Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm Extraarticular fracture of the radius with volar displacement or tilt

back to skeleton

Glossary

General considerations

These are simple extraarticular fractures with a volar tilt. These are often referred to as Smith or Goyrand fractures. These fractures are usually regarded as less stable than the dorsally displaced fractures, so they are more often treated surgically.
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.

Nonoperative treatment - Cast
Main indication Skill Equipment
Reducible fracture in absence of palmar comminution Basic surgical experience, no specialized skills Basic equipment only

The outcome of nonoperative treatment depends on the ability to achieve and maintain good reduction.

Indications

  • Simple (non-comminuted) fractures
  • Low-demand patient
  • Minimal displacement or stable after closed reduction
  • No shortening

Contraindications

  • Unsuccessful closed reduction
  • Neurovascular compromise 

 Advantages

  • No surgical risk
  • Low cost
  • Minimal infrastructure required
  • Local or regional anesthesia

Disadvantages

  • Potential loss of reduction
  • Frequent radiological follow-up necessary
  • Risk of soft-tissue swelling and chronic regional pain syndrome (CRPS)
  • Stiffness due to immobilization
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
  • Unstable fracture
  • Redisplacement in cast
  • Open fracture
  • Local soft-tissues compromised for plating

Contraindications

  • Low-demand patient
  • Patient not fit for surgery
  • Poor state of local soft tissues increasing risk of pin track infection

Advantages

  • Reduced risk of infection at the fracture site compared to open technique
  • Lower risk in cases of significant local soft-tissue injury
  • Restoration of extraarticular anatomy
  • Loss of position unlikely
  • Straightforward technique
  • Less invasive than ORIF

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)
  • Pin-track infection
  • Risk of redisplacement after removal
Closed reduction - K-wires and cast/external fixator
Main indication Skill Equipment
Unstable fractures, loss of reduction Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Unstable fractures
  • Loss of reduction in absence of palmar comminution
  • Irreducible palmar angulation and shortening

Contraindications

  • Low-demand patient
  • Patient not fit for surgery
  • Poor state of local soft tissues
  • Significant comminution

Advantages

  • Less time consuming than ORIF
  • Straightforward technique
  • Lower cost than ORIF
  • Easy to remove
  • Restoration of extraarticular anatomy
  • Loss of position unlikely

Disadvantages

  • Risk of pin-track infection
  • Risk of superficial radial nerve injury
  • Risk of redisplacement, especially in osteoporotic bone
  • Usually requires protection with a cast (or external fixation)

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
Irreducible, or unstable reduction, associated neurovascular injury Highly experienced and skilled surgeon Full specialized surgical and imaging resources

There are many implants now available, most with locking screws, which give better hold in osteoporotic bone.

Indications

  • Irreducible displacement
  • Redisplacement after closed reduction
  • High-demand patients
  • Delayed presentation
  • Associated neurovascular injury
  • Irreducible palmar angulation and shortening

Contraindications

  • Low-demand patient
  • Patient not fit for surgery
  • Poor state of local soft tissues

Advantages

  • Anatomical restoration
  • Minimal risk of redisplacement
  • Early motion
  • Less need for implant removal

Disadvantages

  • Cost
  • Risk of nerve injury
  • Potential tendon irritation
  • Possible need for later implant removal
*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