The Journal of Bone & Joint Surgery

Introduction

Introduction | Anatomy of the Articular Interface between the Distal Aspects of the Radius and Ulna and the Carpus | Effect of Intra-Articular Fracture-Healing on Articular Congruity | Radiographic Studies | Classification of Intra-Articular Fractures of the Distal Aspect of the Radius | Operative Approaches | Associated Fractures of the Ulnar Styloid Process | Associated Injuries of the Intercarpal Ligaments or the Triangular Fibrocartilage Complex | External Fixation Devices | Advantages and Disadvantages of Open Reduction, Arthroscopically Aided Reduction, and Limited Open Reduction | Rehabilitation after Intra-Articular Fractures of the Distal Aspect of the Radius | Results of Treatment | Overview | References

High-energy injuries frequently cause shear and impacted fractures of the articular surface of the distal aspect of the radius with displacement of the fracture fragments. Even fractures with a small amount of displacement can result in degeneration of the joint, causing pain and stiffness of the wrist. The fracture pattern, degree of displacement of the fracture fragments, and stability of the fracture determine whether operative treatment rather than immobilization with a cast is needed. The options for operative treatment include open reduction and internal fixation, to realign the articular surface of the radius; external fixation, for fractures with comminution of the metaphysis of the radius, to maintain the length of the radius; and bone-grafting, to provide support for the articular surface of impacted fractures.

*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 48, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1999.

†No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Department of Orthopaedics, University of Washington, Mailbox 356500, Seattle, Washington 98195.

§Philadelphia Hand Center, 901 Walnut Street, Philadelphia, Pennsylvania 19107.

#Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, Washington 98104-2499.

**Department of Orthopaedic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

††Mayo Clinic, 200 First Street S. W., Rochester, Minnesota 55905.

‡Department of Orthopaedics, University of Washington, Mailbox 356500, Seattle, Washington 98195.

§Philadelphia Hand Center, 901 Walnut Street, Philadelphia, Pennsylvania 19107.

#Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, Washington 98104-2499.

**Department of Orthopaedic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

††Mayo Clinic, 200 First Street S. W., Rochester, Minnesota 55905.

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Fig. 1 Schematic drawing showing the method for measurement of palmar tilt, distal radial tilt, and ulnar variance on posteroanterior and lateral radiographs of the distal aspects of the radius and ulna.

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Fig. 2 Schematic drawing showing the distal articular surface of the radius, which is divided into the lunate and scaphoid facets.

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Fig. 3 Schematic drawing showing how fracture lines frequently propagate between the scaphoid and lunate facets and extend dorsally adjacent to, but not through, the thicker bone that forms the Lister tubercle.

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Figs. 4, 5, and 6: Undecalcified specimen obtained from a sheep twelve weeks after a tibial osteotomy. Fig. 4: The fracture is still evident, with ongoing bone-remodeling. The low side (the depressed segment of the fracture), which has been unloaded by the osteotomy, demonstrates chondrocyte hypertrophy and expansion of the cartilage surface. Compared with sites distant to the osteotomy, the cartilage on the high side (the non-depressed segment of the fracture) is reduced in overall thickness by approximately 20 per cent (Masson trichrome, x 200).

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Fig. 5 High-power scanning electron micrograph showing the collagen fibrils on the high side of the tibial osteotomy. The arrows highlight the bending of the collagen fibrils. Bar = 100 micrometers.

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Fig. 6 Low-power scanning electron micrograph showing an overview of the cartilage flap produced by the response of the articular surface to the osteotomy. The lower arrow demonstrates the fracture line (FX). Bar = one millimeter.

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Fig. 7 A die-punch fracture (arrow) of the scaphoid facet is barely visible on this posteroanterior radiograph.

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Fig. 8 Computerized tomographic scan, made in the sagittal plane, clearly showing the die-punch fracture (arrow) of the scaphoid facet with three millimeters of depression that would have been easy to overlook on plain radiographs.

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Fig. 9 The Frykman classification system¹⁰. The fractures are divided into eight categories according to whether they extend into the articular surface and whether there is an associated fracture of the distal aspect of the ulna.

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Fig. 10 The Mayo classification system^4-6. The fractures are divided into groups according to whether they are extra-articular or intra-articular. Intra-articular fractures are divided further according to the extent of fragmentation. S = scaphoid, L = lunate, RS = radial styloid fragment, D = dorsal, and V = volar. (Reproduced, with modification, from: Missakian, M. L.; Cooney, W. P.; Amadio, P. C.; and Glidewell, H. L.: Open reduction and internal fixation for distal radius fractures. J. Hand Surg., 17A: 745—755, 1992. Reprinted with permission.)

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Fig. 11 The Melone classification system²⁸. The fractures are divided into groups according to the amount of displacement, the pattern of the fracture, the degree of volar metaphyseal comminution, and the extension of the fracture into the diaphysis. 1 = radial shaft, 2 = radial styloid fragment, 3 = volar ulnar fragment, and 4 = dorsal ulnar fragment. (Reprinted, with permission, from: Melone, C. P., Jr.: Distal radius fractures: patterns of articular fragmentation. Orthop. Clin. North America, 24: 241, 1993.)

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Fig. 12 Modification of the AO classification of partial articular fractures of the distal aspect of the radius to include die-punch fractures of the scaphoid and lunate facets (subtype B4). With these fractures, a portion of the articular surface remains in continuity with the metaphysis, providing some stability even if there is loss of congruity.

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Fig. 13 Complex (type-C) fractures, described in the AO classification, have been combined into a single group. The notations indicate whether the displacement was dorsal or volar or whether the fracture was severely impacted from an axial load that caused comminution of both the dorsal and volar portions of the metaphysis or diaphysis, or both. All of these fractures involve complete separation of the metaphysis from the articular surface, making them highly unstable. MC = metacarpal and R = radius.

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Figs. 14 and 15: The dorsal midline approach. EPL = extensor pollicis longus, ECRB = extensor carpi radialis brevis, and ECRL = extensor carpi radialis longus. Fig. 14: The third dorsal compartment is released, and the fourth dorsal compartment is elevated off of the wrist capsule.

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Fig. 15 The capsule, including the dorsal radiotriquetral ligament (DRT), is incised near its insertion onto the dorsal rim of the radius and then is reflected distally to expose the radiocarpal joint. EPL = extensor pollicis longus.

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Figs. 16 and 17: The volar radial approach. Fig. 16: The approach is through the interval between the flexor carpi radialis (FCR) and the radial artery. R = radius and U = ulna.

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Fig. 17 Fractures of the volar rim can be stabilized with use of a contoured buttress plate.

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Fig. 18 The volar ulnar approach, which is through the interval between the flexor tendons to the fingers and the ulnar nerve and artery. R = radius and U = ulna.

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Fig. 19 The method for an arthroscopically guided reduction. The arthroscope is placed in the dorsal 3,4 portal, and a probe is inserted in the dorsal 4,5 portal. The radial styloid fragment is stabilized with percutaneous Kirschner wires.

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Fig. 20 Modification of the AO classification of fractures of the distal aspect of the ulna. Type-2 fractures are divided into small avulsion fractures (type 2A) and fractures near the base of the ulnar styloid process (type 2B) that cause instability of the triangular fibrocartilage complex and, consequently, the distal radioulnar joint.

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Fig. 21 The screw-fixation and tension-band-wire techniques can be used to stabilize fractures of the ulnar styloid process.

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Fig. 22 The partially threaded pins for the external fixation device are inserted in the interval between the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) in order to protect the sensory branch of the radial nerve. MC II = second metacarpal.

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Fig. 23 Photograph of a splint that allows pronation-supination to improve rotation of the forearm when 120 degrees of combined motion has not been regained within eight to ten weeks after the fracture.

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Fig. 24 Photograph of a static progressive splint, used for patients who do not regain 100 degrees of flexion and extension of the wrist within eight to ten weeks after the fracture.

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TABLE I OPERATIVE APPROACH FOR OPEN REDUCTION AND INTERNAL FIXATION OF PARTIAL INTRA-ARTICULAR FRACTURES

Type of Fracture	Operative Approach
Type B1: fractures of radial styloid process	Dorsal or volar, depending on computerized tomographic scans
Type B2: fractures of dorsal rim	Dorsal with buttress plate
Type B3: fractures of volar rim, including those of volar ulnar corner of sigmoid notch	Volar radial (Henry) or volar ulnar with buttress plate
Type B4: die-punch fractures of scaphoid or lunate facet, including those of dorsal ulnar corner of sigmoid notch	Arthroscopic or limited open reduction through dorsal approach and bone-grafting with or without buttress plate

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TABLE I OPERATIVE APPROACH FOR OPEN REDUCTION AND INTERNAL FIXATION OF PARTIAL INTRA-ARTICULAR FRACTURES

Type of Fracture	Operative Approach
Type B1: fractures of radial styloid process	Dorsal or volar, depending on computerized tomographic scans
Type B2: fractures of dorsal rim	Dorsal with buttress plate
Type B3: fractures of volar rim, including those of volar ulnar corner of sigmoid notch	Volar radial (Henry) or volar ulnar with buttress plate
Type B4: die-punch fractures of scaphoid or lunate facet, including those of dorsal ulnar corner of sigmoid notch	Arthroscopic or limited open reduction through dorsal approach and bone-grafting with or without buttress plate

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TABLE II OPERATIVE APPROACH ACCORDING TO THE DIRECTION OF DISPLACEMENT AND THE PRESENCE OR ABSENCE OF COMMINUTION

Direction of Displacement	Comminution	Operative Approach	External Fixation
Dorsal	No	Dorsal	No
Dorsal	Yes	Dorsal	Yes
Volar	No	Volar	No
Volar	Yes	Volar	Yes
Direct impaction with T or Y-split, with or without diaphyseal involvement	Yes	Dorsal and volar	Yes

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TABLE II OPERATIVE APPROACH ACCORDING TO THE DIRECTION OF DISPLACEMENT AND THE PRESENCE OR ABSENCE OF COMMINUTION

Direction of Displacement	Comminution	Operative Approach	External Fixation
Dorsal	No	Dorsal	No
Dorsal	Yes	Dorsal	Yes
Volar	No	Volar	No
Volar	Yes	Volar	Yes
Direct impaction with T or Y-split, with or without diaphyseal involvement	Yes	Dorsal and volar	Yes

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THOMAS E. TRUMBLE, RANDALL CULP, DOUGLAS P. HANEL, WILLIAM B. GEISSLER, RICHARD A. BERGER; Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Intra-Articular Fractures of the Distal Aspect of the Radius*†. The Journal of Bone & Joint Surgery. 1998 Apr;80(4):582-600.

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