Treating intra-articular distal radius fractures

Issue: BCMJ, vol. 60 , No. 1 , January February 2018 , Pages 17 WorkSafeBC

Distal radius fractures are the most frequent upper-extremity fracture, with an incidence of approximately 195.2 per 
100 000 patients per year,[1] most commonly in men younger than 50 and women older than 50.[2] From 1990 to 2015, WorkSafeBC saw 6025 workers with distal radius fractures. Extra-articular distal radius fractures, which are typically the result of a low-energy event, can be treated with conservative management, while intra-articular fractures may require surgery. In younger patients, intra-articular distal radius fractures are usually a result of a high-energy event, while in older patients, these injuries can result from a low-energy event such as a fall on an outstretched hand.

Initial management of distal radius fractures, whether intra-articular or not, involves neurovascular and soft-tissue assessment, reduction, and immobilization. Standard AP and lateral radiographs are sufficient in the majority of cases. Advanced imaging is used infrequently, most commonly where there is minimal intra-articular displacement and the clinician is contemplating the suitability of non-operative management. The American Academy of Orthopaedic Surgeons advises surgical reconstruction for fractures with post-reduction radial shortening > 3 mm, dorsal tilt > 10 degrees, or intra-articular displacement or step-off > 2 mm.[3] However, intra-articular step-off ≥ 1 mm has been shown to correlate with a lower Short Form 36 score and the development of arthritis.[4,5] As such, many surgeons may accept a 2 mm gap, but prefer < 1 mm articular incongruity.[6-8]

Volar distal radius plating, locking or nonlocking, is the most common surgical treatment of intra-articular distal radius fractures. These range from the more conventional single volar plate to fragment-specific plating systems. In cases where the surgeon feels internal fixation is not an option, such as extreme distal comminution, external fixation with ligamentotaxis may be used to achieve reduction.[8] This tends to be more salvage than internal fixation, but in a limited number of cases, may produce the best results for difficult fractures. Dorsal plating remains an option, but is infrequently used due to concerns of extensor tendon aggravation or rupture. As such, the indications are very limited and dorsal plating is usually removed once the fracture has healed, while volar implants are usually left in situ.

Postoperative immobilization, varying from casting to removable splints, is typically for 2 to 8 weeks. Timing depends on fracture/construct stability, bone quality, patient factors, and surgeon preference. Patients may require physiotherapy for motion and strengthening. Full weight-bearing is usually started 3 months postoperatively based on radiographic and clinical union; activity as tolerated may begin once full range of motion and fracture union have been achieved.

If you have questions regarding an injured-worker patient with an intra-articular distal radius fracture, please call a medical advisor in your nearest WorkSafeBC office.
—Derek Smith, MD, FRCSC
WorkSafeBC Orthopedic Specialist Advisor

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.


References

1.    Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006;37:691-697.
2.    MacIntyre NJ, Dewan N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. J Hand Ther 2016;29:136-145.
3.    Hammert WC, Kramer RC, Graham B, Keith MW. Appropriate use criteria for treatment of distal radius fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2013.
4.    Trumble TE, Culp RW, Hanel DP, et al. Intra-articular fractures of the distal aspect of the radius. Instr Course Lect 1999;48:465-480.
5.    Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19:325-340.
6.    Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach. J Bone Joint Surg Br 2000;82:79-86.
7.    Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg Am 1991;16:375-384.
8.    Bini A, Surace MF, Pilato G. Complex articular fractures of the distal radius: the role of closed reduction and external fixation. J Hand Surg Eur Vol 2008;33:305-310.

Derek Smith, MD, FRCSC. Treating intra-articular distal radius fractures. BCMJ, Vol. 60, No. 1, January, February, 2018, Page(s) 17 - WorkSafeBC.



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