There are a number of ways to classify distal radius fractures. Classifications systems are devised to describe patterns of injury which will behave in predictable ways, to distinguish between conditions which have different outcomes or which need different treatments. Most wrist fracture systems have failed to accomplish any of these goals and there is no consensus about the most useful one.
At one extreme, a stable undisplaced extra-articular fracture has an excellent prognosis. On the other hand, an unstable, displaced intra-articular fracture is difficult to treat and has a poor prognosis without operative intervention. [1]
Eponyms such as Colles', Smith's, and Barton's fractures are discouraged.[ by whom? ]
An anatomic description of the fracture is the easiest way to describe the fracture, determine treatment, and assess stability.[ according to whom? ]
The articular joint's surface must be smooth for it to function properly. Irregularity may result in radiocarpal arthritis, pain, and stiffness. More than 1 mm of incongruity places the patient at a high risk for post-traumatic arthritis. Significant articular incongruity typically occurs in young patients after high energy injuries. If the surface is very irregular and cannot be reconstructed, then the only option may be a fusion of the joint.
A dorsal tilt of a distal radius fracture is shown in red in image at right. The angulation goes between: [2]
Sometimes, the diaphysis of the radius is hard to distinguish from the ulna, and a line between them (turquoise line in image) may be used instead. [3]
The angle normally has volar tilt of 11° to 12°. The most common fracture pattern usually demonstrates malalignment of this angle and collapse in a dorsal direction. A dorsal tilt of 0° (11° - 12° deviation from normal anatomic position) causes a substantial risk of developing pain and impaired function. [4] After closed reduction, a residual dorsal tilt of a maximum of 5° (16° - 17° deviation) is regarded as the maximal residual angle for a satisfactory result. [4]
The radial inclination of a distal radius fracture is shown in red in image at right. The angle is measured between: [5] [6]
Radial inclination is normally 21-25°. [7]
Radial length is an important consideration in distal radius fractures. Radial length should be between 9-12mm. [8] Distal radius fractures typically result in loss of length as the radius collapses from the loading force of the injury. With increasing relative lengthening of the uninjured ulna (positive ulnar variance), ulnar impaction syndrome may occur. Ulnar impaction syndrome is a painful condition of excessive contact and wear between the ulna and the carpus with an associated is a degenerative tear of the TFCC.
The system that comes closest to directing treatment has been devised by Melone. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex. [9]
Type | Description | Note |
---|---|---|
I | No displacement of medial complex
| Fracture is stable after closed reduction |
II | Unstable depression fracture of lunate fossa ("die-punch")
|
|
III | Type II fracture plus a 'spike' of the radius volarly | May impinge on median nerve |
IV | Split fracture
| Unstable |
V | Explosion injuries
| Often associated with diaphyseal comminution |
Though the Frykman classification system has traditionally been used, there is little value in its use because it does not help direct treatment. This system focuses on articular and ulnar involvement. The classification is as follows: [10]
Radius Fracture | Ulna Fracture | |
---|---|---|
Absent | Present | |
Extra-articular | I | II |
Intra-articular involving radiocarpal joint | III | IV |
Intra-articular involving DRUJ (distal radio-ulnar joint) | V | VI |
Intra-articular involving both radiocarpal & DRUJ | VII | VIII |
The Universal classification system is descriptive but also does not direct treatment. Universal codes are: [11]
Type | Location | Displacement | Sub-type |
---|---|---|---|
I | Extra-articular | Undisplaced | |
II | Extra-articular | Displaced | A: Reducible, stable B: Reducible, unstable C: Irreducible |
III | Intra-articular | Undisplaced | |
IV | Intra-articular | Displaced | A: Reducible, stable B: Reducible, unstable C: Irreducible D: Complex |
Widely used system that includes 27 subgroups. Three main groups based on fracture joint involvement (A - extra-articular, B - partial articular, C - complete articular). Classification further defined based on level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury. [9]
Simplified system developed in response to AO classification, intended to be based on injury mechanism with more treatment-oriented classifications (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision making on a case-by-case basis) [12]
Type | Description | Stability | Number of Fragments | Associated Lesions (see below) | Recommended Treatment |
---|---|---|---|---|---|
I | Bending fracture - metaphysis | Stable or unstable | 2 main fragments with variable metaphyseal comminution | Uncommon | Stable -> conservative Unstable -> percutaneous pinning or external fixation |
II | Shearing fracture - articular surface | Unstable | 2, 3, comminuted | Less uncommon | Open reduction with screw-plate fixation |
III | Compression fracture - articular surface | Stable or unstable | 2, 3, 4, comminuted | Common |
|
IV | Avulsion fracture, radiocarpal fracture, dislocation | Unstable | 2 (radial/ulnar styloids), 3, comminuted | Frequent (especially ligamentous injury) | Closed or open reduction with pin/screw fixation or tension wiring |
V | Combined fracture (high-energy injury) - Often intra-articular and open | Unstable | Comminuted | Always present | Combined treatment |
Note: Associated Lesions include carpal ligament injury, nerve injury, tendon damage, and compartment syndrome
The carpal bones are the eight small bones that make up the wrist (carpus) that connects the hand to the forearm. The term "carpus" and "carpal" is derived from the Latin carpus and the Greek καρπός (karpós), meaning "wrist". In human anatomy, the main role of the carpal bones is to articulate with the radial and ulnar heads to form a highly mobile condyloid joint, to provide attachments for thenar and hypothenar muscles, and to form part of the rigid carpal tunnel which allows the median nerve and tendons of the anterior forearm muscles to be transmitted to the hand and fingers.
The ulna or ulnal bone is a long bone found in the forearm that stretches from the elbow to the wrist, and when in anatomical position, is found on the medial side of the forearm. That is, the ulna is on the same side of the forearm as the little finger. It runs parallel to the radius, the other long bone in the forearm. The ulna is longer and the radius is shorter, but the radius is thicker and the ulna is thinner. Therefore, the ulna is considered to be the smaller bone of the two bones in the lower arm. The corresponding bone in the lower leg is the fibula.
In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.
The anatomical snuff box or snuffbox or foveola radialis is a triangular deepening on the radial, dorsal aspect of the hand—at the level of the carpal bones, specifically, the scaphoid and trapezium bones forming the floor. The name originates from the use of this surface for placing and then sniffing powdered tobacco, or "snuff." It is sometimes referred to by its French name tabatière.
The forearm is the region of the upper limb between the elbow and the wrist. The term forearm is used in anatomy to distinguish it from the arm, a word which is used to describe the entire appendage of the upper limb, but which in anatomy, technically, means only the region of the upper arm, whereas the lower "arm" is called the forearm. It is homologous to the region of the leg that lies between the knee and the ankle joints, the crus.
In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is common. This nerve is directly connected to the little finger, and the adjacent half of the ring finger, innervating the palmar aspect of these fingers, including both front and back of the tips, perhaps as far back as the fingernail beds.
The scaphoid bone is one of the carpal bones of the wrist. It is situated between the hand and forearm on the thumb side of the wrist. It forms the radial border of the carpal tunnel. The scaphoid bone is the largest bone of the proximal row of wrist bones, its long axis being from above downward, lateralward, and forward. It is approximately the size and shape of a medium cashew nut.
The radius or radial bone is one of the two large bones of the forearm, the other being the ulna. It extends from the lateral side of the elbow to the thumb side of the wrist and runs parallel to the ulna. The ulna is longer than the radius, but the radius is thicker. The radius is a long bone, prism-shaped and slightly curved longitudinally.
The triquetral bone is located in the wrist on the medial side of the proximal row of the carpus between the lunate and pisiform bones. It is on the ulnar side of the hand, but does not directly articulate with the ulna. Instead, it is connected to and articulates with the ulna through the Triangular fibrocartilage disc and ligament, which forms part of the ulnocarpal joint capsule. It connects with the pisiform, hamate, and lunate bones. It is the 2nd most commonly fractured carpal bone.
A Colles' fracture is a type of fracture of the distal forearm in which the broken end of the radius is bent backwards. Symptoms may include pain, swelling, deformity, and bruising. Complications may include damage to the median nerve.
A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and rapid-onset swelling. The ulna bone may also be broken.
A Smith's fracture, is a fracture of the distal radius.
The Galeazzi fracture is a fracture of the distal third of the radius with dislocation of the distal radioulnar joint. It classically involves an isolated fracture of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radio-ulnar joint; the injury disrupts the forearm axis joint.
Madelung's deformity is usually characterized by malformed wrists and wrist bones and is often associated with Léri-Weill dyschondrosteosis. It can be bilateral or just in the one wrist. It has only been recognized within the past hundred years. Named after Otto Wilhelm Madelung (1846–1926), a German surgeon, who described it in detail, it was noted by others. Guillaume Dupuytren mentioned it in 1834, Auguste Nélaton in 1847, and Joseph-François Malgaigne in 1855.
The distal radioulnar articulation is a synovial pivot joint between the two bones in the forearm; the radius and ulna. It is one of two joints between the radius and ulna, the other being the proximal radioulnar articulation. The joint features an articular disc, and is reinforced by the palmar and dorsal radioulnar ligaments.
The styloid process of the ulna is a bony prominence found at distal end of the ulna in the forearm.
The triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage discus (TFC), the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs).
The elbow is the region between the upper arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa, and the lateral and the medial epicondyles of the humerus. The elbow joint is a hinge joint between the arm and the forearm; more specifically between the humerus in the upper arm and the radius and ulna in the forearm which allows the forearm and hand to be moved towards and away from the body. The term elbow is specifically used for humans and other primates, and in other vertebrates forelimb plus joint is used.
Wrist osteoarthritis is gradual loss of articular cartilage and hypertrophic bone changes (osteophytes). While in many joints this is part of normal aging (senescence), in the wrist osteoarthritis usually occurs over years to decades after scapholunate interosseous ligament rupture or an unhealed fracture of the scaphoid. Characteristic symptoms including pain, deformity and stiffness. Pain intensity and incapability are notably variable and do not correspond with arthritis severity on radiographs.
Nissen-Lie classification is a system of categorizing Colles' fractures. In the Nissen-Lie classification system there are seven types of fractures. The classification system was first published in 1939.
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