redisplacement within the first fortnight is the commonest reason for late surgery, particularly with dorsal comminution and osteoporotic bone. Counsel about cast tightness and warn regarding acute carpal tunnel symptoms.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Volar locking plate fixationshowhide
Indication
Unstable or redisplaced patterns, dorsally angulated fractures failing cast treatment, articular incongruity, and active patients requiring early return of function.
Implant design notes
Anatomically pre-contoured plate designed to sit proximal to the watershed line so flexor tendons are not abraded. Fixed-angle locking screws or pegs act as a subchondral buttress, supporting the articular surface without relying on plate-to-bone compression — valuable in osteoporotic metaphyseal bone.
Approach
Volar approach through the bed of flexor carpi radialis, retracting the tendon and the radial artery, then dividing pronator quadratus off the radius for later repair.
Steps overview
- Supine with the arm on a radiolucent table and a tourniquet applied
- Longitudinal incision over flexor carpi radialis; enter its sheath and retract contents ulnarwards
- Elevate pronator quadratus from radial to ulnar as a flap for closure
- Reduce length, inclination and volar tilt; hold provisionally with wires
- Seat the plate proximal to the watershed line and confirm position on fluoroscopy
- Place the shaft screw in the oval hole, fine-tune position, then insert distal locking screws or pegs
- Verify screw lengths on a tangential dorsal view to exclude dorsal tendon irritation
- Repair pronator quadratus, close, and start early wrist and finger motion
Notes
Distal screw prominence into the radiocarpal joint and dorsal cortex penetration are the classic avoidable errors; dedicated tangential views help. Flexor pollicis longus attrition is the late complication linked to plate prominence.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
External fixation, with or without supplementary wiresshowhide
Indication
Severe metaphyseal comminution, open injuries with contamination, or polytrauma where a rapid provisional construct is preferred.
Implant design notes
Bridging frame with pins in the radial shaft and second metacarpal, relying on ligamentotaxis. Non-bridging variants capture the distal fragment directly and allow earlier wrist motion when the distal block is large enough.
Approach
Percutaneous pin placement with small open incisions to protect the superficial radial nerve branches and extensor tendons.
Steps overview
- Plan pin sites away from the superficial radial nerve territory
- Insert two shaft pins through a mini-open incision, and two metacarpal pins
- Reduce by traction and apply the frame at working length; avoid overdistraction
- Add percutaneous wires to support articular fragments if needed
- Confirm alignment fluoroscopically and check finger cascade and motion
- Instruct on daily pin-site care and immediate digital exercises
Notes
Overdistraction causes stiffness and complex regional pain syndrome; the metacarpophalangeal joints must remain freely mobile. Pin-site infection is the routine nuisance complication.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Name the three radiographic parameters you assess: radial height, radial inclination and volar tilt — and quote your own accepted limits with the caveat that they are guidelines, not absolutes.
- Acute carpal tunnel syndrome is an emergency: progressive median paraesthesia not relieved by reduction and splint loosening warrants urgent release.
- Dorsal comminution, initial dorsal angulation, intra-articular extension and advanced age are the classic predictors of secondary displacement in a cast.
- The watershed line matters because plate prominence distal to it is the mechanism of late flexor pollicis longus rupture.
- Always examine the elbow and the distal radioulnar joint — a missed Essex-Lopresti type injury changes management completely.
- In the elderly, a distal radius fracture is a fragility fracture: mention bone health assessment and falls prevention in your answer.
Sources for further reading
- Standard operative orthopaedics textbook — chapter on fractures of the distal radius
- Rockwood and Green's Fractures in Adults — distal radius and distal radioulnar joint chapter
- Apley and Solomon's System of Orthopaedics and Trauma — wrist injuries
- Netter or Hollinshead regional anatomy — volar forearm and carpal tunnel
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.