Relavant Anatomy

a) Ossification of Radius.

One primary centre for shaft appears at 8th wk

of IUL

One secondary centre for lower end appears at

end of I st year of life, fuses c shaft at 18th year.

One secondary centre for upper end appears at

4th year and fuses with shaft at 14-17th year.

FRACTURES OF DISTAL END OF RADIUS

(A) VOLAR SURFACE OF DR Margen surface is covered by pronator Quadratus. The Ridge gives attachment to palmar Radio carpel ligam Lunate surface on Lt. projecting out from surface of Radius. Volar Radial tuberosity at Rt ent.

(B) DORSAL SURFACE OF DR Lister tubercle in the center it receives a strip from ext. Retinaculam

a)Medial to Lister Tubercle is oblique groove for EPLb)Lateral to Lister Tubercle groove for ECRL & ECRBc)Medial to oblique groove groove for Extensor

digitorum and Ext Indices

C) Lateral surface of distal radius There is radial styliod process projecting down wards Anteriorly ther is groove for APL just posterior to that groove for EPB. Surface just above styloid process is insertion of Bracho radials.

D) Ulnar surface There is ulnar notch for articulation c Head of ulna. Below the notch ther is ridge for articular cartillge.

(E) Inferior surface It is divided into medial Quadrilateral and lateral Triangular Area for a ridge. Lateral; Tr Surface articulate c scaphoid medial Quadrangular surface c lateral part of lunate.

Radiographic Anatomy (Page 26,27,28)(a) Radial height Distance between two parallel lines drawn perpendicular to the long axis of Radial shaft – one from tip of Radial styloid process, other from ulnar corner of lunate jossa - Average 12mm.

(B) RADIAL INCLINATIONThe angle between two lines, one line

perpendicular to long Axis of Radius through ulnar croner of lunate fossa, other line passing through the tip of Radial styloid process and ulnar corner of lunate jossa Average: 23o

(C) ULNAR VARIANCE It is the measurement of relative length of radius and ulna at wrist Distance between two parallel lines to drawn perpendicular to the long axis of ulna and radus 60% pts are ulnar neutral.

LATERAL VIEW

PALMER INCLINATION

The angle between two lines – one drawn

perpendicular to long axis of Radius other between

Dorsal and palmar lips of distal articular end of

Radius Average is 12o.

FRACTURES OF THE DISTAL RADIUS

Distal End of Radius subject to six types of Fractures

1. Colle’s # c Dorsal displacement of distal fragment (Cortico cancellos

junction)

2. Smith # c Anterior displacement.

3. Distal fore Arm # in children (Juvenile colles)

4. Radial styloiad #

5. Barton # (# of Dorsal or volar Articular margin of Distal Radius c

Dislocation or subluxation of carpus Dorsally or volar)

6. Comminuted intra Articular #

IN CURRENT PRACTICE THESE EPONYMS ARE

AVOIDED AND THE TERM DRF PROPERLY USES ALL FRACTURES

OF DISTAL ARTICULAR AND METAPLYSEAL AREAS.

FREQUENCY / EPIDEMIOLOGY

1. It represents approximately 1/6th of all #’s

2. There are three main peaks of # distribution.

Ist peak in children between 5 to 14 years.

IInd peak in males under 50 years.

IIIrd peak in females over 40 years.

3. The incidence more in Elderly female followed by younger adult males

The sharpest increase in incidence occurs in elderly women

due to Estrogen withdrawal and low BMD. Risk Factors

Low BMD

Female gender

Hereditory

Early menopaus

ETIOLOGY

1. Younger pts. Have stronger bones so they need more

energy to produce # Eg motorcycle accidents, falls

from height etc.

2. older pts have much weaker bones and needs small

amount of energy to produce #

For Eg. Simple falling on out stretched hand in

ground level fall.

CLINICAL FEATURES / PRESENTATION

1. A through Histry must by take to know the amount of

energy lnvolved , Histry of prior #s should be sought..

2. The Fracured Radius may be shortend relative to the

intact ulna which may lead to radial deviation and Dorsal

prominercy of distal fragment.

3. Median nerve is commonly injuired in distal radial #s.

So median merve function should be assessed.

CLASSIFICATIONMOST FREQUENTLY USED CLASSIFICATIONS FERNANDEZ CLASSIFICATIONIt is based on mechanism of injuiry.

Five types

1. Type I # :- Extra articular metaphysel bending Fractures. Such as colle

(Dorsal angulation) or Smith Fracturs (Volar angulation)

2. Type II # Intra articular and produced by shearing foreces. These are

volar Bartorn, Dorsal Barton and Radial styloid #s

3. Type III #s : It results from compression injuries results in intra articular #

and impaction of metaphyseal bone. These includes complex articular

#s and radial pilon #s.

4. Type IV #s : Are avulsun #s of ligament attachment which occuss c Radio

carpel #

dislocations.

5. Type V #s: These #s arise from high velocity injuries involving multple

forces and extensive injures.

OTHER CLASSIFICATION

• Melone Classification

Which heighlights fragmentation of articular surface

especially dorso ulnar corner of distal radius

• A O Classification

Based on location ie. extra articular, partial articular and

completely articular.

• Three column concept (Picture on Page 3) By Medoff, Rikli & Rigazzoni1. Lateral column (Radial half of radius c slyloid process &

scaphoid facet)2. Central column: Ulnar half of Rdius c lunar facet3. Medial column: (ulna, Triangular Fibro cartillege & Distal

Radio ulnar joint)

INVESTIGATIONIMAGING STUDIESI. X RAYS(A) AP view

1. Fer extra articular #s asses for [a] Radial shortening /

communition, ulnar styloid # location tip, waist, base)

2. For intra articular #s lookfor (a) depression of lunate

facet (b) gap between scaphoid lunate facet (c) Central

impaction of fragments (d) interruption of proximal carpel

row.

B) Lateral view

1. For extra Articular fractures Assess

a)Palmar tlt,

b)Extent of metaphyseal communition

c)Displacement of volar cortex.

d)Scaphoid – lunate angle

e)Position of DRUJ.

2. For intra Articular Fractures Asses

f)Palmar lunate facet

g)Depression of central fragment

h)The gap between palmar and dorsal fragment

i)Rotation of Radial styloid in relation to shaft

(C) OBLIQUE VIEW

1. For extra articular #s asses for Radial communitions

2. For Intra Articular # asses :

Radial styloid for split or depression

Depression of Dorsal lunate facet.

(D) TILTED LATERAL VIEW:

Taken by placing a pad under the hand to incline

the Radius to 220, which eliminates shadow of styloid

process and given clear tangential view of lunate facet.

(E) AP and Lateral traction view to know whether the external

fixation reduce the # sufficiently.

II. CT

Is useful to asses the articular communition.

TREATMENTBASED ON FERNANDEZ TYPES1) Type I # Most pts. with type I # are successfully treated conservativly with closed reduction & immobilsation. Most of “low dement pts.” Needs immobilisation only regardless x-ray findings If reduction needs prolonged immobilstaion or reduction lost early in the treatment percutaneus pinning through stayloid process. When there is significant metaphyseal communition or osteopea External fixation with traction cast or commercially available external fixator is used.

2)Type Ii #s Requires open reductiom and internal fixationalButtress plate fixation is usually done for volar baron #s

3)Type III (Compression #)Operative treatment is necessary for intra Articular damage & if rdial

shortening is severeFixation with multiple K-wire and cancellous is necessary to fill the

impacted areasNow Arthroscopy Assisted K-wire fixation awalable which can

repairTFC and intracarpel tears

4) Type IV # (Avulsion injuries) These #s usually associated c Radio carpel fracture dislocations ie

unstable #sSmall avulsed fragments are sutured. Reduction of carpus to radius

is achied by K-wire fixations

5) Type V # (High velocity injuries)There #s are usually unstable, open and difficult to treat.A combination of percutneus pining and external fixation is usually

needed.

DORSALAND VOLAR BARTON FRACTURES#s involving dorsal articulor surface margin of distal redius c

or without dislocation or subluxation of carpus dorsally is dorsal Barton#s

#s of volar articular margin of radius c volar dislocation subluxation of carpus is volar sarton #s.

These #s can be reduced closed when the marginal # is small and can be manufactured by cast immobilization.

For unstable dorsal Barton #s open reductions c anatomical restoration of articular surface and fixation using k-wires or small screws are used.

Loss of reduction c subluxation of carpus is common with volar Barton fracture, Ellis Buttress plate is used for fixation.

Kirchners wire’s can by used if the marginal

fragments are large and bone is firm.

Fragment specific open reduction and internal fixation of

comminuted DRF

This method was developed by Medoff who cambined

k-wire fixation c plate and screw fixation for stable

reconstruction of distal radius .

FIVE POTENTRAL # FRAGMENTS ARE POSSIBLE

1. Radial column #s: It is fixed by addition of small Butters

plate to radial styloid pin, which prevents collapse and

migration of the fragment. (Picture)

2. Dorsal ulnar fragment is stabilized c an ulnar pin – plate

fixation (picture)

3. Dorsal cortical wall fragment is stabilsed by wire form

implants.

4. Central intra Articular tragments are also fixed by wire form

implants (Trimed system)

5. Volar Rim fragments are fixed c loprofile Butters plate similar

to volar Barton #.

COMPLICATIONS OF DRF

A) EARLY

1) Vascular impairments

2) Nerve injuries :

It is rare, But if occurs median nerve injuiry is common.

It occurs soon after the injuring and symptoms are minimal, it will

resolve with release of dressings and, elevation. If symptoms are

severe transverse ligament should be divided.

3) Reflex sympathetic dystrophy (sudecksatrophy)

B) LATE COMPLICATIONS

1. Malunion

It occus either due to reduction was not complete or due to

displacement within the plaster.

1) For “Low demanding “ like elder parents conservative

management is enough

2) For younger pts. Open wedge osteolomy is needed.

2. Delayed union and Non Union,it is rare

3. Stiffness of shoulder,elbow,fingers and wrist

4. Extensor pollicis longus tendon rupture occurs few Weeks later