Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm Partial articular fracture of the radius, with dorsal dislocation

back to skeleton

Glossary

General considerations

In these injuries, the carpus must be reduced and the articular surface reconstructed accurately, both to stabilize the carpus and protect from subsequent degenerative changes.

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.

Nonoperative treatment - Cast
Main indication Skill Equipment
Patient not fit for surgery, low demand patient Basic surgical experience, no specialized skills Basic equipment only

These fractures should only ever be treated nonoperatively in very low demand or unfit patients.

Indications

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

Contraindication

  • Open fractures, if condition of patient permits surgery

Disadvantage

  • Severe risk of redisplacement and radiocarpal dislocation
  • Poor functional outcome
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

As these are articular injuries, with a high risk of radiocarpal subluxation, they should normally be fixed. 

Anatomic reduction may be possible to achieve through closed manipulation and insertion of percutaneous K-wires.

Indications

  • Temporary stabilization in polytrauma
  • Significant local skin compromise
  • Poor medical condition of patient
  • Congruous reduction of the dislocation possible
  • No more than three sizeable dorsal fracture fragments
  • Anatomical reduction

Contraindications

  • Associated intercarpal ligament injury
  • Osteoporosis
  • Irreducible fracture

Advantages

  • Less complex to perform than plate fixation
  • Can be combined with percutaneous pinning and / or open reduction and fixation of small dorsal / palmar rim fragments and ligament repair
  • Enhanced stability
  • Improved articular congruity

Disadvantages

  • Risk of radial sensory nerve injury
  • Risk of injury to extensor tendon
  • Risk of metacarpal fracture
  • Risk of joint stiffness, especially with over-distraction
  • Risk of pin-track infection
  • Danger of overdistraction leading to complex regional pain syndrome type I (CRPS 1)
  • Prolonged external fixation can lead to joint stiffness
  • Risk of redisplacement after removal
ORIF - Dorsoradial double plate
Main indication Skill Equipment
Almost all partial articular fractures which involve a significant radial styloid fragment. Highly experienced and skilled surgeon Full specialized surgical and imaging resources

As these are articular injuries, with a high risk of radiocarpal subluxation, they should normally be fixed. 

Indications

  • Identified intercarpal ligament injury
  • Identified median nerve compromise (which will require an additional palmar approach)

Contraindications

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

Advantages

  • Improved joint stability
  • Enhanced articular congruity
  • Recognition and treatment of associated ligament injuries

Disadvantages

  • Risk of tendon irritation
  • More complex later implant removal

Note: In case of repair of relevant associated ligament injuries additional immobilization (external fixator / cast) may be needed.

ORIF - Dorsal double plate
Main indication Skill Equipment
Almost all partial articular fractures which involve a significant radial styloid fragment Highly experienced and skilled surgeon Full specialized surgical and imaging resources

As these are articular injuries, with a high risk of radiocarpal subluxation, they should normally be fixed. 

Contraindications

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

Advantages

  • Stability in comminuted fractures
  • Access for intercarpal ligament repair
  • Restoration of articular surface
  • Early motion

Disadvantages

  • Technically demanding
  • Risk of tendon irritation
  • More complex 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