Distal Radius Fractures
Case
Chief complaint: Left wrist pain
History: A 65-year-old right hand-dominant female was brought in by ambulance after a motor vehicle collision with left wrist pain and deformity. She states she was driving when another car turned and drove into the front of her car. She was wearing a seatbelt, the road speed limit was 35 MPH, and the front airbags deployed. There was moderate damage to the vehicle. However, the patient was able to self-extricate and was ambulatory on scene. She denied head strike, loss of consciousness, or taking blood thinners. She states she was in her usual state of health prior to this event.
Past medical history: Insulin dependent type 2 diabetes. Her medications included metformin, insulin (lispro and glargine). She does not have any allergies to medications and has never had surgery before. She did not know the date of her last tetanus shot.
Social history: Smokes 10 cigarettes per day, denied drinking alcohol or other drug use.
Review of systems: Reports abdominal pain, joint pain, injury, swelling, and reduced range of motion. Denies numbness or tingling. All other systems reviewed and negative.
Physical exam:
Vitals BP 152/88, HR 77, Temp 37, Resp 18, 99%
LUE with deformity to distal forearm, 8 mm laceration over dorsal aspect of distal forearm with slow persistent oozing, fingers with intact extension, flexion, adduction, abduction, intact sensation to light touch, intact radial pulse, <2 second capillary refill in fingertips. Compartments soft.
Abdominal exam was significant for left upper quadrant tenderness to palpation, however the abdomen was soft and without rebound tenderness.
C collar in place, otherwise the remainder of exam was within normal limits.
Diagnosis
Given her mechanism of injury and exam findings, a CT Panscan was obtained. The interpretation did not suggest acute thoracoabdominal pathology.
L radius and ulna x rays revealed an acute displaced comminuted fractures of distal radius and ulnar metaphysis with 43.6 degree volar angulation and 2.5 cm of radial shortening.
Figure 1
Figure 2
She was diagnosed with open, comminuted left distal radius and ulnar fractures with significant displacement. This fracture can also be considered a Smith’s fracture given it is a distal radius fracture with volar displacement.
Discussion
Distal radius fractures are the most common orthopedic injury. The most common mechanism of injury is a fall on an outstretched hand, particularly in elderly patients. Younger patients often have a higher energy mechanism of injury. Treatment can be nonoperative or operative depending on fracture stability and fracture displacement, as well as patient specific factors such as age, activity, medical comorbidities, etc. [1]
Associated injuries of nearby structures are common, such as distal radial ulnar joint injury or radial styloid fracture, each of which may require nonoperative vs. operative management, which will not be discussed here. Radial styloid fractures indicate a higher energy mechanism. Soft tissue injuries are seen in up to 70% of cases, which may include injuries to the triangular fibrocartilage complex (40% of cases), scapholunate ligament (30% of cases), or lunotriquetral injuries (15% of cases). Median nerve neuropathy is the most common neurological complication seen in up to 30% of high energy fractures and 12% of low energy fractures. It is prevented by avoiding immobilization in excessive wrist flexion and ulnar deviation. [2,4]
Indications for nonoperative management include extra articular fracture, <5mm radial shortening, and dorsal angulation < 5 degrees or within 20 degrees of contra lateral radius. [3]
Figure 3
Indications for operative management of distal radius fractures are numerous: “Radiographic findings indicating instability, dorsal angulation > 5° or > 20° of contralateral distal radius, volar or dorsal comminution, displaced intra-articular fractures > 2mm, radial shortening > 5mm, associated ulnar fracture, severe osteoporosis, articular margin fractures (dorsal and volar Barton's fractures), involvement of the volar ulnar corner (critical corner), which supports the volar lunate facet with its strong radiolunate ligament attachments (failure to address this fragment can result in volar carpal subluxation), comminuted and displaced extra-articular fractures (Smith's fractures), progressive loss of volar tilt and radial length following closed reduction and casting, open fractures.”[1]
Indications for advanced imaging:
Indications for CT include evaluation for intra-articular involvement and surgical planning. Indications for MRI are to evaluate for soft tissue injuries: triangular fibrocartilage complex, scapholunate ligament, or lunotriquetral injuries. [1]
Case resolution
Patient received cefazolin, tetanus prophylaxis, analgesia, reduction and splinting, elevation, icing, and then underwent ORIF the following day.
In this case, operative management was selected given the patient’s fracture was unstable, comminuted, had significant radial shortening, and an associated ulnar fracture.
Take-Aways
1. Indications for nonoperative management include extra articular fracture, <5mm radial shortening, and dorsal angulation < 5 degrees or within 20 degrees of contralateral radius.
2. Indications for CT include evaluation for intra-articular involvement and surgical planning.
3. Indications for MRI are to evaluate for soft tissue injuries: triangular fibrocartilage complex, scapholunate ligament, or lunotriquetral injuries.
4. Associated injuries of nearby structures are common, such as distal radial ulnar joint injury or radial styloid fracture. Soft tissue injuries are seen in 70% of cases which include injuries to the triangular fibrocartilage complex (40% of cases), scapholunate ligament (30% of cases), or lunotriquetral injuries (15% of cases).
5. Median nerve neuropathy is the most common neurological complication seen in up to 30% of high energy fractures and 12% of low energy fractures. It is prevented by avoiding immobilization in excessive wrist flexion and ulnar deviation. [1]
Author: Chris Koehler, MD is a first year emergency medicine resident at Brown Emergency Medicine Residency.
Faculty Reviewer: Kristina McAteer, MD is an attending emergency medicine physician at Rhode Island Hospital and Newport Hospital
References:
Chen, Neal C., and Jesse B. Jupiter. "Management of distal radial fractures." JBJS 89.9 (2007): 2051-2062.
Distal radius fractures. (2022, October 2). Orthobullets - www.orthobullets.com. https://www.orthobullets.com/trauma/1027/distal-radius-fractures.
Gofton, Wade T and Allan S Liew. “Distal radius fractures: nonoperative and percutaneous pinning treatment options.” Hand clinics 26 1 (2010): 43-53.
Nellans, Kate W., Evan Kowalski, and Kevin C. Chung. "The epidemiology of distal radius fractures." Hand clinics 28.2 (2012): 113-125.