Distal Radius Fractures

What is Distal Radius Fractures?

Emergency departments and primary care clinics often deal with orthopedic issues. Therefore, it’s important for healthcare providers to be comfortable handling basic orthopedic problems. A common type of fracture involves the distant part of the forearm, known as the distal radius (DR). These fractures are becoming more common as people live longer, which means more people are at risk.

These types of fractures mostly occur in children, teenagers, and older adults. How these fractures occur, how they’re treated, and the potential complications can vary depending on the patient’s age. That’s why it’s vital for healthcare providers to understand these differences. They need to know which fractures require immediate attention and when to refer patients for more thorough care.

It’s also vital for these providers to understand the structure of the forearm and wrist. We recommend that readers review these topics alongside reading this article. This article will discuss the cause and occurrence rate, as well as the specific types of fractures, treatment strategies, and complications of distal radial fractures.

What Causes Distal Radius Fractures?

Distal radial fractures, or breaks in the far end of the forearm bone, can happen due to a variety of traumas. Some common types of these fractures include Smith’s, Colle’s, Torus/Buckle, Greenstick, Die-punch, and isolated radial shaft fractures. These usually occur when someone falls onto an outstretched hand.

In older adults, these fractures often result from low-energy falls, such as from standing or sitting height. They tend to be complex fractures involving many bone fragments and the joint, and therefore don’t typically fit into the usual classification systems.

For children and teens, these fractures usually happen after high-energy falls, like those that occur on a playground or during sports.

There are also more complex types of wrist and forearm fractures, including Galeazzi fracture-dislocation, both bone fractures, radial styloid fractures, and Barton’s and Chauffeur’s fractures. The reasons behind these fractures are often more complicated than single distal radial fractures.

Risk Factors and Frequency for Distal Radius Fractures

Distal radial fractures, often happening alone or with other injuries, are very common. In the United States, about 67 out of every 10,000 people have a fracture in their upper extremity each year. Out of these, around 25% are distal radial and ulnar fractures. Worldwide, these kinds of fractures are becoming more prevalent each year. For instance, a study from the US in 1998 noticed a 17% increase in distal radial fractures from 1945 to 1994. Another study from Sweden in 2017 found an annual increase of 2% in men and 3.4% in women aged 50-59 between 1999 and 2010.

Many factors might be responsible for this increase, such as growing rates of childhood obesity, longer lifespans with health conditions like osteoporosis, and more participation in sports. Improved access to healthcare may also be a factor as more fractures are reported. However, it’s also possible that the actual number of fractures has remained consistent, and we’re just better at detecting and reporting them.

These fractures can happen at any age, but there are two age groups where distal radial fractures are most common: children under 18 and adults over 50. Children aged 12-14 (boys) and 10-12 (girls) are particularly prone to these fractures because their bones are growing rapidly but aren’t yet fully mineralized, leaving them vulnerable to fractures from minor accidents. About 64% of these fractures occur in boys, often in the spring, and typically caused by falls.

The other peak incidence of distal radial fractures happens in adults over 50, particularly in Caucasian women over 65. Osteoporosis, affecting 40% of postmenopausal women, is a common risk factor. A measure known as the ‘T-score’ compares bone mineral density to that of a healthy 30-year-old, and a score of less than -2.5 (which indicates osteoporosis) means around a 15% risk of a fragility fracture in the next 10 years. Other risk factors for these fractures in people over 50 include a history of falls, fractures after the age of 50, use of corticosteroids, advanced age, and dementia. Each additional risk factor increases the likelihood of a distal radial fracture. This type of fracture is twice as common in women with diabetes.

Signs and Symptoms of Distal Radius Fractures

Distal radial fractures, or breaks in the bone at the wrist end of the forearm, can cause pain in the lower part of the arm. These fractures can occur in isolation or as part of multiple injuries from an accident or trauma. It’s important not to focus only on the obvious wrist issue, but to also check for other potential life-threatening injuries. This is particularly significant with children, who might not be able to clearly express their symptoms or explain what happened. They may seem fine and just favor their non-injured arm, which may be the only hint of an underlying fracture.

The evaluation of a patient with a suspected distal radial fracture should consider several aspects:

• The circumstances of the injury, how long the patient has had symptoms, and how severe these symptoms are
• Details about the patient’s dominant hand, profession, and health conditions as these could influence treatment decisions
• Possible complications, indicated by symptoms like numbness, tingling, weakness, or a change in limb color. The median nerve, which is often damaged in wrist fractures, can cause symptoms similar to acute carpal tunnel syndrome
• In children, the possibility of non-accidental injuries should always be assessed

A focused physical examination is crucial in evaluating the injury:

• Inspect the exterior condition of the lower arm for visible deformities
• Check the skin for any tearing or cuts that could indicate an open fracture, which needs immediate attention
• The forearm should feel soft, suggesting no compartment syndrome (a serious condition caused by pressure buildup from internal bleeding or swelling of tissues)
• The pulse in the wrist should be strong and identical in both arms
• The blood refill time, observed by pressing a fingernail until it turns white and then monitoring how quickly it returns to red, should be less than 2-3 seconds
• Tests can be performed to ensure the nerves are functioning. Motor function tests include extending the finger joints against resistance, moving the thumb against resistance, and spreading the fingers against resistance. Sensation can be tested by examining if the patient can distinguish between two close but separate points with their eyes closed. The acceptable distance varies slightly, but is typically less than 5mm, or 6mm in older adults
• Also, the doctor should perform a detailed evaluation of the elbow, hand and the wrist’s connection to the forearm bones to ensure no additional injuries have been missed

Testing for Distal Radius Fractures

If you’ve injured your wrist and your doctor suspects a distal radial fracture, they will first take your history and perform a physical examination. Based on these early assessments, they will then decide which imaging tests should be done. In most cases, X-rays are the standard imaging technique used to diagnose distal radial fractures. The X-ray can show if any changes have occurred in the wrist bones, such as changes in height and inclination of the radial bone, shifting or tilt in the wrist joint, fractures of the ulnar styloid bone, or widening of the distal radioulnar joint.

In certain situations where the X-rays aren’t decisive, but your symptoms and physical examination suggest a fracture, a Computed Tomography (CT) scan could be carried out. This advanced imaging technique can also help in planning surgeries, specifically for fractures that involve the joint surfaces. Magnetic Resonance Imaging (MRI), though, doesn’t usually add much value to the diagnosis of a distal radial fracture, but can be useful if it’s suspected that ligaments may have been damaged. Typically, MRIs are carried out within the outpatient setting rather than in the Emergency Department and are more commonly used by orthopedic specialists.

After imaging your wrist, doctors use classification systems to help understand the severity of your distal radial fracture. One such system is the Frykman Classification, which grades these fractures based on factors like involvement of different joints and the presence of any ulnar styloid fractures. However, it doesn’t consider other important factors such as bone fragmentation (comminution) or displacement. Some critics of these systems say they don’t offer enough guidance on how to treat the fracture, aren’t consistent between different observers, and can be difficult to use. Consequently, there’s no agreement among experts on the best classification system to use for distal radial fractures.

When discussing your X-ray results with an orthopedic surgeon, it’s usually better to describe the fracture using specific anatomical terms rather than a classification grade. Descriptions of the fracture’s location, whether it’s an open or closed fracture, its impact on the blood supply and nerves, and the extent of the displacement, fragmentation, compaction, and rotation are more helpful for planning treatment.

Treatment Options for Distal Radius Fractures

When someone has a confirmed distal radial fracture (a break near the end of the radius bone in the arm), certain steps have to be taken. This includes managing pain, immobilizing the area, and checking for any problems involving open fractures – where the bone has broken the skin – or issues with the nerves and blood supply. If someone is showing symptoms like decreased sensation, movement deficits or heightened tension in their forearm, they will need a urgent examination by an orthopedic specialist. If the arm has no pulse, a doctor specializing in bones and a vascular surgeon should examine it right away.

Open fractures invite an immediate evaluation by an orthopedic specialist. The seriousness of open fractures is evaluated according to the Gustillo-Anderson Scale, which rates from Grade I to Grade IIIc. Grade I refers to a small wound with minimal contamination and tissue damage. Grade IIIc refers to serious tissue damage and injury to arteries. Open fractures rated II or above often require surgical cleaning, though the decision rests with the surgeon. All open fractures require a tetanus shot and antibiotics. If you’re allergic to penicillin, they’ll give you a different antibiotic. For Grade 3 or above, they’ll give you another antibiotic called gentamicin.

Pain management for each patient will be unique. Some patients initially need strong painkillers, although others can be successfully treated with pills. Sometimes, the area around the fracture might be numbed or the patient sedated. Children might be given a combination of medicines through the nose.

Most simple distal radial fractures can be set back in place without surgery, using traction. A doctor can use different methods to apply this pulling pressure, from finger traps to hanging weights from the wrist. Once the fracture is reset, the arm is stabilized with a splint or cast. After this, the position of the bone is checked with an X-ray.

Finally, the treatment for each specific type of distal radial fracture varies. Some fractures can be well-managed using the methods above, but other, more complex fractures may require surgery. In children, for instance, these fractures are often less severe and can heal without surgery. On the other hand, complex fractures involving the wrist joint or a dislocated injury usually require surgical treatment. Some types of fractures won’t need surgery, but they should still be examined by a doctor within 7 days. Fractures in children sometimes involve the growth plate and should be monitored regularly, as damage to this area can affect bone growth.

For incomplete fractures in children, treatment depends on the type of fracture. For example, for torus fractures, no intervention may be necessary and they typically heal within three weeks. Greenstick fractures are usually managed conservatively, with minimally displaced or non-displaced fractures being treated with a cast or splint. Children with these fractures can also tolerate different degrees of angulation, which is the angle at which the break occurs. Lastly, fractures involving the growth plate in children, known as Salter-Harris fractures, can sometimes be managed with casting, while higher-grade fractures may require surgery. These types of fractures need to be carefully evaluated to prevent permanent damage to the growth plate.

What else can Distal Radius Fractures be?

When a doctor is trying to figure out what type of wrist or hand injury you might have, they consider a long list of possibilities that could cause symptoms similar to a regular wrist fracture. These can include:

• Colles’ fracture (a break in the bone at the end of the arm, near the wrist)
• Smith’s fracture (a fracture at the same location as Colles’ fracture, but the bone affects points in the opposite direction)
• Barton fracture (a fracture at the wrist involving a dislocation)
• Chauffeur’s fracture (also known as a radial styloid fracture, an injury to the bone on the thumb side of the wrist)
• Isolated distal radial fracture (a break in the larger bone of the forearm, close to the wrist)
• Both bone fracture (a break in both the ulna and radius bones in the forearm)
• Scaphoid fracture (a break in one of the small bones in the wrist)
• Scaphoid dislocation (when this same small wrist bone gets moved out of place)
• Distal radioulnar joint dislocation (when the joint between the two forearm bones at the wrist gets dislocated)
• Carpal ligamentous disruption (an injury to the ligaments in the wrist)
• Die-punch fracture (a break in the end of the radius bone in the wrist)
• Proximal metacarpal fracture (a break in the long bones in the hand near the wrist)
• Monteggia fracture (a fracture of the ulna bone in the forearm with dislocation of the wrist)
• Galeazzi fracture (a break in one forearm bone, with dislocation of the wrist bone)
• Greenstick fracture (a partial break in the bone common in children)
• Torus or buckle fracture (where the bone buckles rather than breaks)
• Salter-Harris fracture (a break at the end of children’s long bones that affects the growth plate)

The doctor will thoroughly examine the injury and may also order some tests to correctly identify the type of fracture or injury.

What to expect with Distal Radius Fractures

Simple fractures at the end of the radius bone in the arm usually heal well without any lasting complications. However, more complicated fractures can have a variety of outcomes that depend on several factors. These complicated fractures have a higher risk of not healing correctly or at all, and can lead to decreased function in the joint, nerve-related pain, a specific kind of pain disorder called complex regional pain syndrome, and arthritis caused by an injury.

The most common complications from such a fracture are carpal tunnel syndrome and complex regional pain syndrome, followed by inflammation of the tendon. Serious blood vessel damage can happen if the injury is significant, but delayed blood vessel complications are not common. Children, on the other hand, risk lasting damage to their growth plates and are more likely to develop stubborn tightness in their forearm muscles.

Healthcare providers in primary care and emergency settings can help prevent these complications by properly setting and splinting the fractures, and by arranging early follow-up appointments with orthopaedic specialists. Also, most older adults who have such fractures should be checked for low bone density conditions like osteoporosis or osteopenia. The reason being, in older adults, these fractures might hint at higher risks of osteoporosis, abnormal fractures, and overall heightened health risks.

Preventing Distal Radius Fractures

The radius is one of the two long bones in your forearm, located below your thumb, and stretching between your wrist and elbow. The part of the radius bone closest to the wrist is called the “distal radius.” This particular part is susceptible to breaking if you fall and land on an outstretched hand. But, it’s also possible for it to break from any fall or injury to the upper part of your arm.

The most common signs of a fracture in the distal radius include pain and limited movement of your wrist. These types of fractures are often identified with an X-ray, but in some cases, other kinds of imaging tests may be needed.

Many people who have a fracture in the distal radius can recover at home by simply wearing a cast or splint for several weeks. However, some may need immediate or emergency surgery to fix the fracture. If you think that you may have a distal radius fracture, it’s critical that you go to your nearest emergency room right away for an assessment.