Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm Complete simple articular, simple metaphyseal radial fracture

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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.

If the intraarticular component is a single split, with relatively little comminution it may be possible to obtain a closed reduction. If this is not possible or there are associated injuries open reduction is recommended.

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.

Special attention must be paid to fractures with a dorsomedial fragment. The dorsomedial fragment is part of the radiocarpal and the distal radioulnar joint and should be reduced anatomically. If the fragment does not reduce after closed reduction with ligamentotaxis, percutaneous manipulation with a K-wire or formal open reduction and internal fixation (dorsal double plating) may be required.

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

Indications

  • 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
Closed reduction - K-wires and cast/external fixator
Main indication Skill Equipment
Reducible and large fragments, low demand patients Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Reducible by closed means
  • Large fragments

Contraindications

  • Osteoporosis
  • Residual articular surface depression after closed reduction
  • Significant loss of radial length
  • Substantial metaphyseal comminution
  • Articular surface depression
  • Severe swelling
  • Patient not fit for surgery
  • Poor state of soft tissues

Advantages

  • Less time consuming than ORIF
  • Simpler than ORIF
  • Lower cost than ORIF
  • Easy to remove
  • Restoration of articular anatomy (both radiocarpal and DRU joint)

Disadvantages

  • Risk of pin track infection
  • Risk of radial sensory nerve injury
  • Risk of tendon transfixion
  • Risk of redisplacement
  • Requires additional cast immobilization or external fixator
  • Poor hold in osteoporotic bone

Note: A cast is quicker, simpler and cheaper to apply than an Exfix.
An Exfix gives greater stability, is more effective in prevention of shortening, and allows easier access to deal with any soft tissue problems.

ORIF - Palmar plate
Main indication Skill Equipment
Almost all complete articular simple fractures of the radius Highly experienced and skilled surgeon Full specialized surgical and imaging resources

As these are articular injuries, they should normally be fixed. 

Contraindications

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

Advantages

  • Stability in comminuted fractures
  • Articular congruity
  • Early motion

Disadvantages

  • Risk of soft tissue irritation
  • Complex 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
  • Persistent displacement following other methods
  • Redisplacement
  • Active patients

Contraindications

  • Palmar displaced fractures
  • Dorsal soft-tissue injury
  • Median nerve compromise
  • Severe swelling
  • Poor state of soft tissues
  • Patient not fit for surgery

Advantages

  • Stable 3-column reconstruction
  • Stable restoration of radial length
  • Stable anatomical reduction of DRU joint
  • Significantly greater stability in osteoporotic bone with locking plates
  • Early motion
  • Identification of associated inter carpal ligament injury

Disadvantages

  • Tendon irritation (less likely with 2.4mm implants)
  • Possible need for later implant removal
  • Cost for locking plates
  • Nerve injury
  • Tendon irritation
*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