Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm Extraarticular wedge or multifragmentary fracture of the radius

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Glossary

General considerations

These metaphyseal fractures are extraarticular, but multifragmentary. They are subclassified according to the degree of fragmentation and compression of the metaphysis.

The decision to treat these fractures operatively or nonoperatively will be influenced partly by the fracture configuration, but also by local protocols and the functional demands of the patient.

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
Low-demand patient; surgery not possible Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Acceptable displacement
  • Low-demand patient
  • Surgery not possible

Contraindications

  • Unacceptable displacement or shortening
  • Irreducible
  • Neurovascular compromise
  • Open fracture

Disadvantages

  • Stiffness due to immobilization
  • Significant risk of further displacement
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
  • Instability
  • Open fracture
  • Unacceptable shortening or dorsal inclination
  • Extension of fracture into diaphysis
  • Local soft-tissues compromised for plating
  • Axial impaction

Contraindications

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

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

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 reduction in cast alone
  • Redisplacement following reduction

Contraindications

  • Extension of fracture into diaphysis
  • Patient not fit for surgery
  • Poor state of soft tissues

Advantages

  • Less time-consuming technique than ORIF
  • Less invasive technique than ORIF
  • Lower cost than ORIF
  • Easy to remove

Disadvantages

  • Risk of infection
  • Risk of nerve injury
  • Risk of redisplacement, particularly 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 bridge plate
Main indication Skill Equipment
Irreducible, or unstable reduction: associated neurovascular injury Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Preferably locking plates, as conventional plates require additional dorsal radial cortical cancellous bone graft.
Dorsal plating has largely been superseded by palmar plating.

Indications

  • Short distal segment
  • Active patients
  • Open fractures
  • Associated neurovascular injury
  • Irreducible
  • Unacceptable shortening or dorsal inclination, initially or following other methods
  • Extensive metaphyseal comminution
  • Extension of fracture into diaphysis
  • Early malunion / delayed presentation

Contraindications

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

Advantages

  • More straightforward surgical approach than dorsal plating
  • Anatomical restoration of radial length and rotation
  • Minimal risk of redisplacement
  • Fewer soft-tissue problems than dorsal plating
  • Less need for implant removal than with dorsal plates
  • No bone graft required when using locking plates
  • Early motion

Disadvantages

  • Cost (locking plates)
  • Nerve injury
  • 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