Distal Radius Fractures
Distal radius fractures are the most common orthopedic injury seen in the emergency department, with a
- bimodal patient distribution:
- young persons from high-energy mechanisms and elderly patients from a fall on an outstretched hand (FOOSH).
- Maintain a high index of suspicion for associated ligamentous injuries.
- DRUJ injuries
- radial styloid fractures
- indicates higher energy mechanism
- soft tissue injuries - seen in 70%
- TFCC injury (40%)
- scapholunate ligament injury (30%)
- lunotriquetral ligament injury (15%)
Presentation & Diagnosis
| Feature | Details |
|---|---|
| Exam findings | Tenderness at the distal radius, swelling, often visible deformity |
| Initial imaging | AP and lateral x-rays |
| CT | Obtain if intraarticular involvement is suspected on x-ray |
| MRI | Consider outpatient referral if ligamentous injury is clinically suspected |
Fracture Classification
| Fracture Type | Displacement | Mechanism | Notes |
|---|---|---|---|
| Colles’ | Dorsally angulated, extraarticular | FOOSH, elderly | Most common type |
| Smith’s | Volarly angulated, extraarticular | Fall onto flexed wrist or blow to dorsum of hand | — |
| Die-Punch | Depressed fracture of lunate fossa | Axial loading | — |
| Dorsal Barton | Fracture-dislocation of radiocarpal joint with intra-articular fx involving the dorsal lip | — | Often associated with radiocarpal joint dislocation |
| Volar Barton | Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar lip | ||
| Chauffeur’s / Hutchinson | Radial styloid fracture | Blow to volar wrist | Frequently associated with scaphoid or ligamentous injuries |
Emergency Department Management
1. Anesthesia
Two options:
- IV procedural sedation
- Hematoma block — effective and does not increase infection risk
- Technique: Enter skin directly over the fracture, advance to bone, aspirate blood to confirm position, then administer lidocaine
- Ultrasound guidance may improve efficacy
2. Reduction
Three main methods:
- Manual traction
- Finger trap traction — 2018 meta-analysis showed this is most effective for radial shortening, with better pain control and fewer complications
- Active traction/counter-traction — manual traction may be more effective specifically for dorsal tilt
⚠️ Important: If the first reduction attempt fails, a second attempt is unlikely to succeed — only ~5% of patients requiring two attempts achieve acceptable final alignment on x-ray.
3. Splinting
Place the patient in a sugar tong splint following reduction.
Surgical Referral Indications
Consult hand surgery or orthopedics when there is significant:
- Loss of radial inclination
- Change in radial height
- Loss of volar tilt