Gregory Waryasz MD, Ashley Davidoff MD 

The Common Vein Copyright 2011

Definition

Fractures of the radius  are usually caused by  a fall on the outstretched hand.  Radial shaft and distal radial fractures are commonly associated with direct trauma and falls.

Radial head fractures occur when the radial head is compressed into the capitellum.  The Mason Classification of radial head fractures is based upon the displacement, comminution, and dislocation status of the elbow.  Type I is a nondisplaced fracture of the radial head.  Type II is a displaced fracture with impaction, depression, and/or angulation. Type III is a comminuted fracture of the radial head.  Type IV is a radial head fracture with an elbow dislocation.  An Essex-Lopresti lesion is a radial head fracture or distal radial ulnar joint dislocation with a disruption of the interosseous ligament.

The radial shaft can break either in isolation or in combination with the ulnar shaft.  The fractures of both bones are classified as closed vs open, by location, by the number of fragments, displacement, angulation, and rotational alignment.  Fractures can be comminuted, segmental or multifragmental.  Isolated radial shaft fractures can occur in the proximal two-thirds of the radius.  A Galeazzi or Piedmont fracture is a radial diaphyseal fracture at the junction of the middle and distal thirds with an injury to the distal radioulnar joint.

The distal radius has a few different classification systems.  The ulnar styloid can be fractured along with the distal radius. The eponyms associated with distal radius fractures are Colles fracture, Smith fracture, Barton fracture, Chauffeur’s fracture (radial styloid fracture), The Colles fracture is an extra- and intra-articular distal radius fracture with combinations of dorsal angulation, dorsal displacement, radial shift, and radial shortening.  The Smith fracture or reverse Colles fracture is a distal radius fracture with volar angulation.  The Barton fracture is a fracture-dislocation or subluxation where the dorsal or volar rim of the distal radius is displaced.  The Chauffer’s fracture or radial styloid fracture is an avulsion fracture with intact extrinsic ligaments to the styloid. It can be associated with scapholunate dissociation or perilunate dislocation.

The fracture may be complicated in the acute phase by neurovascular injury, or in the subacute or chronic phases by nonunion, malunion, infection, osteonecrosis, or osteoarthritis. More specific to the radius are complications that include stiffness, reflex sympathetic dystrophy, Volkmann ischemia, posttraumatic radioulnar synostosis, tendon injuries, midcarpal instability, and compartment syndrome.

The diagnosis of this injury is usually made by a combination of physical examination and x-ray imaging.

Imaging includes the use of plain x-rays, and if indicated CT-scan, or MRI.

Radial head fracture treatment aims to correct range of motion. Nondisplaced fractures can be treated non-operatively with a sling and early range of motion within 24 to 48 hours.  Displaced radial head fractures and those involving dislocation are treated surgically with ORIF or a prosthetic radial head replacement.

Most fractures of both the radial and ulnar shaft in adults are treated with open reduction and internal fixation.

Proximal radius fractures that are nondisplaced can be managed nonoperatively with a long arm cast.  Displaced fractures are treated with ORIF and a dynamic compression plate.

Galeazzi fractures require ORIF with plate and screw fixation due to high failure rate with closed treatments.  An unstable distal radioulnar joint can be fixed with K-wires.

Distal radius fractures are initially treated with closed reduction and splinting.  If the reduction is satisfactory, some patients do not require surgery.  Unstable fractures or non-reducible fractures undergo ORIF with plate and screw fixation or percutaneous pinning. Sometimes an external fixation device is necessary to help get the bones out to length.

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radius fracture shape deformity elevation of fat pad hemarthrosis sail sign shape radial head fracture Courtesy Ashley Davidoff MD copyright 2008 all rights reserved 41882c05b.8s

Fracture through the Shaft of the Radius and Ulna

The transverse fractures of the shafts of both the radius and ulna are easily appreciated caused by a single force across the forearm arm resulting in simple transverse fractures of both. The forearm is now placed in a cast with significant improvement of the alignment of the radius and moderate improvement of alignment of the ulna. Courtesy Ashley Davidoff MD 72826.800 72824.800

Normal (left) and Colle’s Fracture (right)

frx line is almost always on volar side dx Colle’s fracture Courtesy Ashley Davidoff MD 70034c03

Dorsal Malalignment Ventral Angulation

The image demonstrates the lateral projection of an X-ray from a 40 year old man who fell on an outstretched hand and sustained a fracture of the distal radius. This fracture is called a Colle’s fracture and is characterized by its location being about 1.5 inches from the distal end of the radius, at the weak portion of the distal radius where the diaphysis meets the metaphysis called the at the cortico-cancellous junction. Additionally it is characterized by dorsal displacement of the distal fracture fragment but with ventral angulation of the fracture. The shape of the combined appearance of the proximal fragment, distal fragment and the carpals and metacarpals on clinical and lateral radiological examination is reminiscent of a dinner fork and hence the deformity is called dinner fork deformity. The anatomical position of the forearm is with the palm of the hand facing forward (anteriorly), and so the palm of the hand is the ventral surface. The back of the hand is called the dorsal or posterior surface. The direction of the forces and weight pushes on the wrist so that the radius gets pushed to the anatomically named ventral portion of the forearm and the distal fragment attached to the wrist gets pushed dorsally. Courtesy Ashley Davidoff Copyright 2011 101288c02.8

Distal Fracture of the Radius CT Reconstruction

The reconstructed CT scan of the wrist is shown in A-P (a,b) lateral (c,d) and 3D rendering (e,f). The images exemplifiy the pathogenesis of a compression force and subsequent impaction fracture of the shaft (orange in b,d,f) into the broader distal radius (green b,d,f). The mechanism of injury is falling on to an outstretched hand with an excessive force directed along the shaft of the radius resulting in an almost transverse fracture. In this case, the lateral examination shows near anatomical alignment, but demonstrates with impaction of the proximal radius into the distal portion. Courtesy Philips Medical Systems 88374c02.9s

References

Davis MF, Davis PF, Ross DS. Expert Guide to Sports Medicine. ACP Series, 2005.

Elstrom J, Virkus W, Pankovich (eds), Handbook of Fractures (3rd edition), McGraw Hill, New York, NY, 2006.

Koval K, Zuckerman J (eds), Handbook of Fractures (3rd edition), Lippincott Williams & Wilkins, Philadelphia, PA, 2006.

Lieberman J (ed), AAOS Comprehensive Orthopaedic Review, American Academy of Orthopaedic Surgeons, 2008.

Moore K, Dalley A (eds), Clinically Oriented Anatomy (5th edition), Lippincott Williams & Wilkins, Philadelphia, PA, 2006.

Wheeless’s Textbook of Orthopaedics: Fractures of the Radius and Ulna Menu (http://www.wheelessonline.com/ortho/fractures_of_the_radius)