Aust. J.

Rural Health (1999) 7, 121–126

Review Article OA 226 EN

AN OVERVIEW OF DISTAL RADIAL

FRACTURES
Janak A. Mehta1 and Gregory I. Bain1,2
1 Modbury Public Hospital, 2Royal Adelaide Hospital, Adelaide, and 2University of Adelaide,
Adelaide, South Australia, Australia

ABSTRACT: Fractures of the distal radius include a wide spectrum of fracture patterns. As well as involving the
distal radius, these injuries can involve the wrist, the distal radio-ulnar joint and the distal ulna. The management of
these injuries is consequently diverse, ranging from a plaster cast to advanced surgery. The principles of treatment are
to reduce and maintain the reduction by restoring the radial height, volar tilt and intra-articular step. The acceptable
reduction is to have radial height to within 2 mm of the ulnar, volar tilt greater than 0° and intra-articular step less
than 1 mm. The present paper reviews the current concepts in the diagnosis, management and complications of distal
radial fractures.
KEY WORDS: fracture, radius, wrist.

INTRODUCTION unique in that it articulates with the lunate distally and on

Fractures of the distal radius involve the distal 2.0–2.5
cm of the distal end of the radius, which is essentially
metaphyseal (cancellous bone) in the adult (Fig. 1).1
These fractures are more common in women and increase
in incidence with age.2 These injuries can cause signifi-
cant disability if not managed properly.3–9 Recognition of
the type of fracture is vital to determine the mode of man-
agement. While some fractures may be managed conserv-
atively, others may require specialised surgical
intervention to restore the bony morphology.4–9
ANATOMY
The distal radial articular surface is composed of the
scaphoid and the lunate fossae, separated by a low median
ridge. These fossae articulate with the scaphoid and the
lunate bones of the carpus (Fig. 2). The lunate fossa is
Correspondence: Gregory I. Bain, 206 Melbourne Street,
North Adelaide, SA 5006, Australia.
Email: <orthodoc@ctel.com.au>
J.A. Mehta, MS(Orth), DNB(Orth). G.I. Bain, FRACS, FAOrthA.
its ulnar aspect with the distal ulna to form the distal
radio-ulnar joint.10 The triangular fibrocartilage (TPC) is
interposed between the distal end of the ulna and the car-
pus. It originates on the ulnar border of the distal radius
(border of the lunate fossa) and is inserted at the base of
the ulnar styloid (Fig. 2). On the radial aspect, the radial
styloid overhangs the scaphoid and its tip lies distal to the
ulnar styloid.
Radial height: The distal articular surface of the
radius is close to the level of the distal ulnar articular sur-
face.
Volar tilt: The articular surface is inclined volarly in
the sagittal plane by 1°.
Radial inclination: The articular surface slopes
ulnarly in the coronal plane by 22°11 (Fig. 1).
Pathoanatomy
Extra-articular fractures
Extra-articular fractures often result in dorsal tilt, dorsal
displacement, radial tilt and shortening of the distal frag-
ment. The dorsal tilt results in compression of the dorsal
cortex of the distal radius and, thereby, comminution.
Associated fractures of the ulnar styloid are common.

Accepted for publication December 1998. The resulting deformity, if not corrected, can result in
122
pain and dysfunction of the wrist and the distal radio-
ulnar joint with limited pronation and supination, which
will interfere with the function of the hand.5
Intra-articular fractures
Intra-articular fractures of the distal radius usually follows
a predictable pattern, resulting in four fragments (Figs
3,4). These fragments are the radial styloid, the radial
shaft and two lunate fossa fragments.12 The intra-articular
disruption may be such that the articular surface is
sheared and split to produce a fracture subluxation of the
wrist (Fig. 5). These are very unstable fractures and do
poorly with only a plaster. They are usually managed with
a plate.
An intra-articular fracture with a step of 2 mm or more
has been associated with a high incidence of osteoarthritis
of the wrist joint (Fig. 6).3 The authors recommend that
the clinician aim for a 0 mm step and only accept a 1 mm
step.13
Occasionally, intracarpal injuries, such as disruption
of the scapholunate ligament (resulting in scapholunate
A U S T R A L I A N JO U R N A L O F R U R A L H E ALT H
FIGURE 1: The distal radius.
FIGURE 2: Anatomy of the distal radius.
diastasis-widening), TFC tears or fracture of the scaphoid,
may be concomitantly present.14–16 Isolated fractures of
the radial styloid should be viewed with caution. They
may be associated with other injuries such as perilunate
fracture dislocations or scapholunate ligament injuries.
Classification
Several classification systems have been proposed.17,18
For simplicity we propose that distal radial fractures
should be described primarily as: (i) intra/extra-articular;
(ii) reduced or displaced; and (iii) fractures with associ-
ated injuries.
MANAGEMENT
Investigations
Clinical
The knowledge of the nature of injury is essential. Low-
energy injuries are sufficient to cause fractures in an
elderly patient with osteoporosis. High energy is required
to produce fractures in the young adult. Compartment syn-
D I STAL RADIAL FRACTURES : J . A. M EHTA AND G . I . B A I N
FIGURE 3: Radiograph of an intra-articular distal radial
fracture.
drome as well as acute compression of the median nerve
in the carpal tunnel have been described in association
with distal radial fractures. Therefore, the neurovascular
status should be noted and subsequently monitored. The
hand and the elbow should be examined to rule out any
associated injury.
Radiology
Plain radiographs, including postero-anterior and the lat-
eral projection, are required to determine the extent and
the nature of injury.19
TREATMENT
The principles of treatment are simple:
(1) Reduce the fracture by restoring the radial height,
volar tilt and intra-articular step. The acceptable reduc-
123
FIGURE 4: Typical four-part intra-articular distal radial
fracture.
tion is to have radial height to within 2 mm of the ulnar-
volar tilt greater than 0° and intra-articular step less than
1 mm (Table 1).
(2) Maintain the reduction with suitable means until the
fracture heals.
(3) Monitor the position of the reduction until fracture
union.
(4) Rehabilitate the patient.
If the fracture is only minimally displaced and fulfils
the aforementioned criteria, then only a cast is required. If
these criteria are not achieved, then a closed reduction is
required. If a closed reduction is unsuccessful, then other
options such as an open reduction is required. Closed
reduction is performed under general anaesthesia or intra-
venous regional anaesthesia. The traction is applied, the
deformity increased (to unlock the fracture) and then the
deformity is corrected. A below elbow cast is applied with
moulding over the volar mid-forearm and dorsally over the
distal fragment. The cast extends from the distal palmar
crease to just distal of the elbow flexion crease (Fig. 7).
There should be no impingement of the cast in full elbow
flexion or when the patient makes a full fist. The most
common problems are placing the wrist (not the fracture)
TABLE 1: Acceptable reduction
Radial shortening ≤ 2 mm
Volar tilt ≥ 0°
Intra-articular step ≤ 1 mm
124
in flexion and not providing enough space for the thumb.
Fluoroscopy or radiographs should be performed to con-
firm the position obtained.13
Percutaneous Kirschner wires are being used more
commonly and are a simple technique that can maintain
FIGURE 5: Radiograph of an unstable volar distal radial
fracture that will require open reduction and plate fixation.
A U S T R A L I A N JO U R N A L O F R U R A L H E ALT H
the closed reduction (Fig. 8).20,21 Highly unstable fractures
may require additional bone grafting and/or an external
fixator (Fig. 9).22 The external fixator maintains distraction
across the fracture site, thus preventing collapse.
FIGURE 6: Radiograph of an intra-articular step following
distal radial fracture and resulting osteoarthrosis.
FIGURE 7: Below elbow cast with
moulding over volar forearm and dorsal
distal fragment.
D I STAL RADIAL FRACTURES : J . A. M EHTA AND G . I . B A I N
Postoperative management
Following the reduction and stabilisation of the fracture, a
check radiograph is performed. The hand and forearm are
strictly elevated above the heart for 48 h postoperatively.
Neurovascular status of the injured upper limb is moni-
tored for 24 h. Antibiotics may be administered for com-
pound fractures. Mobilisation of the fingers and the
shoulder is commenced immediately postoperatively and
maintained.
Follow-up at 1 and 2 weeks is recommended, with new
FIGURE 8: K-wire fixation of distal radius fracture.
125
radiographs, to ensure satisfactory positioning of the frac-
ture. If the fracture has re-displaced, then it should be re-
manipulated and fixation used to maintain the reduction.
The fracture usually heals by 6–8 weeks, at which
time the cast (and Kirschner wires or external fixator) can
be removed and mobilisation commenced.
COMPLICATIONS
Acute complications of distal radial fractures include
compartment syndrome and carpal tunnel syndrome.
Long-term complications include stiffness of the wrist and
fingers; reflex sympathetic dystrophy; painful and
restricted range of movement, including supination and
pronation; ulnar-sided wrist pain (usually because of
symptomatic triangular fibrocartilage tear); and arthritis of
the wrist.3,5,7,17,23
In conclusion, the treatment of distal radial fractures
aims to achieve an acceptable reduction. Regular follow-
up and rehabilitation complete the management of these
injuries.
ACKNOWLEDGEMENTS
We thank Ron Heptinstall for preparation of the manu-
script and illustrations, Dedrie Craig for illustrations and
Ruth Finn (Orthopaedic ward, Royal Darwin Hospital,
Darwin, Australia) for reading the manuscript.
REFERENCES
1 Colles A. On the fracture of the carpal extremity of the
radius. Edinburgh Medicine and Surgery Journal 1814; 10:
182–186.
2 Fernandez DL, Jupiter JB. Epidemiology, mechanism, classi-
fication. In: Fractures of the Distal Radius: A Practical
FIGURE 9: Fixation with an external
fixation, which is used for fractures with
gross comminution.
126
Approach to Management. New York: Springer-Verlag,
1996; pp. 23–52.
3 Knirk JL, Jupiter JB. Intra-articular fractures of the distal
end of the radius in young adults. Journal of Bone and Joint
Surgery 1986; 68-A: 647–659.
4 Bradway JK, Amadio PC, Cooney WP. Open reduction and
internal fixation of displaced, comminuted intra-articular
fractures of the distal end of the radius. Journal of Bone
and Joint Surgery 1989; 71-A: 839–847.
5 McQueen M, Caspers J. Colles fracture: Does the anatomi-
cal result affect the final function? Journal of Bone and
Joint Surgery 1988; 70-B: 649–651.
6 Fernandez DL. Limited open reduction of the joint surface
of the distal radius. In: Vastamaki M (ed.). Current Trends in
Hand Surgery. Amsterdam: Elsevier Science, 1995; pp.
139–144.
7 Ark J, Jupiter JB. The rationale for precise management of
distal radius fractures. Orthopedic Clinics of North America
1993; 24: 205–209.
8 Leibovic SJ, Geissler WB. Treatment of complex intra-
articular distal radius fractures. Orthopedic Clinics of North
America 1994; 25: 685–706.
9 Bass RL, Blair WF, Hubbard PP. Results of combined
internal and external fixation for the treatment of severe
AO-C3 fractures of the distal radius. Journal of Hand
Surgery 1995; 20A: 373–381.
10 Fernandez DL, Jupiter JB. Functional and radiographic
anatomy. In: Fractures of the Distal Radius: A Practical
Approach to Management. New York: Springer-Verlag,
1996; pp. 54–65.
11 van der Linden W, Ericson R. Colles’ fracture: How should
its displacement be measured and how should it be immo-
bilized? Journal of Bone and Joint Surgery 1981; 63-A:
1285–1288.
12 Melone Jr CP. Distal radius fractures: Patterns of articular
fragmentation. Orthopedic Clinics of North America 1993;
24: 239–253.
A U S T R A L I A N JO U R N A L O F R U R A L H E ALT H
13 Bain GI, Hunt J, Mehta JA. Operative fluoroscopy in hand
upper limb surgery: First 100 cases. Journal of Hand
Surgery. British Volume (Edinburgh) 1997; 22B: 656–658.
14 Roth JH, Richards RS, Bennett JD, Milne Jr K. Soft tissue
injuries in distal radial fractures. In: Vastamaki M (ed).
Current Trends in Hand Surgery. Amsterdam: Elsevier
Science, 1995; pp. 151–156.
15 Geissler WB, Freeland AE, Savoie FH et al. Intracarpal
soft tissue lesions associated with an intra-articular fracture
of the distal end of the radius. Journal of Bone and Joint
Surgery 1996; 78A: 357–365.
16 Saffar P. Radial styloid fractures associated with scapholu-
nate ligament sprains. In: Saffar P & Cooney III WP (eds).
Fractures of the Distal Radius. London: Martin Dunitz,
1995; pp. 160–166
17 Frykman G. Fracture of the distal radius including seque-
lae–shoulder–hand–finger syndrome, disturbance in the
distal radio-ulnar joint and impairment of nerve function: A
clinical and experimental study. Acta Orthopaedica Scandi-
navica Supplementum 1967; 108: 30–31.
18 Muller ME, Nazarian S, Koch P. Classification AO Der
Fracturen. Berlin: Springer, 1987.
19 Johnston GHF, Friedman L, Kriegler JC. Computerized
tomographic evaluation of acute distal radial fractures.
Journal of Hand Surgery 1992; 17A: 738–744.
20 Mah T, Atkinson RN. Percutaneous Kirshner wire stabiliza-
tion following closed reduction of Colles’ fractures. Journal
of Hand Surgery 1992; 17B: 55–62.
21 Kapandji AI. Treatment of articular distal radial fractures
by intrafocal pinning with arum pins. In: Saffar P & Cooney
III WP (eds). Fractures of the Distal Radius. London: Mar-
tin Dunitz 1995; pp. 160–166.
22 Leung KS, Shen WY, Leung PC. Ligamentotaxis and bone
grafting for comminuted fractures of the distal radius. Jour-
nal of Bone Joint Surgery 1989; 71B: 838.
23 Cooney WP, Dobyns JH, Linscheid RL. Complications of
Colles’ fractures. Journal of Bone Joint Surgery 1980; 62A:
613–619.