Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm Complete multifragmentary fracture of the radius

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Glossary

General considerations

These are complete articular fractures of the distal radius, with no part of the articular surface in continuity with the diaphysis. As these are intraarticular fractures they require anatomic reduction, except in very low demand patients.
Any patient who has had a fall on the outstretched hand may have sustained an intercarpal ligament injury; these may easily be missed on initial clinical assessment.

Note: CT scans may be helpful for treatment decisions.
In fractures with extension into the diaphysis, open treatment with a long T-plate (bridging plate) is preferred due to the longer time to healing of the diaphyseal fracture component.

Nonoperative treatment - Cast
Main indication Skill Equipment
Unfit or low-demand patient, undisplaced fracture Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Relatively undisplaced and stable fracture
  • Patient not fit for surgery
  • Poor state of soft tissues
  • low-demand patient

Contraindication

  • Displaced fracture

Disadvantage

  • Increased risk of long-term mobility loss
Joint-spanning external fixation (temporary or definitive)
Main indication Skill Equipment
Temporary stabilization in polytrauma, unfit patient, insufficient hold in a cast, patient not suitable for ORIF Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Temporary stabilization in polytrauma/ unfit patient
  • Open fracture
  • Unacceptable shortening or dorsal inclination
  • Extension of fracture into diaphysis
  • Local soft-tissues compromised for plating
  • Closed reduction possible

Contraindications

  • Poor state of local soft tissues increasing risk of pin track infection
  • Patient not fit for surgery
  • Severely comminuted injury
  • Osteoporosis
  • Significant metaphyseal defect after restoring radial length

Advantages

  • Reduced risk of infection at the fracture site compared to plating
  • Lower risk in cases of significant local soft-tissue injury than ORIF
  • Straightforward technique
  • Restoration of articular anatomy (both radiocarpal and DRU joint)

Disadvantages

  • Radial sensory nerve injury
  • Risk of metacarpal fracture
  • Risk of loss of radial length
  • Risk of injury to extensor tendon
  • Stiffness, especially with over distraction
  • Risk of complex regional pain syndrome (type I) (CRPS-I)
  • Risk of pin-track infection
  • Risk of redisplacement after removal
  • Unable to accurately control fragments without supplementary pinning
ORIF - Palmar bridge plate
Main indication Skill Equipment
Marked metaphyseal comminution Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Small articular fragments
  • Impacted fragments
  • Persistent or recurrent displacement following other methods
  • Carpal instability
  • High-demand patients
  • Marked metaphyseal comminution

Contraindications

  • Poor state of soft tissues
  • Severe swelling
  • Patient not fit for surgery

Advantages

  • Anatomical reduction
  • Stability
  • Early motion
  • Identification of associated intercarpal ligament injury
  • Restoration of articular anatomy (both radiocarpal and DRU joint)

Disadvantages

  • Risk of nerve injury
  • Risk of tendon irritation
  • Possible need for later implant removal
ORIF - Joint-spanning distraction plate
Main indication Skill Equipment
Severe comminution Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Small articular fragments
  • Impacted fragments
  • Persistent or recurrent displacement following other methods
  • Carpal instability
  • Polytrauma patients
  • Marked metaphyseal comminution

Contraindications

  • Poor state of soft tissues
  • Severe swelling
  • Patient not fit for surgery

Advantages

  • Anatomical reduction
  • Stability
  • Early motion
  • Identification of associated intercarpal ligament injury
  • Restoration of articular anatomy (both radiocarpal and DRU joint)

Disadvantages

  • Risk of nerve injury
  • Risk of tendon irritation
  • Possible need for later implant removal
ORIF - Dorsoradial double plate
Main indication Skill Equipment
When a posterior approach is necessary to treat intercarpal instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Optimum hold and stability is probably best obtained with separate plating of the radial and intermediate columns. The fixation of the small, distal fragments is more secure with locking plates, and additional bone graft is not then necessary.

Indications

  • Dorsally displaced fractures (using indirect reduction technique for locking plates if required)
  • Loss of radial length
  • Displaced coronal split in lunate fossa
  • Impacted articular fragments and associated carpal ligament tears
  • Small articular fragments
  • Complex metaphyseal and/or diaphyseal components
  • Open fractures

Contraindications

  • Dorsal soft-tissue injury
  • Poor state of soft tissues
  • Patient not fit for surgery

Advantages

  • Stable 3-column reconstruction
  • Stable restoration of radial length
  • Stable anatomical reduction of both radiocarpal and DRU joints
  • Significantly greater stability in osteoporotic bone with locking plate
  • More likely to achieve anatomical reduction
  • Early motion
  • Identification of associated intercarpal ligament injury

Disadvantages

  • Tendon irritation (less likely with 2.4mm implants)
  • Possible need for later implant removal
  • Cost for locking plates
  • Dorsal approach technically more demanding than palmar approach
  • Diaphyseal component may require separate reconstruction
  • Nerve injury
ORIF - Dorsoradiopalmar triple plate
Main indication Skill Equipment
Gross articular injury which can be reconstructed Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Optimum hold and stability is probably best obtained with separate plating of the radial and intermediate columns. The fixation of the small, distal fragments is more secure with locking plates, and additional bone graft is not then necessary.

Indications

  • Hyperextended palmar articular fragments
  • Irreducible dorsal ulnar fragments
  • Impressed articular fragments
  • Significant ligament injury of the proximal carpal row
  • Small articular fragments
  • Complex metaphyseal and/or diaphyseal components
  • Open fractures

Contraindications

  • Significant closed skin injuries
  • Poor state of soft tissues
  • Patient not fit for surgery

Advantages

  • Stable 3-column reconstruction
  • Stable restoration of radial length
  • Stable anatomical reduction of both radiocarpal and DRU joints
  • Significantly greater stability in osteoporotic bone with locking plate
  • More likely to achieve anatomical reduction
  • Early motion
  • Identification of associated intercarpal ligament injury

Disadvantages

  • Tendon irritation (less likely with 2.4mm implants)
  • Possible need for later implant removal
  • Cost for locking plates
  • Multiple approaches required, which is the most technically demanding procedure
  • Diaphyseal component may require separate reconstruction
  • Nerve injury
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources