Distal Radius Fracture: Epidemiology, Classification, Treatment Decision-Making, and Complications

Epidemiology

• Most common upper extremity fracture (17–20% of all fractures).
• Bimodal distribution: young males (high-energy trauma) + postmenopausal women (low-energy fall).
• FOOSH with wrist dorsiflexion → dorsal displacement (Colles fracture pattern).

Classification Systems

• AO/OTA 23-A/B/C: Extra-articular (A), partial articular (B), complete articular (C).
• Frykman: Historic; combines articular involvement + ulnar styloid fracture.
• Melone: Four fragments (styloid, dorsal medial, volar medial, radial shaft)—surgical planning.
• Universal Classification: Combines geometry, displacement, bone quality, soft tissue status.

Clinical Presentation

• Pain, swelling, deformity ("dinner fork" / "bayonet" appearance).
• Tenderness at distal radius, DRUJ.
• Median nerve symptoms (acute carpal tunnel) — 15–20%.
• Compartment syndrome (rare; forearm tense, pain on passive stretch).

Imaging

• PA, lateral, oblique wrist views.
• CT: intra-articular fractures (pre-op planning, fragment assessment).
• MRI: if TFCC, scapholunate, or occult fracture suspected.

Treatment Decision Framework

Factor	Non-Operative	Operative
Displacement	Reducible, stable, within limits	Irreducible, unstable, exceeds limits
Articular step-off	<1–2 mm	>2 mm
Radial shortening	<3–5 mm	>5 mm
Dorsal tilt	<10–15°	>15° (or volar tilt)
Ulnar variance	Neutral/positive	Negative >2 mm
Patient factors	Low demand, osteoporotic, high anesthesia risk	Active, young, high demand, bilateral

Non-Operative Management

• Closed reduction (hematoma block / procedural sedation) → well-molded sugar-tong splint → short arm cast.
• Weekly X-rays × 2–3 weeks (redisplacement risk highest early).
• Cast 4–6 weeks → removable wrist splint → therapy.

Operative Management

• Volar locking plate (VLP): Gold standard for most operative cases. Anatomic, stable, allows early motion.
• Dorsal plate: For volar displacement, complex dorsal comminution.
• Fragment-specific fixation: K-wires, mini-plates for articular fragments.
• External fixation: Severe open fractures, infection, bridging.
• Percutaneous pinning: Simple extra-articular, good bone quality.

Complications

• Malunion: Dorsal tilt/shortening → DRUJ arthritis, ulnar impaction, decreased grip strength.
• Stiffness: Especially flexion/pronation. Early motion (VLP) mitigates.
• Post-traumatic osteoarthritis: Intra-articular incongruity.
• CRPS (Type I): 5–15%; early mobilization, vitamin C 500 mg/day × 50 days reduces incidence.
• Tendon irritation/rupture: EPL (3rd compartment), FCR—plate prominence.
• Median neuropathy: Acute (decompress at fixation) vs. delayed (carpal tunnel release).

Prevention

• Fall prevention: home hazards, vision, balance exercise, medication review.
• Bone health: Calcium 1200 mg, Vitamin D 800–1000 IU, weight-bearing exercise, bisphosphonate/denosumab if osteoporotic.
• Wrist guards for high-risk sports (skating, snowboarding).