distal end radius is a common fracture in elderly groups and also in young by high velocity trauma its assessment and radiology should know for its management

1. ASSESSMENT AND
RADIOLOGY OF DISTAL
RADIUS FRACTURE
By Dr Susanta kumar khuntia
JR ORTHOPEDICS
Moderate by Dr Anil k. Sahu
Asso.prof essor
dept. of orthopedics
MKCG MC,Berhampur odisha

2. Distal Radius Fractures
 Common injury
 Potential for functional
impairment and frequent
complications

3. HISTORY

4. HISTORY
 Barton 1838 described wrist subluxation consequent to
intraarticular fracture of radius which could be dorsal or
volar.
 Smith described fracture of distal radius with ‘forward’
displacement.
 Advent of X rays at the end of nineteenth century
contributed much to the understanding of different
patterns of injury.

5. Anatomy
 scaphoid and lunate
fossa
 Ridge normally exists
between these two
 sigmoid notch: second
important articular
surface
 triangular fibrocartilage
complex(TFCC): distal
edge of radius to base of
ulnar styloid

7. Cross-sectional anatomy of the radial metaphysis.
Note that the dorsal surface is much more
irregular than the palmar surface.TheV-shape
dorsally caused by Lister's tubercle (arrow) makes
it difficult to contour a plate to fit the dorsum of
the radius.

8. Applied anatomy
 Jakob and his co-authors interpreted the wrist as consisting
of three distinct columns, each of which is subjected to
different forces and thus must be addressed as discrete
elements

9. The radial column, or lateral column
The radial column consists of the
scaphoid fossa and the radial styloid.
Because of the radial inclination of 22
degreees, impaction of the scaphoid on
the articular surface results in a shear
moment on the radial styloid causing
failure laterally at the radial cortex.The
radial column, therefore, is best stabilized
by buttressing the lateral cortex

10. The intermediate column
The intermediate column consists of the
lunate fossa and the sigmoid notch of the
radius.The intermediate column may be
considered the cornerstone of the radius
because it is critical for both articular
congruity and distal radioulnar function.
Failure of the intermediate column occurs
as a result of impaction of the lunate on
the articular surface with dorsal
comminution.The column is stabilized by
a direct buttress of the dorsal ulnar aspect
of the radius

11. The medial column
The ulnar column consists of
the ulna styloid but also
should include theTFCC and
the ulnocarpal ligaments

17. Incidence
 One sixth of all fractures treated in the Emergency
Room
 Bimodal distribution
 less than 30 years (70% men)
 over 50 years (85% women)

18. Different characteristics of fracture depends on
 Position of hand (60 -90 degree)
 Type of surface
 Velocity of force
 Quality and strength of bone

19. Pathomechanism of distal radius
fracture
 The theory of compression impaction by
dupuytren in 1834
 The avulsion theory in 1852
 The incurvation theory by mayer in 1940

20. Pathomechanism of posteriorly
displaced fracture
 The usual cause is fall on the hyperextended wrist
 A)The theory of compression impaction when is
hyperextended proximal carpal bones come and impact dorsal
aspect of radius and body weight is transmitted through long
axis of radius to distal end and compression occur at dorsal
aspect of distal radius leading to fracture
 B)The avulsion theory-The indirect force presented by the
body weight are transmitted through humerus,ulna,radius and
then a volar wrist ligaments.Then fracture occured by avulsion
mechanism applied by the tensile forces transmitted by the
volar wrist ligaments.

21. CONTINUE....
 The Incurvation theory-depends on position of the hand,the
extent of the area of impact,the magnitude of the applied
force
 Commonly in elderly age group due to osteoporosis bone
and high incidence of fall .

22. Pathomechanism of anteriorly
displaced fracture
 A)Axial stress on the radius with a backward fall on
the palm of the hand.Wrist in extension and without
displacement of the body over the hand.The radius
incurved sustains compression force on the volar
cortex and tensile forces on the dorsum
 B)Forced flexion where direct compression stress on
volar cortex combined with traction exerted by the
dorsal ligament

23. Diagnosis: History and Physical
Findings
 History of a FOOSH

24. Physical Findings
INSPECTION
. Visible deformity of the wrist,
with the hand most
commonly displaced in the
dorsal direction.
. Dinner fork deformity occurs
in colles and dorsal barton
farcture .
. Gardenspade deformity
occurs in smith or palmar
bartons fracture
. Dorsal aspect of hand and
wrist are usually swollen and
ecchymosed

25. PALPATION
 The wrist should be examined for tenderness
 Radial and ulnar styloids at same level (laugier
sign)
 Movement of the hand and wrist are painful.
 Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out
 Median nerve function and flexor and
extensor tendon action should be tested

26. CONTINUE
 associated fractures of either the radial head or
supracondylar humerus.
 An effort should also be made to identify an
ipsilateral scaphoid fracture, which may direct the
surgeon to consider operative versus nonoperative
management.
 attention should be directed to the extensor pollicis
longus, which may be injured acutely at Lister's
tubercle or may present with a late spontaneous
rupture.

27. Radiology
DIFFERENT X RAYVIEWS:
.PAView
.Lateral view
.Oblique view
.Tilted lateral view
.Traction view

28. Continue
 X-ray APVIEW
 For extraarticular asses 1)radial
shortening/communition 2)ulnar
styloid fracture location
 For intraarticular asses 1)depression
of the lunate facet 2)gap b/n
scaphoid and lunate facet 3)central
impaction fragements
4)interruption of the proximal carpal
row

29.  X-ray lateral view
For extraarticular
fracture asses1)palmar
tilt 2)extent of
metaphyseal
communition
3)displacement of the
volar cortex
4)scapholunate angle
5)position of the DRUJ

30. OBLIQUEVIEW
 Assessing radial comminution
 Split or depression of radial styloid
TILTED LATERALVIEW
. Lunate facet
TRACTIONVIEWS
.Help to plan out the management

31. RADIOLOGY
 Radial inclination (23deg)
 Volar inclination (11deg)
 Radial length (11mm)
 Ulnar variance(+ / - 1mm)

32. Radial Inclination
• Inclination of radius towards the ulna
• measured by the angle between a line drawn
from the tip of the radial styloid to the medial
corner of the articular surface of the radius
and a line drawn perpendicular to the long
axis of the radius
• Average : 23 degree (13-30)

33. Radial Length
• Inclination of radius towards the ulna
• measured by a line drawn perpendicular to
the long axis of the radius and tangential to
the most distal point of the ulnar head and a
line drawn perpendicular to the long axis of
the radius and at the level of the tip of the
radial styloid
• Average : 11 mm (8-18)

34. Dorsal/Palmar tilt
• A line is drawn connecting the most distal
points of the volar and dorsal lips of the
radius.The dorsal or palmar tilt is the angle
created with a line drawn perpendicular along
the longitudinal axis of the radius

35. Ulnar variance
• A line parallel to the medial corner of the articular
surface of the radius and a line parallel to the most
distal point of the articular surface of the ulnar
head, both of which are perpendicular to the long
axis of the radius
• Measure of radial shortening
• Normal : -2 to +2 mm

36. Carpal Malalignment
• In lateral view, one line is drawn along the long axis of the
capitate and one down the long axis of the radius. If the
carpus is aligned, the lines will intersect within the carpus.
If not, they will intersect outwith the carpus.
• More than 2 mm of intra articular step off leads to articular
incongruity

37. TEARDROP ANGLE & AP DISTANCE
 Angle between central axis of
teardrop (u shaped outline of
lunate facet) and radial shaft
 < 45 degree indicate
displacement of lunate facet
 AP distance is distance
between apices of dorsal and
volar rims of lunate facet
 Also measure articular
incongruity

38. 1: Line connecting dorsal and
volar tip of lunate
2: Line perpendicular to
lunate
3: Line along axis of scaphoid
Scapholunate angle measured between lines 2 and 3
(normal 47 ± 15 degrees)

39. Computed Tomography
Indications:
 Intra-articular fxs with
multiple fragments
 centrally impacted fragments
 DRUJ incongruity
 CT scan:For conformation of
occult fracture like
intraarticular fracture of
lunate fossa

40. Continue
 MRI scan:For evaluation of
suspected soft tissue injuries
1. Flexor or extensor tendon
injuries
2. Median nerve injuries
3. Early diagnosis of necrosis of
sacphoid or lunate
4. Perforation ofTFCC
5. Rupture of carpal ligaments

41. Classification
 A)classification based on different fracture types
 1)Colles fracture/pouteau’s fracture
 2)Smith’s farcture/reverse colles fracture
 3)Barton’s fracture
 4)Chauffer’s fracture
 5)Lunate load or die punch fracture

42. Colles fracture
 It is an extraarticular fracture occurs at corticocancellous
junction of distal end of radius within 2cm from the articular
surface
 It may extend into DRUJ with six displacements
1. Impaction
2. Lateral displacement
3. Lateral rotation (angulation)
4. Dorsal displacement
5. Dorsal rotation (angulation)
6. Supination.
 It may often accompany fracture of the ulnar styloid which
signify avulsion of theTFCC and ulnar collateral ligaments

43. Smith’s fracture/Reverse colles
fracture
 Occurs at the same level on the distal radius as a colles'
fracture.
 Distal fragment displaced in palmar (volar) direction with a
"garden spade" deformity.
 ModifiedThomas Classification of Smith's Fracture:
 Type I: Extraarticular
 Type II:Crosses into the dorsal articular surface
 Type III:Enters the radiocarpal joint(equivalent to volar
barton fracture dislocation)

44. Smith's fracture (reverse colle's or volar Barton's)
typical deformity: garden-spade deformity
1. Dorsal prominence of the distal end of the
proximal fragment
2. Fullness of the wrist on the volar side due to
the displaced distal fragment
3. Deviation of the hand toward the radial side

45. Barton’s fracture
 It is an intrarticular fracture dislocation or
subluxation in which the rim of the distal radius
dorsally or volarly is displaced with the hand and
carpus
 There are 2 types
Dorsal barton
volar barton

46. 1. Dorsal Barton:
 Dorsal rim fracture of distal radius
 Mechanism:
 Fall with dorsiflexion and pronation of the distal
forearm on a flexed wrist.
2.Volar Barton:
Palmar rim fracture of distal radius
 Mechanism:
 It is due to palmar tensile stress and dorsal shear
stress and is usually combined with radial styloid
fracture.

47. Volar barton Dorsal barton

48. Chauffeur’s fracture/hutchison
fracture
 It is an intraarticular fracture involving the radial
styloid,the radius is cleaved in a sagittal plane and
the fragment is displaced proximally.Isolated
fracture of the radial styloid are fairly common from
backfiring of starting handle of car

49. Lunate load/Die punch fracture
 It is an intraarticular fracture with displacement
of the medial articular surface which usually
represents a depression of dorsal aspect of
lunate fossa

50. Common Classifications
 Gartland/Werley
 Frykman
 Weber (AO/ASIF)
 Column theory
 Melone
 Fernandez (mechanism)

51. Frykman Classification
Extra-
articular
Radio-carpal joint
Radio-ulnar joint
Both joints
{
Same pattern as
odd numbers,
except ulnar styloid
also fractured

52. AO/ OTA Classification
Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C: Complete
Intra-articular

53. Column Theory
Rikli & Regazzoni, 1996
3 Columns: radial, intermediate,
medial

54. Three Column Theory
 Radial Column
Lateral side of radius
 Intermediate Column
Ulnar side of
radius
 Ulnar Column
distal ulna
Radial column
Intermediate column
Ulnar column

55. Classification – Fernandez
(1997)
 I. Bending-metaphysis
fails under tensile stress
(Colles, Smith)
 II. Shearing-fractures of
joint surface (Barton,
radial styloid)

56. Classification – Fernandez
(1997)
 III. Compression-
intraarticular fracture with
impaction of subchondral
and metaphyseal bone (die-
punch)
 IV. Avulsion-fractures of
ligament attachments
(ulna, radial styloid)
 V. Combined/complex -
high velocity injuries

57. CONTINUE
 B)Universal classification
1)Extraarticular
2)Intraarticular
 C)Other types