Orthopedics Book

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Distal Radius Fracture

Aka: Distal Radius Fracture, Colles Fracture, Colles' Fracture, Smith's Fracture, Smith Fracture, Reverse Colles Fracture, Barton's Fracture, Barton Fracture, Hutchinson Fracture, Chauffeur Fracture, Chauffeur's Fracture, Hutchinson's Fracture, Radial Styloid Fracture
  1. See Also
    1. Forearm Fracture
    2. Forearm Fracture in Children
    3. Distal Radius Fracture
    4. Galeazzi Fracture
    5. Monteggia's Fracture
    6. Supracondylar Fracture of Humerus
    7. Radial Head Fracture
    8. Radial Epiphyseal Fracture
  2. Epidemiology
    1. Most Common Wrist Injury
    2. Represents one sixth of all Fractures overall
    3. More common at extremes of age (age<18 years and age>65 years)
      1. Young (<18 years): High energy injury (e.g. skateboarding, Inline Skating, Downhill Skiing)
      2. Elderly: Low impact injury (e.g. fall) and underlying Osteoporosis
  3. Mechanism
    1. Fall on an outstretched hand
  4. Exam
    1. See Forearm Fracture
    2. See Hand Exam
    3. See Wrist Exam
    4. Injury exam mantra: "joint above, joint below, circulation, motor function and Sensation, skin and compartments"
    5. Evaluate for open Fracture
    6. Evaluate for Ecchymosis, deformity, shortening, rotation
    7. Evaluate Wrist Range of Motion
    8. Evaluate for Carpal Bone injury (e.g. Navicular Fracture)
    9. Complete Hand Neurovascular Exam
      1. Evaluate for Median Nerve injury (finger opposition, Sensation palm and first 3.5 fingers)
  5. Types
    1. Colles Fracture
      1. Occurs with Fall on Outstretched Hand with Forearm pronated
      2. Transverse Distal Radius Fracture with dorsal dorsal displacement and angulation of distal fragment
      3. "Dinner fork" deformity (distal fragment angulated dorsally)
      4. Often associated with ulnar styloid Fracture
    2. Smith Fracture (Reverse Colles Fracture)
      1. Example Injury: Bicycling injury with injury when falling over handlebars
      2. Transverse Distal Radius Fracture with volar dorsal displacement and angulation of distal fragment
      3. Volar angulation of distal radius fragment
    3. Barton Fracture
      1. High force injury (e.g. direct blow or motorcycle injury)
      2. Distal Radius Fracture with dislocation or subluxation of radiocarpal joint
      3. Colles Fracture or Smith Fracture AND radiocarpal dislocation
      4. Higher risk injury for Compartment Syndrome and open Fracture
    4. Hutchinson Fracture (Chauffeur Fracture)
      1. Occurs with posterior directed Fall on Outstretched Hand with hand in ulnar deviation
      2. Intra-articular Radial Styloid Fracture
      3. Associated with carpal injury (Scaphoid Fracture, lunate Fracture)
  6. Signs
    1. Distal Radius Fracture
      1. Displacement ("Dinner Fork" Deformity)
      2. Dorsal Angulation with volar prominence
      3. Shortening
      4. Radial Deviation of hand
    2. Ulnar styloid Injury often associated (60%)
    3. Thumb Ulnar Collateral Ligament Injury often associated
  7. Complications
    1. Compartment Syndrome
      1. Significantly increased pain after reduction despite analgesia may suggest Compartment Syndrome
    2. Median Nerve Injury
      1. Most common nerve injury after angulated, displaced Distal Radius Fracture (esp. Colles Fracture)
      2. Presents with thumb and index finger Muscle Weakness (test with opposition) and median sensory deficit
    3. Ligamentous Injury
      1. Thumb Ulnar Collateral Ligament Rupture
  8. Imaging: Wrist XRay
    1. See Forearm Fracture
    2. See Wrist XRay
  9. Management: General
    1. See Forearm Fracture
    2. External Fracture Reduction as indicated (see below)
    3. Fracture Immobilization initially with Splinting and then with Casting (see below)
    4. Orthopedic referral (see indications below)
      1. Within 3-5 day follow-up if further reduction or surgery otherwise needed
    5. Colles Fracture
      1. See Management below
    6. Smith Fracture (Reverse Colles Fracture)
      1. Volar angulation of distal radius fragment
      2. Fracture does not involve articular surface
        1. Traction and Manipulation
        2. Immobilization with Splinting and Casting
      3. Fracture involves articular surface
        1. Often involves volar subluxation of Carpal Bones
        2. Open Reduction and Internal Fixation (ORIF)
    7. Barton Fracture
      1. Distal Radius Fracture with dislocation)
      2. Open reduction and Internal fixation (ORIF) required (joint surface is involved)
      3. Evaluate for Compartment Syndrome, open Fracture
  10. Management: Anesthesia
    1. Conscious Sedation
      1. First-line Anesthesia unless skilled with hematioma block
      2. Fracture >4 hours prior (Hematoma Block less likely to be effective)
    2. Regional Anesthesia
      1. See Hand and Wrist Regional Anesthesia
    3. Local Anesthetic (sufficient if recent Fracture within prior 4 hours)
      1. Hematoma Block
        1. Needle inserted dorsally into Fracture hematoma
        2. Aspirate to confirm needle within hematoma
        3. Inject 5-10 ml local Anesthetic
      2. Inject tip of ulna as well
  11. Management: Manual Reduction (Technique 1)
    1. Assistant Position
      1. Grasps Forearm for countertraction
    2. Surgeon Position
      1. Grasps hand of affected wrist
      2. Thumb of other hand is placed on distal fragment
    3. Break up Impaction
      1. Wrist is hyperextended
    4. Dorsal Displacement and rotation is corrected
      1. Apply traction and countertraction
      2. Continue Thumb pressure on distal fragment
      3. Distal fragment dorsal cortex apposed with proximal
    5. Radial and Dorsal Angulation Corrected
      1. Apply Ulnar and Volar pressure over distal fragment
    6. Assess if Length is Restored
      1. Palpate radial styloid
  12. Management: Finger Trap Reduction (Technique 2)
    1. Anesthesia as above
    2. Break up Impaction by hyperextending wrist
    3. Place Index finger and thumb in finger traps
    4. Apply counterweight to upper arm
    5. Manipulate Fracture as above
  13. Management: Immobilization with Sugar Tong Splint
    1. Fluoroscopy (C-Arm) confirms alignment during Splinting
    2. Assistant applies steady traction at hand
    3. Wrist in slight pronation
    4. Avoid volar flexion of wrist
      1. Risk of Median Nerve Compression (Carpal Tunnel)
    5. Apply cast padding from MCP heads to above elbow
    6. Apply felt pad to volar surface of proximal fragment
    7. Splint with 10 cm wide, 12 plaster plies around elbow
    8. Dorsal half ends at MCP heads
      1. Mold over the distal fragment
    9. Volar half ends 1-2 cm distal to Fracture
    10. Maintain wrist in ulnar deviation
      1. Wrap a strip of plaster around distal splint
      2. Include distal MCP
      3. Keep strip proximal to distal palmar crease
    11. ACE Wrap Sugar Tong in place
  14. Management: Isolated Distal Radius Fracture
    1. Non-displaced Distal Radius Fracture
      1. See Forearm Fracture in Children (torus Fracture, buckle Fracture, greenstick Fracture)
      2. Immobilize in a Short Arm Cast for 3 weeks
      3. Removable splints have been used with similar outcomes to Castingin buckle Fracture (not greenstick Fracture)
        1. Williams (2013) Pediatr Emerg Care 29(5):555-9 +PMID:23603644 [PubMed]
    2. Displaced and overlapping Distal Radius Fracture
      1. Ulna Fracture also
        1. See Colles Fracture management above
      2. Ulna greenstick Fracture
        1. Complete Ulna Fracture for adequate reduction
        2. Manage as Colles Fracture
      3. Ulna intact or greenstick Fracture
        1. Do not re-Fracture
        2. Reduction may be quite difficult
          1. Maximally supinate wrist
          2. Digital pressure to replace the distal radius
        3. Alignment is paramount
          1. Re-align as best as possible
        4. Apposition is secondary to alignment
          1. Bayonet apposition is acceptable
  15. Management: Discharge Instructions
    1. Ice for 72 hours
    2. Elevation
    3. Maintain active Range of Motion of fingers and Shoulder
    4. Shoulder Sling
      1. Do not use longer than 2-3 days
      2. Risk of Shoulder stiffness
  16. Management: Orthopedic Referral Indications
    1. Images
      1. RadialFractureXRayMeasureLat.png
      2. RadialFractureXRayMeasureAP.png
    2. Distal radius dorsal angulation >5 to 10 degrees
    3. Distal Radius Measurements
      1. Line 1 (proximal transverse)
        1. Draw a horizontal, transverse line across the wrist at the distal aspect of the medial radius (ulna articulation)
      2. Line 2 (distal transverse)
        1. Draw a horizontal, transverse line across the wrist at the most distal aspect of the lateral radius (radial styloid)
        2. Radial length (Radial Height) represents the distance between line 1 and line 2
      3. Line 3 (Radial Inclination)
        1. Draw an oblique line between the medial distal radius and the lateral distal radius
        2. Radial Inclination represents the angle between Line 1 (proximal transverse) and this oblique Line 3
    4. Radial Inclination (normal measurements are for adults)
      1. Normal Radial Inclination: 23.6 +/- 2.5 degrees
      2. Acceptable inclination: 139-30 degrees
    5. Radial Height (radial length) shortening (normal measurements are for adults)
      1. Normal Radial Height: 11-12 mm
      2. Acceptable Radial Height: 8-18 mm
      3. Refer for >2 mm of radial shortening
    6. Young athletes, or those with occupation or hobby requiring highly functional hand and wrist
    7. Rotational deformity tolerated (criteria contingent on 50% apposition or greater)
      1. Age >8 years: Refer for >10 degrees rotational deformity
      2. Age <8 years: Refer for 15-20 degrees rotational deformity
    8. Other indications
      1. Fracture-dislocation
      2. Carpal Fracture
      3. Ulnar styloid Fracture
      4. Unstable Fracture or significantly comminuted
      5. Radiocarpal or radioulnar ligament injury or instability
      6. Scaphoid Fracture
      7. Fracture nonunion
      8. Epiphyseal Fracture suspected (children)
  17. Management: Follow-Up
    1. Days 1-2
      1. Phone: Is Splint too tight?
    2. Days 5-7
      1. Repeat Wrist XRay
        1. Strongly consider weekly XRay for first 3 weeks in displaced Fracture
      2. Apply Short Arm Cast
        1. Do not limit motion of the elbow or the metarcarpophalangeal joints
      3. Anticipate mal-union after swelling decreases
        1. Elderly
          1. Mal-union may be acceptable
          2. Re-manipulation may result in greater morbidity
        2. Young
          1. Malunion unacceptable
            1. Radial head shortening results in dysfunction
          2. Correction of mal-union
            1. Re-manipulation and closed reduction
            2. Open reduction and internal fixation (ORIF)
            3. External fixator
    3. Week 3
      1. Non-displaced Fracture follow-up and consider cast removal
    4. Weeks 4-6
      1. Cast may be removed
    5. Weeks 7-9
      1. Wrist support or cast until pain subsides
  18. References
    1. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
    2. Krishnan (2002) Orthopedics 25(2): 175-9 [PubMed]
    3. Patel (2021) Am Fam Physician 103(6): 345-54 [PubMed]
    4. Van Delft (2019) J Wrist Surg 8(5): 430-8 +PMID:31579555 [PubMed]

Colles' Fracture (C0009353)

Definition (MSH) Fracture of the lower end of the radius in which the lower fragment is displaced posteriorly.
Concepts Injury or Poisoning (T037)
MSH D003100
ICD10 S52.53
SnomedCT 157214000, 123971006
English Colles Fracture, Colles' Fracture, Fracture, Colles', Fracture Colles', Colles' Fracture [Disease/Finding], Fracture;Colles, colle fracture, colles fractures, colles fracture, colles' fracture, fracture of radius distal end colles', Colles' fracture (diagnosis), Colles' fracture, Colles' fracture (disorder), fracture; Colles, Colles; fracture, Colles
Dutch Colles-fractuur, Colles; fractuur, fractuur; Colles, Collesfraktuur, Fractuur, colles-
French Fracture de Colles, Fracture de Pouteau-Colles
Portuguese Fractura de Colles, Fratura de Colles
Japanese コーレス骨折, コーレスコッセツ
Swedish Colles fraktur
Czech Collesova fraktura, Collesova zlomenina
Finnish Tyypillinen värttinäluun murtuma
Russian LUCHEVOI KOSTI PERELOM KLASSICHESKII, KOLLISA PERELOM, LUCHEVOI KOSTI PERELOM TIPICHNYI, КОЛЛИСА ПЕРЕЛОМ, ЛУЧЕВОЙ КОСТИ ПЕРЕЛОМ КЛАССИЧЕСКИЙ, ЛУЧЕВОЙ КОСТИ ПЕРЕЛОМ ТИПИЧНЫЙ
Polish Złamanie Collesa
Hungarian Colles-féle törés, Colle-törés
Norwegian Fractura radii typica
Spanish fractura de Colles (trastorno), fractura de Colles, Fractura de Colles
German Colles-Fraktur
Italian Frattura di Colles
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Barton's fracture (C0272646)

Concepts Injury or Poisoning (T037)
ICD10 S52.56
SnomedCT 54645004
Dutch Barton's breuk, Barton; fractuur, fractuur; Barton
French Fracture de Barton
German Barton-Fraktur
Italian Frattura di Barton
Portuguese Fractura de Barton
Spanish Fractura de Barton, fractura de Barton (trastorno), fractura de Barton
Japanese バートン骨折, バートンコッセツ
Czech Bartonova zlomenina
English Barton fracture, fracture of radius distal end barton's, Barton's fracture of radius, Barton's fracture of radius (diagnosis), Barton's fracture, Barton's fracture (disorder), Barton; fracture, Barton, fracture; Barton
Hungarian Barton-törés
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Reversed Colles' fracture (C0347795)

Concepts Injury or Poisoning (T037)
ICD10 S52.54
SnomedCT 123972004
Dutch Smith-fractuur, Smith; fractuur, fractuur; Smith
French Fracture de Smith
German Smith-Fraktur
Italian Frattura di Smith
Portuguese Fractura de Colles invertida
Spanish Fractura de Smith, fractura de Colles invertida (trastorno), fractura de Colles invertida, fractura de Smith
Japanese スミス骨折, スミスコッセツ
Czech Smithova zlomenina
English smith fracture, smith's fracture, smiths fracture, fractures smith, fractures smith's, fracture of radius distal end smith's, Smith's fracture of radius (diagnosis), Smith's fracture of radius, Smith's fracture, Reversed Colles' fracture (disorder), Smith, Smith; fracture, fracture; Smith, Reversed Colles' fracture
Hungarian Smith-féle törés
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Fracture of distal end of radius (C0435585)

Concepts Injury or Poisoning (T037)
ICD10 S52.5
SnomedCT 208355005, 157217007, 263199001
English Frac distal end of radius, Fracture / lower end of radius, fracture of distal end of radius, fracture of radius distal end, Fracture of distal end of radius (diagnosis), Fracture of distal end of radius, Fracture of lower end of radius, Fracture of distal end of radius (disorder)
German Distale Fraktur des Radius
Korean 노뼈하단의 골절
Spanish fractura del radio distal (trastorno), fractura de radio distal (trastorno), fractura de radio distal, fractura del radio distal
Dutch Fractuur van ondereinde van radius
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Hutchinson's fracture (C1961067)

Concepts Injury or Poisoning (T037)
SnomedCT 426467005
English Hutchinson's fracture, Hutchinson's fracture (disorder), Chauffeur's fracture, Hutchinson fracture, fracture of radius distal end styloid process closed hutchinson's, Hutchinson's fracture (diagnosis)
Spanish fractura de Chauffeur, fractura de Hutchinson (trastorno), fractura de Hutchinson
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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