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Distal Radius Fractures—Classification of Treatment and Indications for Surgery
Orthop Clin N Am 38 (2007) 167–173
Distal Radius FracturesdClassification of Treatment and Indications for Surgery Asif M. Ilyas, MD, Jesse B. Jupiter, MD* Harvard Medical School, Orthopaedic Hand Service, Massachusetts General Hospital, Yawkey 2100, 55 Fruit Street, Boston, MA 02114, USA
Distal radius fractures remain an injury that fosters considerable interest and debate. It is an injury seen with high frequency, representing approximately one sixth of all fractures seen in emergency departments. Most are extracurricular and result from a fall. They typically present in a bimodal distribution with two distinct groups: children and the elderly. In the older population, it is more common in women and is attributed to postmenopausal osteoporosis. Interest in distal radius fractures stems not only from its high incidence but also from the developing understanding of outcome variables and the influence of technology in evaluation and treatment. For years distal radius fractures were injuries assumed to warrant no more than a cast following Colles’ [1] writings that they ‘‘will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain.’’ Today, the literature is burgeoning with data, often contradictory, on the indications for operative and nonoperative management. The goal of treatment for distal radius fractures is to obtain sufficient pain-free motion, allowing return to activities while minimizing the risk for future degenerative changes or disability. Multiple variables must be considered when evaluating a distal radius fracture and determining whether to operate. Closed reduction and casting has historically been the mainstay of treatment. However, the adequacy of closed treatment versus the need for operative intervention depends on several variables. These variables
* Corresponding author. E-mail address: [email protected] (J.B. Jupiter).
can be broadly divided into patient factors, fracture displacement, fracture stability, and associated injuries. Classification Any evaluation of fractures invokes the discussion of classifications. Traditionally, classification systems are used to categorize injuries and direct treatment based on expected outcome. Classifications are inherently meant to encompass the issue of fracture displacement and stability. In addition, they should provide a reproducible diagnosis with a high degree of intra- and interobserver reliability, take into account soft-tissue injuries, and offer prognostic considerations. Distal radius fractures more than any other fracture are wrought with various classifications. However, because of the large number of variables to consider and the spectrum of fracture characteristics of the distal radius, no one classification is adequate. Instead, different classifications have historically revealed certain important characteristics of distal radius fractures. To be effective, a classification system must accurately categorize the fracture type and injury severity to serve as a guideline for treatment and prognosis [2]. Although the many classification systems have attempted to provide a more accurate representation of various distal radius fracture patterns, some have proven more useful than others in guiding treatment and predicting outcome. Today, although many classification systems are of only historical interest, their review is relevant to the understanding and evolution of those more commonly used and their contributions to modern treatment.
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Gartland and Werley In their sentinel article in 1951, Gartland and Werley [3] brought attention to the fact that many distal radius fractures were being ineffectively treated, leading to a high percentage of poor results. They created a detailed evaluation system and classification system that included consideration of intra-articular fractures and their implications. They showed that a large percentage of distal radius fractures are intra-articular, 88% in their population, with approximately one third yielding unsatisfactory results and one fifth showing evidence of posttraumatic arthrosis through radiograph, also in their series. Lidstrom In his detailed study on distal radius fractures published in 1959, Lidstrom [4] outlined that early classifications were based on: 1. The fracture line 2. The direction of displacement of the distal fragment 3. The degree of displacement of the fracture 4. The extent of articular involvement 5. Any involvement of the distal radioulnar joint Lidstrom added a sixth criteria, the direction of displacement. He also expanded on the nature and extent of articular involvement. Older and colleagues In 1965 Older and colleagues [5] published a classification system that incorporated radial shortening of the distal fragment. This feature was later shown to be central to assessing fracture stability and providing prognostic information. In addition, the classification expanded on dorsal angulation, comminution, and the direction of displacement in a graded manner. Frykman In 1967, Frykman [6] introduced the involvement of the ulna in distal radius fractures. The classification system identified the individual involvement of the radioulnar joints and the presence or absence of a fracture of the ulna or ulnar styloid process. Aside from its significance in bringing the ulna into the discussion of distal radius fractures, the classification otherwise does not allow for quantification of the extent or direction of the initial fracture displacement, extent of
comminution, or shortening, thereby limiting its ability to direct treatment and predict prognosis. Thomas After Barton’s [7] description of dorsal fracture–dislocations, most classification systems focused instead on Colles’ type distal radius fractures. In 1957, Thomas [8] included the volar fracture dislocation in his classification system of volarly displaced distal radius Smith fractures. Melone Recent classification systems have focused on developing accurate identification of intra-articular fragments. In 1984, Melone [9] heralded the contemporary classifications by observing that there were four components of the radiocarpal joint and that intra-articular fractures appeared to fall into five basic patterns. The four components included the radial shaft, radial styloid, dorsal medial fragment, and the palmar medial fragment. In addition, he termed the medial two components that attach to both the carpal bones distally and the ulna medially the medial complex. The extent and direction of these fragments form the basis of the classification and are a prognostic indicator of the fracture’s stability. Jenkins In 1989, Jenkins [10] added to Melone’s classification by adding the direction and distribution of comminution. McMurtry and Jupiter In 1990, McMurtry and Jupiter [11] defined an intra-articular fracture as including any fracture that extends into the radiocarpal or radioulnar joint and is displaced more than 1 mm, building on the findings of Knirk and Jupiter [12] that intra-articular step-off of greater than 1 mm can lead to radiocarpal arthrosis. These fractures were further divided into two-part, three-part, four-part, and five-part fractures if the part or fragment was large enough to be manipulated and internally fixed. Universal classification In 1990, a universal classification was proposed by Cooney [13] in a symposium on distal radius fractures. The classification was modeled after the Grartland and Werley system and divided groups into extra- versus intra-articular fractures and stable versus unstable fractures.
DISTAL RADIUS FRACTURES: TREATMENT AND SURGERY
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Mayo Clinic
Indications for surgery
An additional classification focusing on intraarticular fractures was developed by the Mayo Clinic in 1992. The Mayo classification focused on the role of specific articular contact areas. The classification was formulated to include the specific articular surfaces of the distal radius and highlight fracture components involving these articulations [14].
The treatment plan for patients with distal radius fractures can be broken down broadly into the following criteria:
Association for the Study of Internal Fixation The Swiss Association for the Study of Internal Fixation (AO/ASIF) group developed the ‘‘Comprehensive Classification of Fractures of Long Bones’’ to serve as a basis for treatment and evaluating results. It is organized in order of increasing severity of the bone and articular lesions. Each bone and segment of bone is given a designation. The three basic types include extraarticular fractures (type A), simple intra-articular fractures (type B), and complex intra-articular fractures (type C) [2]. Despite the exhaustive nature and extensive capabilities offered by the AO/ASIF classification, it is cumbersome, especially when treatment options are considered. However, its value in research and documentation cannot be overstated. Fernandez In 1993, Fernandez [15] developed a more simplified approach for classification that moved away from focusing on the fracture fragments and instead recognized that fracture patterns reflect specific mechanisms of injury. This system is designed to be practical, determine stability, include associated injuries, and provide general treatment recommendations (Fig. 1). The major groups include: Type 1 ¼ Bending: the metaphyseal cortex fails because of tensile stresses with the opposite cortex undergoing a certain degree of comminution. Type 2 ¼ Shearing: resulting in volar or dorsal fracture dislocation. Type 3 ¼ Compression: leading to subchondral bone collapse with intra-articular extension. Type 4 ¼ Avulsion: involving fractures of the radial or ulnar styloids. Type 5 ¼ Combined: in high-energy injuries, combinations of bending, compression, shearing, or avulsion are encompassed.
1. 2. 3. 4.
Patient factors Fracture pattern Fracture stability Associated injuries
Patient factors Patient factors must be taken into account when considering treatment options. Variables include lifestyle, mental attitude, associated medical conditions, and compliance with treatment. In addition, chronologic age should be considered but in the perspective of expected loading. Anticipated functional loading of the distal radius after recovery should influence the choice of method of stabilization far more than the absolute chronologic age of the patient alone. Fracture pattern For extra-articular distal radius fractures, adequacy of closed reduction is assessed by reducing the fracture to the normal radiographic parameters and maintaining them until the fracture heals [16]. Biomechanical studies have helped define the acceptable radiologic parameters of reduction relative to their association to function. Loss of radial inclination or radial shortening causes significant increase in stress across the lunate facet and disruption of distal radioulnar mechanics and distortion of the triangular fibrocartilage complex [17–19]. Malunions with angulations greater than 20 dorsally or volarly cause changes in the position of the carpus and higher load concentrations. A compensatory dorsal intercalary segmental instability forms with dorsal angulation and can result in marked alterations in carpal mechanics [20]. In addition, dorsal malunions often result in rotational deformities that can result in pronation and supination deficits [21]. Finally, malposition of a fracture has been shown to accelerate degenerative changes over the long-term [18,19,22]. For intra-articular distal radius fractures, articular congruity must be assessed in addition to the normal radiographic parameters of the distal radius. Several studies have shown that articular step-off of even 1 mm or more can result in late radiocarpal arthrosis [12,15,23,24]. The significance of this finding is relative because the presence of posttraumatic radiocarpal arthrosis alone does
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Fig. 1. Practical, treatment-oriented classification of fractures of the distal radius and associated distal radioulnar joint lesions. (From Fernandez D, Jupiter J. Fractures of the distal radius, 2nd edition. New York: Springer; 2002. p. 48; with permission.)
not necessarily correlate with poor functional outcome [25]. In addition, discernment of 1 to 3 mm of step-off is has low interobserver reliability [26]. To assess articular step-off, reliable parameters must be developed and used to optimize identification. Fracture displacement directs initial management of a distal radius fracture and requires accurate assessment of the position of the fracture after closed reduction and consideration of the biomechanical implications. With these variables in mind, guidelines for acceptable closed reduction have been formulated [27,28].
outlined, the next question is whether the fracture is stable. In other words, will the fracture pattern and soft tissue injuries allow the distal radius to maintain a reduced position in the acceptable alignment until union. Reliably determining factors that may lead to fracture instability at presentation would enable more timely surgical intervention and avoid unnecessary closed management and observation. Radiographic signs that should alert the surgeon that the fracture is probably unstable and closed reduction will be insufficient include [15,29]:
Radial inclination: greater than or equal to 15 on posteroanterior view Radial length: less than or equal to 5 mm shortening on posteroanterior view Radial tilt: less than 15 dorsal or 20 volar tilt on lateral view Articular incongruity: less than to 2 mm of step-off
Dorsal comminution greater than 50% of the width laterally Palmar metaphyseal comminution Initial dorsal tilt greater than 20 Initial displacement (fragment translation) greater than 1 cm Initial radial shortening more than 5 mm Intra-articular disruption Associated ulna fracture Severe osteoporosis
Fracture stability If a fracture is reduced and the position is within the acceptable parameters of reduction as
Multiple studies examining distal radius fracture stability have validated these factors of
DISTAL RADIUS FRACTURES: TREATMENT AND SURGERY
instability. The definition of absolute instability has varied, with little consensus on specific criteria. Cooney and colleagues [30] considered fractures that were widely displaced with extensive dorsal comminution, dorsal angulation greater than 20 , or extensive intra-articular involvement to have a significant chance of redisplacement after reduction. Weber [31] expanded this concept to include fractures with dorsal comminution that extended volar to the midaxial plane of the radius on the lateral radiograph. Jenkins [10] examined 121 distal radius fractures and found that the position of the fracture at presentation was the best predictor of position at union and that the lack of dorsal comminution was protective against dorsally angulated malunions. Abbaszadegan and colleagues [32] examined 267 fractures initially treated nonoperatively using stepwise regression analysis and found that initial radial shortening (greater than 4 mm) was the greatest prognostic indicator of instability. Lafontaine and colleagues [33] suggested five factors that indicated instability: (1) initial dorsal angulation greater than 20 , (2) dorsal comminution, (3) radiocarpal intra-articular involvement, (4) associated ulna fractures, and (5) age greater than 60 years. The study concluded that fractures presenting with three or more of these gravity factors correlated with loss of position despite cast immobilization. Several subsequent studies have attempted to validate Lafontaine’s criteria for instability. Hove and colleagues [34] analyzed 645 nonoperatively treated distal radius fractures, and using multiple regression analysis determined that the initial dorsal angulation, radial length, and patient age were all predictors of malunion. Leone and colleagues [35] also found that the degree of radial shortening and volar tilt were predictive of early instability, with dorsal comminution also approaching statistical significance. An interesting result showed that one-third of undisplaced fractures went on to fail, most of which occurred in those patients over the age of 65. Nesbitt et al. [36] also examined criteria of instability and found age (greater than 58 years old) to be the only statistically significant factor for instability. More recently, examination of approximately 4000 distal radius fractures attempted to validate the known predictive factors and make a distinction between early and late fracture collapse. Mackenney and colleagues [37] found that the most important predictive factors were the age of the patient, dorsal comminution, and the
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position of the fracture at presentation. With increasing age, early and late instability increased proportionately. Associated injuries Several associated or secondary injuries may indicate operative intervention for distal radius fractures. Open fractures warrant operative management following well-established protocols of early irrigation and debridement followed by fixation of the fracture. Various multi-injury patterns also warrant operative intervention, including bilateral distal radius fractures and ipsilateral concomitant fractures of the upper extremity. Examination of the ipsilateral elbow and shoulder should always be performed. Proximal fractures can have significant implications for rehabilitation considerations. In addition, distally, carpal fractures or dislocations should be sought and surgically treated, including scaphoid fractures [38,39]. Acute median nerve dysfunction is a common neurologic complication of distal radius fractures. Median nerve symptoms after distal radius fractures typically include pain and burning in the median distribution of the hand, often out of proportion and not responsive to elevation and narcotic analgesia. Compartment pressures have been measured acutely after distal radius fractures and found to be highest at approximately 2 to 4 hours after injury or immediately after reduction [40]. However, acute carpal tunnel syndrome is not associated with specific fracture patterns of the distal radius [41]. These symptoms may represent an acute or an acute on chronic carpal tunnel syndrome. Initial intervention should include reduction and splinting of the fracture. Symptoms that do not improve with reduction may represent direct injury or contusion to the nerve. Persistent or worsening symptoms warrant surgical fixation of the fracture and open carpal tunnel release.
Summary Distal radius fractures are common injuries. Multiple classification systems exist that have helped identify different aspects of distal radius fracture that can affect its outcome. Identification of surgical indications includes consideration of patient factors, fracture reduction, fracture stability, and the presence of any associated injuries.
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References [1] Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med Surg 1814;10:182–6. [2] Muller ME, Nazarian S, Koch P. AO classification of fractures. Berlin: Springer; 1987. [3] Gartland JJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am 1951;33(4): 895–907. [4] Lidstrom A. Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop Scand Suppl 1959;41:1–118. [5] Older TM, Stabler EU, Cassebaum WH. Colles’ fracture: evaluation of selectin of therapy. J Trauma 1965;5:469–76. [6] Frykman GK. Fracture of the distal radius including sequelaedshoulder hand finger syndrome. Disturbance in the distal radioulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand Suppl 1967;108:1–155. [7] Barton JR. Views and treatment of an important injury of the wrist. Medical Examiner 1838;1:365–8. [8] Thomas FB. Reduction of Smith’s fracture. J Bone Joint Surg Br 1957;39:463–70. [9] Melone CP. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36. [10] Jenkins NH. The unstable Colles’ fracture. J Hand Surg [Br] 1989;14:149–54. [11] McMurtry RY, Jupiter JB. Fractures of the distal radius. In: Browner BD, Jupiter JB, Levine AM, et al, editors. Skeletal trauma. Philadelphia: Saunders; 1991. p. 1063–94. [12] Knirk J, Jupiter J. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am 1986;68(5):647–59. [13] Cooney WP. Fracture of the distal radius: a modern treatment-based classification. Orthop Clin North Am 1993;24:211–6. [14] Missakian ML, Cooney WP, Amadio PC, et al. Open reduction and internal fixation for distal radius fractures. J Hand Surg [Am] 1992;17:745–55. [15] Fernandez DL. Fractures of the distal radius. Operative treatment. Instr Course Lect 1993;42:73–88. [16] Friberg S, Lundstrom B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol Diagn (Stockh) 1976;2:249–56. [17] Fourrier P, Bardy A, Roche G, et al. [Approach to a definition of malunion callus after PouteauColles fractures]. Int Orthop 1981;4:299–305. [18] Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Sur [Am] 1990;15:721–7. [19] Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg [Am] 1993;18:492–8. [20] Park MJ, Cooney WP, Hahn ME, et al. The effects of dorsally angulated distal radius fractures on carpal kinematics. J Hand Surg [Am] 2002;12(2): 223–32.
[21] Prommersberger KJ, Froehner SC, Schmitt RR, et al. Rotational deformity in malunited fractures of the distal radius. J Hand Surg [Am] 2004;29(1): 110–5. [22] Short WH, Palmer AK, Werner FW, et al. A biomechanical study of distal radius fractures. J Hand Surg [Am] 1987;12:529–34. [23] Geissler WB, Fernandez DL. Percutaneous and limited open reduction of the articular surface of the distal radius. J Orthop Trauma 1991;5(3): 255–64. [24] Kopylov P, Johnell O, Redlund-Johnell I, et al. Fractures of the distal end of the radius in young adults: a 30-year follow-up. J Hand Surg [Br] 1993; 18(1):45–9. [25] Catalano LW, Cole RJ, Gelberman RH, et al. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am 1997;79(9):1290–302. [26] Kreder HJ, Hanel DP, McKee M, et al. X-ray film measurements for healed distal radius fractures. J Hand Surg [Am] 1996;21:31–9. [27] Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997;5:270–81. [28] Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159–71. [29] Ruedi TP, Murphy WM, editors. AO principles of fracture management. New York: Thieme; 2000. p. 362. [30] Cooney WP, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles’ fractures. J Bone Joint Surg Am 1979;61:840–5. [31] Weber ER. A rational approach for the recognition and treatment of Colles’ fracture. Hand Clin 1987;3: 13–21. [32] Abbaszadegan H, Jonsson U, von Sivers K. Prediction of instability of Colles’ fractures. Acta Orthop Scand 1989;60:646–50. [33] Lafontaine M, Hardy D, Delince P. Stability assessment of distal radial fractures. Injury 1989;20: 208–10. [34] Hove LM, Solheim E, Skjeie R, et al. Simultaneous scaphoid and distal radial fractures. J Hand Surg [Br] 1994;19(3):384–8. [35] Leone J, Bhandari M, Adili A, et al. Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. Arch Orthop Trauma Surg 2004;124(1):38–41. [36] Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg [Am] 2004;29(6):1128–38. [37] Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006;88:1944–51. [38] Trumble TE, Benirschke SK, Vedder NB. Ipsilateral fractures of the scaphoid and radius. J Hand Surg [Am] 1993;18(1):8–14.
DISTAL RADIUS FRACTURES: TREATMENT AND SURGERY
[39] Hove LM, Solheim E, Skjeie R, et al. Prediction of secondary displacement in Colles’ fracture. J Hand Surg [Br] 1994;19:731–6. [40] Dresing K, Peterson T, Schmit-Neuerburg KP. Compartment pressure in the carpal tunnel in distal
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fractures of the radius. A prospective study. Arch Orthop Trauma Surg 1994;113(5):285–9. [41] Bienek T, Kusz D, Cielinski L. Peripheral nerve compression neuropathy after fractures of the distal radius. J Hand Surg [Br] 2006;31(3):256–60.
Distal Radius FracturesdClassification of Treatment and Indications for Surgery Asif M. Ilyas, MD, Jesse B. Jupiter, MD* Harvard Medical School, Orthopaedic Hand Service, Massachusetts General Hospital, Yawkey 2100, 55 Fruit Street, Boston, MA 02114, USA
Distal radius fractures remain an injury that fosters considerable interest and debate. It is an injury seen with high frequency, representing approximately one sixth of all fractures seen in emergency departments. Most are extracurricular and result from a fall. They typically present in a bimodal distribution with two distinct groups: children and the elderly. In the older population, it is more common in women and is attributed to postmenopausal osteoporosis. Interest in distal radius fractures stems not only from its high incidence but also from the developing understanding of outcome variables and the influence of technology in evaluation and treatment. For years distal radius fractures were injuries assumed to warrant no more than a cast following Colles’ [1] writings that they ‘‘will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain.’’ Today, the literature is burgeoning with data, often contradictory, on the indications for operative and nonoperative management. The goal of treatment for distal radius fractures is to obtain sufficient pain-free motion, allowing return to activities while minimizing the risk for future degenerative changes or disability. Multiple variables must be considered when evaluating a distal radius fracture and determining whether to operate. Closed reduction and casting has historically been the mainstay of treatment. However, the adequacy of closed treatment versus the need for operative intervention depends on several variables. These variables
* Corresponding author. E-mail address: [email protected] (J.B. Jupiter).
can be broadly divided into patient factors, fracture displacement, fracture stability, and associated injuries. Classification Any evaluation of fractures invokes the discussion of classifications. Traditionally, classification systems are used to categorize injuries and direct treatment based on expected outcome. Classifications are inherently meant to encompass the issue of fracture displacement and stability. In addition, they should provide a reproducible diagnosis with a high degree of intra- and interobserver reliability, take into account soft-tissue injuries, and offer prognostic considerations. Distal radius fractures more than any other fracture are wrought with various classifications. However, because of the large number of variables to consider and the spectrum of fracture characteristics of the distal radius, no one classification is adequate. Instead, different classifications have historically revealed certain important characteristics of distal radius fractures. To be effective, a classification system must accurately categorize the fracture type and injury severity to serve as a guideline for treatment and prognosis [2]. Although the many classification systems have attempted to provide a more accurate representation of various distal radius fracture patterns, some have proven more useful than others in guiding treatment and predicting outcome. Today, although many classification systems are of only historical interest, their review is relevant to the understanding and evolution of those more commonly used and their contributions to modern treatment.
0030-5898/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ocl.2007.01.002
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168
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Gartland and Werley In their sentinel article in 1951, Gartland and Werley [3] brought attention to the fact that many distal radius fractures were being ineffectively treated, leading to a high percentage of poor results. They created a detailed evaluation system and classification system that included consideration of intra-articular fractures and their implications. They showed that a large percentage of distal radius fractures are intra-articular, 88% in their population, with approximately one third yielding unsatisfactory results and one fifth showing evidence of posttraumatic arthrosis through radiograph, also in their series. Lidstrom In his detailed study on distal radius fractures published in 1959, Lidstrom [4] outlined that early classifications were based on: 1. The fracture line 2. The direction of displacement of the distal fragment 3. The degree of displacement of the fracture 4. The extent of articular involvement 5. Any involvement of the distal radioulnar joint Lidstrom added a sixth criteria, the direction of displacement. He also expanded on the nature and extent of articular involvement. Older and colleagues In 1965 Older and colleagues [5] published a classification system that incorporated radial shortening of the distal fragment. This feature was later shown to be central to assessing fracture stability and providing prognostic information. In addition, the classification expanded on dorsal angulation, comminution, and the direction of displacement in a graded manner. Frykman In 1967, Frykman [6] introduced the involvement of the ulna in distal radius fractures. The classification system identified the individual involvement of the radioulnar joints and the presence or absence of a fracture of the ulna or ulnar styloid process. Aside from its significance in bringing the ulna into the discussion of distal radius fractures, the classification otherwise does not allow for quantification of the extent or direction of the initial fracture displacement, extent of
comminution, or shortening, thereby limiting its ability to direct treatment and predict prognosis. Thomas After Barton’s [7] description of dorsal fracture–dislocations, most classification systems focused instead on Colles’ type distal radius fractures. In 1957, Thomas [8] included the volar fracture dislocation in his classification system of volarly displaced distal radius Smith fractures. Melone Recent classification systems have focused on developing accurate identification of intra-articular fragments. In 1984, Melone [9] heralded the contemporary classifications by observing that there were four components of the radiocarpal joint and that intra-articular fractures appeared to fall into five basic patterns. The four components included the radial shaft, radial styloid, dorsal medial fragment, and the palmar medial fragment. In addition, he termed the medial two components that attach to both the carpal bones distally and the ulna medially the medial complex. The extent and direction of these fragments form the basis of the classification and are a prognostic indicator of the fracture’s stability. Jenkins In 1989, Jenkins [10] added to Melone’s classification by adding the direction and distribution of comminution. McMurtry and Jupiter In 1990, McMurtry and Jupiter [11] defined an intra-articular fracture as including any fracture that extends into the radiocarpal or radioulnar joint and is displaced more than 1 mm, building on the findings of Knirk and Jupiter [12] that intra-articular step-off of greater than 1 mm can lead to radiocarpal arthrosis. These fractures were further divided into two-part, three-part, four-part, and five-part fractures if the part or fragment was large enough to be manipulated and internally fixed. Universal classification In 1990, a universal classification was proposed by Cooney [13] in a symposium on distal radius fractures. The classification was modeled after the Grartland and Werley system and divided groups into extra- versus intra-articular fractures and stable versus unstable fractures.
DISTAL RADIUS FRACTURES: TREATMENT AND SURGERY
169
Mayo Clinic
Indications for surgery
An additional classification focusing on intraarticular fractures was developed by the Mayo Clinic in 1992. The Mayo classification focused on the role of specific articular contact areas. The classification was formulated to include the specific articular surfaces of the distal radius and highlight fracture components involving these articulations [14].
The treatment plan for patients with distal radius fractures can be broken down broadly into the following criteria:
Association for the Study of Internal Fixation The Swiss Association for the Study of Internal Fixation (AO/ASIF) group developed the ‘‘Comprehensive Classification of Fractures of Long Bones’’ to serve as a basis for treatment and evaluating results. It is organized in order of increasing severity of the bone and articular lesions. Each bone and segment of bone is given a designation. The three basic types include extraarticular fractures (type A), simple intra-articular fractures (type B), and complex intra-articular fractures (type C) [2]. Despite the exhaustive nature and extensive capabilities offered by the AO/ASIF classification, it is cumbersome, especially when treatment options are considered. However, its value in research and documentation cannot be overstated. Fernandez In 1993, Fernandez [15] developed a more simplified approach for classification that moved away from focusing on the fracture fragments and instead recognized that fracture patterns reflect specific mechanisms of injury. This system is designed to be practical, determine stability, include associated injuries, and provide general treatment recommendations (Fig. 1). The major groups include: Type 1 ¼ Bending: the metaphyseal cortex fails because of tensile stresses with the opposite cortex undergoing a certain degree of comminution. Type 2 ¼ Shearing: resulting in volar or dorsal fracture dislocation. Type 3 ¼ Compression: leading to subchondral bone collapse with intra-articular extension. Type 4 ¼ Avulsion: involving fractures of the radial or ulnar styloids. Type 5 ¼ Combined: in high-energy injuries, combinations of bending, compression, shearing, or avulsion are encompassed.
1. 2. 3. 4.
Patient factors Fracture pattern Fracture stability Associated injuries
Patient factors Patient factors must be taken into account when considering treatment options. Variables include lifestyle, mental attitude, associated medical conditions, and compliance with treatment. In addition, chronologic age should be considered but in the perspective of expected loading. Anticipated functional loading of the distal radius after recovery should influence the choice of method of stabilization far more than the absolute chronologic age of the patient alone. Fracture pattern For extra-articular distal radius fractures, adequacy of closed reduction is assessed by reducing the fracture to the normal radiographic parameters and maintaining them until the fracture heals [16]. Biomechanical studies have helped define the acceptable radiologic parameters of reduction relative to their association to function. Loss of radial inclination or radial shortening causes significant increase in stress across the lunate facet and disruption of distal radioulnar mechanics and distortion of the triangular fibrocartilage complex [17–19]. Malunions with angulations greater than 20 dorsally or volarly cause changes in the position of the carpus and higher load concentrations. A compensatory dorsal intercalary segmental instability forms with dorsal angulation and can result in marked alterations in carpal mechanics [20]. In addition, dorsal malunions often result in rotational deformities that can result in pronation and supination deficits [21]. Finally, malposition of a fracture has been shown to accelerate degenerative changes over the long-term [18,19,22]. For intra-articular distal radius fractures, articular congruity must be assessed in addition to the normal radiographic parameters of the distal radius. Several studies have shown that articular step-off of even 1 mm or more can result in late radiocarpal arthrosis [12,15,23,24]. The significance of this finding is relative because the presence of posttraumatic radiocarpal arthrosis alone does
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Fig. 1. Practical, treatment-oriented classification of fractures of the distal radius and associated distal radioulnar joint lesions. (From Fernandez D, Jupiter J. Fractures of the distal radius, 2nd edition. New York: Springer; 2002. p. 48; with permission.)
not necessarily correlate with poor functional outcome [25]. In addition, discernment of 1 to 3 mm of step-off is has low interobserver reliability [26]. To assess articular step-off, reliable parameters must be developed and used to optimize identification. Fracture displacement directs initial management of a distal radius fracture and requires accurate assessment of the position of the fracture after closed reduction and consideration of the biomechanical implications. With these variables in mind, guidelines for acceptable closed reduction have been formulated [27,28].
outlined, the next question is whether the fracture is stable. In other words, will the fracture pattern and soft tissue injuries allow the distal radius to maintain a reduced position in the acceptable alignment until union. Reliably determining factors that may lead to fracture instability at presentation would enable more timely surgical intervention and avoid unnecessary closed management and observation. Radiographic signs that should alert the surgeon that the fracture is probably unstable and closed reduction will be insufficient include [15,29]:
Radial inclination: greater than or equal to 15 on posteroanterior view Radial length: less than or equal to 5 mm shortening on posteroanterior view Radial tilt: less than 15 dorsal or 20 volar tilt on lateral view Articular incongruity: less than to 2 mm of step-off
Dorsal comminution greater than 50% of the width laterally Palmar metaphyseal comminution Initial dorsal tilt greater than 20 Initial displacement (fragment translation) greater than 1 cm Initial radial shortening more than 5 mm Intra-articular disruption Associated ulna fracture Severe osteoporosis
Fracture stability If a fracture is reduced and the position is within the acceptable parameters of reduction as
Multiple studies examining distal radius fracture stability have validated these factors of
DISTAL RADIUS FRACTURES: TREATMENT AND SURGERY
instability. The definition of absolute instability has varied, with little consensus on specific criteria. Cooney and colleagues [30] considered fractures that were widely displaced with extensive dorsal comminution, dorsal angulation greater than 20 , or extensive intra-articular involvement to have a significant chance of redisplacement after reduction. Weber [31] expanded this concept to include fractures with dorsal comminution that extended volar to the midaxial plane of the radius on the lateral radiograph. Jenkins [10] examined 121 distal radius fractures and found that the position of the fracture at presentation was the best predictor of position at union and that the lack of dorsal comminution was protective against dorsally angulated malunions. Abbaszadegan and colleagues [32] examined 267 fractures initially treated nonoperatively using stepwise regression analysis and found that initial radial shortening (greater than 4 mm) was the greatest prognostic indicator of instability. Lafontaine and colleagues [33] suggested five factors that indicated instability: (1) initial dorsal angulation greater than 20 , (2) dorsal comminution, (3) radiocarpal intra-articular involvement, (4) associated ulna fractures, and (5) age greater than 60 years. The study concluded that fractures presenting with three or more of these gravity factors correlated with loss of position despite cast immobilization. Several subsequent studies have attempted to validate Lafontaine’s criteria for instability. Hove and colleagues [34] analyzed 645 nonoperatively treated distal radius fractures, and using multiple regression analysis determined that the initial dorsal angulation, radial length, and patient age were all predictors of malunion. Leone and colleagues [35] also found that the degree of radial shortening and volar tilt were predictive of early instability, with dorsal comminution also approaching statistical significance. An interesting result showed that one-third of undisplaced fractures went on to fail, most of which occurred in those patients over the age of 65. Nesbitt et al. [36] also examined criteria of instability and found age (greater than 58 years old) to be the only statistically significant factor for instability. More recently, examination of approximately 4000 distal radius fractures attempted to validate the known predictive factors and make a distinction between early and late fracture collapse. Mackenney and colleagues [37] found that the most important predictive factors were the age of the patient, dorsal comminution, and the
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position of the fracture at presentation. With increasing age, early and late instability increased proportionately. Associated injuries Several associated or secondary injuries may indicate operative intervention for distal radius fractures. Open fractures warrant operative management following well-established protocols of early irrigation and debridement followed by fixation of the fracture. Various multi-injury patterns also warrant operative intervention, including bilateral distal radius fractures and ipsilateral concomitant fractures of the upper extremity. Examination of the ipsilateral elbow and shoulder should always be performed. Proximal fractures can have significant implications for rehabilitation considerations. In addition, distally, carpal fractures or dislocations should be sought and surgically treated, including scaphoid fractures [38,39]. Acute median nerve dysfunction is a common neurologic complication of distal radius fractures. Median nerve symptoms after distal radius fractures typically include pain and burning in the median distribution of the hand, often out of proportion and not responsive to elevation and narcotic analgesia. Compartment pressures have been measured acutely after distal radius fractures and found to be highest at approximately 2 to 4 hours after injury or immediately after reduction [40]. However, acute carpal tunnel syndrome is not associated with specific fracture patterns of the distal radius [41]. These symptoms may represent an acute or an acute on chronic carpal tunnel syndrome. Initial intervention should include reduction and splinting of the fracture. Symptoms that do not improve with reduction may represent direct injury or contusion to the nerve. Persistent or worsening symptoms warrant surgical fixation of the fracture and open carpal tunnel release.
Summary Distal radius fractures are common injuries. Multiple classification systems exist that have helped identify different aspects of distal radius fracture that can affect its outcome. Identification of surgical indications includes consideration of patient factors, fracture reduction, fracture stability, and the presence of any associated injuries.
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