JACK K. MAYFIELD

F.: Carpal dislocations: Pathmnechanics5urn., 5:226-241, i980.¯ : Ti~e Scapholunate Joint: New Insights?roceedings of the American Society forary 3, 1980.Mmtomy of the Scapholunate Joint, 1979.

t Surg., 1:110, 1976.

Symposium on The Wrist

Articular Fractures ofthe Distal Radius

Charles P. Melone, Jr., M.D.*

Fractures of the distal radius often have beeu considered primarily extra-articular injuries of elderly females. However, there are increasing reportsof distal radial fractures causing serious articular dmnage and profoundlyaffecting the wrists of a greater population.5a’am’t: Clearly, the distal radialarticulations of younger patients are being exposed to increasingly severetrauma.

Better understanding of the spectrum of distal radial fi-actures is leadingto changing concepts of management. Basic among these is the need todifferentiate the more serious articular fractures from the extra-articularinjuries commonly called Colles’ and Smith’s fractures. First, the articularinjuries are more frequently comminuted, unstable, and less suitable fortraditional methods of closed manipulation and cast immobilization. Second,the articular fractures are associated with a significantly higher rate of com-plications,4.~,~,m,~4 and it is :increasingly clear that preservation of the distalradial articular surfaces is necessary for maximum recovery. Finally, the moresevere articular fractures ar~ frequently associated with other serious inju-ries, particularly injuries of the median nerve, ulnar nerve, and flexor ten-dons. 1,4AS,ls,2~-~4 Maximum recover.v requires not only precise correction ofarticular disruption but also prompt recognition and repair of any coneom__zitant soft tissue or skeletal injuries.

Based on experiences with 330 articular fractures of the distal radius,this article defines more precisely the patterns of injury, proposes a classi-fication to guide optimal treatment, and describes techniques that haveproved consistently successful for the more complex injuries.

DESCRIPTION OF ARTICULAR FRACTURES

Mechanism of Injury

Tension, usually hyperextension, is commonly considered the majorforce causing fractures of the distal radius. However, compression is an

*Associate Professor of Orthopaedic Surgery, New York University Medical Center; Director,Hand Surgery Service, Cabrini Medical Center, New York, New York

Orthopedic Clinics of North America---Vol. 15, No. 2, April 1984 217

218 CHARLES P. MELONE, JR.

TRIQUETRUM

LUNATE

SCAPHOID

ULNASTYLOID

4-PART ARTICULAR FRACTUREI. SHAFT

2. RADIAL STYLOID3. DORSAL MEDIALA 4. PALMAR MEDIAL

RADIO-CARPAL RADIO’ULNARARTICULAR SURFACES ARTICULAR SURFACES

LUNATE

4-PART ARTICULAR FRACTUREL SHAFT

2. RADIAL STYLOID5. DORSAL MEDIAL

E) 4. PALMAR MEDIAL

Figure 1. A and B, The articular fracture comprises tbur basic components: (1) radialshaft; (2) radial styloid; (3) dorsal medial fragment; and (4) palmar medial fragment. Displacementof the key medial fragments profoundly affects both the radiocarpal and distal radioulnar joints.

equally important, or perhaps even more significant, force causing articularfractures. In their descriptions of distal radial fractures, Stevenst9 andScheck17 compared the lunate to a die punch, compressing and disruptingthe articular surface of the radius. Undoubtedly, a compression force trans-mitted primarily by the lunate accounts largely for the fracture planes thatoccur across the distal radial-articular surfaces.

Fracture Components

Despite a variable degree of comminution, the articular fracture com-prises four basic fragments: (1) radial shaft; (2) radial styloid; (3) dorsal medial--fragment; and (4) palmar medial fragment (Fig. 1). Owing to their criticalposition as the cornerstone of the radiocarpal and distal radioulnar joints,the medial fragments have a profound effect on normal wrist mechanics.Even minor displacement of these key fragments may seriously disturb thedistal radial articulations.

Radiographs of articular fractures consistently demonstrate a transversefracture line, separating the shaft from the medial and styloid fragments, ator just proximal to the sigmoid notch of the radius. This fracture plane resultsfrom the tension component: of the injury and extends across the distal radialmetaphysis. Although the fracture plane is predominantly extra-articular, itfrequently extends into the sigmoid notch and contributes to articular dis-ruption. From this, a second fracture line, resulting from compression, ex-tends distally and vertically into the radiocarpal joint. This usually occursin the area of the scapholu:aate articulation and separates the medial frag-,ments from the styloid fragment. A third fracture line, best seen on the

CHARLES P. MELONE, JR.

,RPAL RADIO’ULNAR,R SURFACES ARTICULAR SURFACES

)ART ARTICULAR FRACTUREI. SHAFT2, RADIAL STYLOID3. DORSAL MEDIAL

~ 4. PALMAR MEDIAL

;es tbur basic components: (l) radialahnar lnedial fragment. Displacementdiocarpal and distal radioulnar joints.

ificant, force causing articulardial fractures, Stevens19 and, compressing and disruptingtly, a compression force trans-.ly for the fracture planes thatS.

)n, the articular fracture corn-radial styloid; (3) dorsal medial’ig. 1). Owing to their crifi.caltl and distal radioulnar joints,t on normal wrist mechanics.ents may seriously disturb: the

~ntly demonstrate a transverseedial and styloid fragments, at[ius. This fracture plane resultsextends across the distal radial’edominantly extra-articular, it~d contributes to articular dis-,’suiting from compression, ex-rpal joint. This usually occurs~nd separates the medial frag-,.’acture line, best seen on the

ARTICULAR FRACTURES OF THE DISTAL PtADIUS 219

TYPE Ill ~TYPE IV

ROTATION

Figure 2. Compression of the distal radius results in four basic fracture types and pre-dictable patterns of displacement. A major eompression force causes wide separation of thepalmar and dorsal medial fragments (type IV) and serious disruption of the distal radial artic-ulations.

lateral radiograph, extends horizontally across the lunate fossa of the distalradius. This fracture may be in either the dorsal or the palmar aspect of thearticular surface, depending on the direction of force and the site of lunateimpact. Severe compression in this plane causes separation of the palmarand dorsal medial fragments and serious disruption of both the radiocarpaljoint and the distal radioulnar joint (Fig. 2).

Although the components of the articular fracture are quite consistent,variations in the basic patterns may occur. For example, if the mechanism.of force is primarily compression, the medial corner of the radius is mostseverely affected. This may result in only a three-part fracture With separationof the medial fragments from each other and from the radial shaft and styloid,which remain as a unit. Without a tension force, a transverse fracture acrossthe distal radial metaphysis is less likely to occur. Similarly, if the mechanismis primarily tension, the major fracture plane will occur across the distalradial metaphysis with variable and possibly minor involvement of the ra:dioulnar and radiocarpal joints. The type and direction of force account forthe diversity of articular fractures.

Fracture Displacement

Instability of the fracture fragments results in basic patterns of displace-ment (see Fig. 2). Most commonly, the medial fragments are displaced

220 CHAtlLES P. MELON~. J~.

a unit. Ho~vever, because compression by the lunate is usually in a posteriordirection, the dorsal medial fragment is impacted more than the palmarmedial fragment, and the lateral radiograph demonstrates typical posteriordisplacement. In his study of distal radial fi’actures, Scheckt7 consistentlyobserved this pattern of ~tisplacement and referred to the dorsal medialcomponent as the "die punch" fragment. Less commonly, a force in ananterior direction results in. greater compression of the pahnar medial ii’ag-ment, and anterior displacement is demonstrated on the radiograph (seeFig. 7). This pattern of articular displacement is commonly referred to as Smith type II fracture, a ]3arton fl-acture-dislocation, or a reverse Bartonfracture,s.e~ As in this case, the traditional eponyms associated with distalradial fractures can be a source of coni\~sion in diagnosis and mauagement.An accurate description of the fracture components and displacement avoidsconfusion and is the preferred method of defining articular fractures.

Displacement of the medial fragments as a unit is occasionally associatedwith displacement of an a,dditional fragment fl’om the comminuted radialshaft (see Fig. 2). The fragment may be displaced at the time of injury’ at the time of fracture manipulatio’n. Typically, it rotates into a verticalposition and projects as a spike into the flexor compartment of the xvrist,causing injury to the median nerve or flexor tendons. Less frequently, adorsal spike t~ragment is encountered, but displacement is usually minimaland acute extensor tendon injury is uncommon.

The most severe type of displacement is that of splitting, with wideseparation of the medial fl:agments (see Fig. 2). This always results fi’om major compression force, which is usually generated by a serious athleticinjury, a fall from a great height, or a high-speed vehicular accident. Onefragment, usually the palmar medial one, may rotate as much as 180°, re-sulting in a marked disruption of the articular su~aces. This pattern occursonly with serious concomita.nt soft tissue damage, often with injury to themedian or ulnar nerves as Well as the flexor tendons.

Ligament ComponentsThe carpus is nearly always displaced with one or both of the medial

fragments owing to exceptionally strong soft tissue attachments. Personalstudies of 20 cadaver wrists confirm this clinical obse~wation (Fig. 3). Themedial fragments are connected to the ulnar styloid by the triangular fibro-cartilage, to the triquetrum by the ulnocarpal meniscus, and to the lunateby the ulnolunate ligament, as well as the strong dorsal aiad volar or capsularligaments. These ligaments collectively constitute a major part of the ulno-carpal complex of the ext~rinsic wrist ligaments, described in detail by Tal-eisnik.2°

DePalma~ demonstrated experimentally that even with the most se-verely comminuted fractures, the ligaments of the wrist remain intact. Thestrength of these ligaments is of obvious clinical importance because theirintegrity permits the successful use of traction to maintain reduction of manyof the complex articular fractures. In addition, the strength of the triangularfibrocartilage accounts for the frequency of ulnar styloid fractures in asso-ciation with distal radial articular fractures. Many years ago, Stevens~9 statedthat the ulnar styloid fracture results from a force transmitted through an

CttARLES P. ~IELONE. JR.

hate is usually in a posterior,’ted more than the pahnarmonstrates typical posteriortnres, Scheckt: consistently:erred to the dorsal medial;s commonly, a force in ann of the pahnar medial fi’ag-tied on the radiograph (see.s co:’nmonly referred to as a~cati0~:, or a reverse Barton~nyms associated with distaldiagnosis and management.

ents and displacement avoids~ing articular fractures.unit is occasionally associatedfi’om the comminuted radialaced at the time of injury orlly, it rotates into a vertical~r compartment of the wrist,tendons. Less frequently’, a

placement is usually minimaln.

s that of splitting, with wide2). This always results fi’om :uerated by a serious athletic3eed vehicular accident. One~v rotate as much as 180°, re-. sm~aces. This pattern occursaage, often with injury to the:endons.

~th one or both of tI~e medial:tissue attachments. Personallical observation (Fig. 3). Thestyloid by the triangular fibro-~1 meniscus, and to the lunatemg dorsal and volar or capsulartitute a major part of the ulno-xts, described in detail by Tal~

z that even with the most se-of the wrist remain intact. Thenical importance because theira to maintain reduction of manya, the strength of the triarigularulnar styloid fractures in asso-~lany years ago, Stevenst9 stateda force transmitted through an

ARTICULAR FRACTURES OF THE DISTAL I~,ADIUS 221

Figure 3. Cadaver wrist demonstratingthe strong soft tissue attachments between the

medial corner of the radius and the l:,roximalcarpals and ulnar styloid. (In this specimenthe carpals are flexed on the distal radius.) Thesuccessful use of traction depends on thestrength of these ligaments. (STY = ulnar sty-loid; TFC = triangular fibrocartilage; UCM= ulnocarpal ~neniscus; ull = utnolunate lig-ament: SLL = scapholunate ligament.)

intact triangular fibrocartilage and occurs secondarily to the major fracture,which is that of the radius. This concept is borne out by this study, in which90 per cent of unstable articular fractures were found to have associatedulnar styloid fractures. The ulnar styloid fracture and, significantly, its fre-quent failure to unite do not seem to ’affect the prognosis, provided the majorarticular fracture is treated successfully.

¯ CLASSIFICATION

There is need for a practical classification of fractures of the distal radiusto guide optimal treatment. T]hfs is borne out by the wide variation in resultsof treatment reported for these injuries,a’r’-7’u’’°’la’~4’~7 From their classic de-scription, neither Colles’ nor Smith’s fractures are intra-articular and thusshould be excluded from discussion or series including the more complexarticular distal radial fractures.

The classification used in this study is a modification of that proposedby Gartland and Werley. ~o They stressed the frequency of articular involve-ment and its being the major determinant of the prognosis. The classificationpresented here developed from the observation that components of articularfractures consistently fall into four basic parts: (1) radial shaft; (2) radialstyloid; (3) dorsal medial fragment, and (4) palmar medial fragment. medial fragments and their strong ligamentous attachments with the proximalcarpals and the ulnar styloid have been termed the medial complex (Fig. 4).Displacement of the medial c.omplex is the basis for classification of articularfractures into four types (see Fig. 2).

Type I

These fractures are undisplaced or demonstrate variable displacementof the medial complex as a urtit. Regardless of displacement, these fracturesare not comminuted, and they are stable after closed reduction.

222

ULNAR

CHARLES P. MELONE, JR.

TRIANGULARFIBROCARTILAGE

DORSAL MEDIAL\FRAGMENT

PALMAR MEDIALFRAGMENT

UETRUM

NO-CARPALMENISCUS

NO-LUNATE LIG.

-- LUNATE

;ARPAL LIG.

LIG.

RADIAL SHAFTFRAGMENT

SCAPHOID

ADIO-CARPAL LEG.

RADIAL STYLOID FRAGMENT

Figure 4. The medial complex (shaded area) comprises the medial fragments and theirstrong ligamentous attachments, Displacement of the medial complex is the basis for classifi-cation of articular fractures.

Type II (Die Punch Fractures)

These are unstable fractures with moderate or severe displacement of_the medial complex as a unit. The hallmark of the unstable fracture is com-minution of both the posterior and anterior cortices of the radius. This is3ften associated with three other characteristic radiographic features: (1)separation of the medial frora the styloid fragments; (2) radial shorteninggreater than 5 to 10 mm; and (3) considerable angulation, usually exceeding20°. The presence ofcomminution, particularly of the anterior cortex, shouldalert the examiner to the probability of instability. Fractures that initiallyappear to be stable have been observed to become displaced as late as 14days following injury.

Type III (Spike Fractures)

These are unstable fractures that demonstrate displacement of the me-dial complex as a unit as well as displacement of an additional spike fragmentfrom the comminuted radial shaft. As previously stated, the spike fragmentcharacteristically projects into the flexor compartment of the wrist and causesinjury to adjacent nerves or tendons.

CHARLES P. MELONE, JR.

~GULARCARTILAGE

IETRUM

NO-CARPALMENISCUS

NO-LUNATE LIG.

UNATE

-CARPAL LIG.

~ ,~

SCAPHOLUNATE LIG.

SCAPHOID

"-~ RADIO-CARPAL LIG.

ises the medial fragments and their:lial complex is the basis for classifi-

tte or severe displaqement ofthe unstable fracture is com-..ortices of the radius. This istic radiographic features: "(1)gments; (2) radial shorteningangulation, usually exceeding’ of the anterior cortex, shouldbility. Fractures that initially~come displaced as late as 14

trate displacement of the me-~f an additional spike fragmentsly stated, the spike fragment:rtment of the wrist and causes

ARTICULAR FRACTURES OF THE DISTAL RADIUS

Table 1. Unstable Fractures: Concomitant Injury

223

FRACTURE TYPE

II III IV TOTALCONCOMITANT INJURY iT0)* (3)* (I2)* (85)*

Median nerve eontnsion 10 3 9 22Median nerve laceration 0 0 1 1Ulnar nerve contusion 3 0 4 7Flexor pollicis longus laceration 0 0 3 3Arterial laceration 0 0 2 2Scapholunate dissociation 3 0 0 3Scaphoid fracture 2 0 0 2Ulnar head fracture 4 0 0 4

*Number of fractures

Type IV (Split Fractures)

These are unstable fractures in which the inedial complex is severelycompressed by the lunate, resulting in ~vide separation or rotation of thedorsal and pahnar medial fragments. The injury causes a major biarticulardisruption and is always accmnpanied bv serious soft tissue damage.

The exact fracture type cannot always be determined by the initialradiographs and may become apparent onlv after an attempt is made toreduce the fi’acture. This is especially true fo’r the type II fracture, in whichinstability due to comminution of both radial cortices is demonstrated mostclearly on the postreduction radiographs. Furthermore, there are instanceswhen displacement of a comminuted spike fragment (type III) becomesobvious only after reduction and other instances when the severity of splittingor rotation of the medial fragments (type IV) is not apparent until dosedreduction or traction is unsuccessful. In such eases, the unsuccessful reduc-tion indicates an increasing complexity of injury and the need for moreprecise treatment. ~"

TREATMENT

The primary goal of treatment of articular fractures of the distal radiusis an accurate and stable reduction of the medial complex. This is essentialfor preservation of both radiocarpal and radioulnar joints and may requireopen treatment. In addition, because the unstable fractures are frequentlyeomplieated by serious concmnitant injury (Table 1), optimal treatment re-quires prompt repair of many of these injuries.

iAeeuraey of Reduction

Personal experience with over 300 articular fractures supports the g~n-eral opinion that the success of recovery parallels the accuracy of the re-duction. Although there are exceptions of unsatisi~mtmT reduction resultingin satisfactory function, malunion should be recognized as the common i~actorpredisposing to poor results. Undoubtedly, complications are less likely tooccur with prompt and precise fracture reduction.

Traditionally, measurements of radial length on the posteroanterior ra-

224 CHARLES P. MELONE, JR.

Figure 5. The major disturbance of thearticular fracture occurs bet~veen themedialcorner of the radius and the ulnar head. Thisarticular fracture resulted in 5 mm of short-ening of the medial complex (positive ulnarvariance), but, characteristically, it did not~fffect the radial styloid-ulnar head distance.The most precise measurement of the accu-racy of reduction is the vertical distance be-tween the distal ends of the medial corner oftbe radius and tbe ulnar head.

diograph and the volar tilt on the lateral radiograph have been used to assessthe accuracy of reduction. Often quoted normal values are 9 to 14 mm ofradial length and 10° to 12° of volar tilt. :~.’~,~.~.~ Radial length is usuallymeasured as the vertical distance between the distal ends of the radial styloid

14and the ulnar head, and Lidstr6m has demonstrated that a loss of 6 mmor more of length will seriously compromise wrist function.

These measurements have been useful guidelines for treatment of distalradial fractures. However, the major disturbance of the articular fractureoccurs between the medial corner of the radius (not the radial styloid) andthe ulnar head. Even :minimal displacement of the medial complex resultsin disruption of the radioearpal joint and subluxation of the radioulnar joint.Moreover, severe displacement of the medial complex resulting in disru_Etionof the radial articular surfaces may not affect the distance between the radialstyloid and the ulnar head. Therefore, a more precise measurement of theaccuracy of reduction of articular fractures is the vertical distance betweenthe distal ends of the medial corner of the radius and the ulnar head (Fig.5). This is the same measurement, referred to as ulnar variance, used ex-tensively in the evaluation of Kienb6ek’s disease.VZ

In the majority of people, the ulnar head and the medial corner of theradius are at the same level bilaterally (neutral variance). However, withfracture displacement, this relationship is disturbed and the ulnar head isin a distal position relative to the medial complex (positive variance). Clinicalexperience bears out that a discrepancy of 5 mm or more in 16ngth canprofoundly affect wrist function, and because even the most accurate andstable reductions ultimately collapse several millimeters owing to impaetionofeomminuted fragments, an accurate reduction should restore the preinjuryrelationship between the medial complex and the ulnar head. Obviously,comparison radiographs of the uninjured wrist are necessary to determinenormal length and to minimize misinterpretation due to normal variations.

CHARLES P. N1ELONE, JR.

The major disturbance of thetre occurs between the medial-adius and the ulnar head. Thisare resulted in 5 mm of short-~nedial complex (positive ulnar:, characteristically, it did notial styloid-ulnar head distance,cise measurement of the accu-:ion is the vertical distance be-tal ends of the medial corner oft the ulnar head.

h have been used to assessvalues are 9 to 14 mm of~6 Radial length is usually

al ends of the radial styloid:rated that a loss of 6 mm;t function.lines for treatment of distal.e of the articular fracture’,not the radial styloid) andhe medial complex results:ion of the radioulnar joint.plex resulting in disruptiontistance between the..: radialrecise measurement of the; vertical distance between..s and the ulnar head (Fig.~s ulnar variance, used ex-

ad the medial corner of the. variance). However, withrbed and the ulnar head is(positive variance). Clinicalnm or more in length canven the most accurate andlimeters owing to impaetionshould restore the preinjurythe ulnar head. Obviously,are necessary to determine,n due to normal variations.

ARTICULAR FRACTURES OF THE DISTAL I:{ADIUS 225

Type I Fractures

Undisplaced fractures are best managed by 3 to 4 weeks of short armsplint or cast immobilization and, most importantly, early wrist motion whenthe fracture is sufficiently healed, as determined by clinical examination.Active and unrestricted digital, elbow, and shoulder motion is encouragedimmediately after injury and immobilization of the fracture.

Reduction of displaced fractures is facilitated by regional or local anes-thesia and sedation. Under sterile conditions, aspiration of the fracture he-matoma and injection of 3 to 5 ml of 2 per cent Xylocaine constitute aneffective and safe method of anesthesia. The criticism that this techniqueconverts a closed fracture into an open fracture and increases the risk ofinfection is not supported by clinical experience.

Correction of the usual posterior displacement is achieved by steadytraction, followed by palmar flexion of the wrist, ulnar deviation, and pro-nation. Effective cast immobilization must maintain reduction and, by in-corporating ~he base of the thumb and the hmneral epicondyles, eliminatepotentially deforming forces across the fracture. The ~vrist is carefully im-mobilized in mild positions of flexion, ulnar deviation, and pronation. Al-though positioning in pronation is controversial,5’~6 its efficacv is in approx-imation of the anteriorly displaced ulnar head to the posteriorly displacedmedial complex. Extreme positions’, of immobilization, particularly excessivepalmar flexion (the Cotton-Loder position), are associated ~vith a high inci-dence of median nerve compression and joint contractures and should beavoided. ~.4

A satisfactory reduction requires restoration of normal radial length(usually neutral variance) and stability provided by accurate apposition the anterior cortices of the radius. Invariably, the dorsal cortex is commi-nuted, and stability of the reduction hinges on the buttress of a relativelyintact anterior cortex. If both cortices are extensively comminuted, the frac-ture is unstable, and collapse with loss of reduction is inevitable (Fig. 6).In such cases, closed reduction and cast immobilization are insufficient treat-ment. Multiple attempts at reduction are pointless and potentially harmful.

Anterior displacement of the medial complex is usually associated withextensive comminution and is less suitable for closed manipulation. Althoughreduction by supination of the wrist may be successful for the less commi-nuted injuries, ~t manipulation of the distal fragments, particularly the palmarmedial fragment, is extremely difficult and usually unsatisfactory. It is im-portant to recognize that dorsiflexion of the wrist does not correct anteriordisplacement but rather increases l~anate compression of the medial complex,resulting in persistent and possibly further displacement. Articular fractureswith anterior displacements are usually type II injuries or, less frequently,type IV injuries and should be treated accordingly (Fig. 7).

Type lI Fractures

There is general agreement that continuous skeletal traction is necessaryto maintain a stable reduction of type II fractures, z,a.~-Tm.m7 Despite anaccurate reduction, these unstable injuries are prone to redisplacement,often to the prereduction position.~° The successful use of traction depends

226 CHAI~LES P. MELONE, JR.

Figure 6. A and B, Articular fi’acture with excessive shortening of-the medial complexand extensive comminution of both posterior and anterior cortices. Despite a seemingly suc-cessful closed manipulation (C and D), collapse with loss of reduction is inevitable (E). This an unstable type II fracture, and traction is the preferred method of treatment.

CHARLES P. MELONE, JR. ARTICULAR FRACTURES OF THE DISTAL RADIUS 227

tortening of-the medial complexrtices. Despite a seemingly suc-;duction is inevitable (E). This thod of treatment.

7. Most articular fractures with anterior displacement are type II injuries and cansuccessfully with traction. A and B, Type II fracture with displacement of the palmar

fragment. C and D, Successful reduction with traction and excellent preservation of thejoint surfaces.

228 CHARLES ~. MELONE, JR.

Figure 8. Pins and plaster tech-nique. A, The distal pin is passedthrough the base of the index and ~:nid-dle metacarpals, and the proximal, pinis passed through the radius. Inset, Theproximal pin must securely engageboth cortices of the radius but avoidthe critical soft tissue of the forearm.B, An unstable type II fracture treated~vith traction. C and D, The postre-duction radiographs demonstrate dis-traction of the medial complex and ac-curate restoration of its articulations.E, At 7 weeks, fracture healing withmaintenance of reduction and preser-vation of the articulations.

CHABLES P. MELONE, ARTICULAR FRACTURES OF THE DISTAL RADIUS 229

Figure 8 (Continued). See legend on oppositepage.

on the strength of the ligament component of the medial complex. Thecritical soft tissue attachments remain intact regardless of the severity of thefracture.

In my experience, fixation with pins and plaster, using two pereutaneousGz-ineh smooth Steinmann pins incorporated in a short arm east, is a con-sistently successful method of traction (Fig. 8). However, it is emphasizedthat success depends on precise technique and requires the use of a powerdrill. A variable-speed drfll’faeilitates atraumatie and accurate pin placement,avoids reaming of the pin holes, and undoubtedly minimizes complicationssuch as pin loosening and fracture at the site of pin insertion.

The distal pin is passed transversely through the base of the second andthird metacarpals. During placement of this pin, the thumb is held in widepalmar abduction and the width of the palm is maintained in order to preventthe development of web space eontraetures. The radius rather than the ulnais preferred for placement of the proximal pin because it provides bettercontrol of the fracture and interferes less with elbow function. The site ofinsertion is just proximal to the abductor pollicis longus muscle in the intervalbetween the wrist and finger extensors. The proximal pin is placed perpen-dicular to the distal pin ~,nd engages both cortices of the radius. Projectionof the pin several millim,eters beyond the anterior cortex of the radius pro-vides a firm purchase in the bone and avoids the critical soft tissues of the

The hand is suspended by a traction bow attached to the metacarpalpin, and with the elbow flexed to 90°, a 2- or 3-kg counterweight, suspended

a sling, is applied to the arm. In a short period, the operative radiographdemonstrates distraction of the medial complex and accurate resto-

CHARLES P. ~~ELONE, JR.

ration of its articulations. If there is residnal angulation, gentle manipula-tion-usually flexion and pronation--completes the reduction.

Following an accnrate reduction, the pins are incorporated in a shortarm cast, which is carefully applied leaving the fingers and thumb free forimmediate active motion. The wrist is positioned in slight flexion aud theforearm in mid-rotation. Once the fracture is stabilized, neither pronationnor supination influences displacement of the key medial fragments becausethey are free of muscle attachments. When the plaster is hard, the tractionbo~v and weights are removed, and the patient is strongly urged to beginactive motion of the digits, hmnobilization is continued for at least 6 weeksor until the eomminuted fragments are completely healed. In the office, thecast and pins are removed, and a carefully planned program of therapy beginsimmediately. Over a period of several months, the patient progresses fromactive exercises to increasingly resistive exercises with weights. Steadv im-provement is expected! for at least 6 months after removal of the cast.

Technical problems have occurred in only 3 of 70 type II fracturespersonally treated with pins and plaster: There was one instance of fractureredisplacement, ~vhich occurred when the pins ~vere removed prematurelyat 5 weeks. This patient later required an osteotomy, following ~vhich sheregained satisfactory function. There ~vere t~vo instances of loosening of theproximal radial pin, one occurring 3 weeks after insertion and the other 6~veeks after insertion. The former ease required placement of an ulnar pinfor continuation of traction, but in the latter case, the fracture was healedand did not require fnrther traction. Fracture displacement did not occurin either case. There was no instance of infection, soft tissue injuries, orfracture resulting from this method of percutaneous pinning and traction.

Concomitant Injury. Careful examination at the time of injury andbefore the administration of an anesthetic is necessary to detect nerve injury,which is prone to occur with type II articular fractures (see Table 1). Medianand ulnar neuropathy is invariably associated with a marked displacementof the medial complex and severe disruption of its ulnar articulation. C__har-acteristically, there is neurapraxia with loss of sensibility immediately afterinjury. In all cases, accurate closed reduction maintained by traction hasbeen followed by complete recovery of nerve function over a period of 4months.

Most of the serious concomitant skeletal injuries have occurred withtype II fractures (Fig. 9). Scapholunate dissociation occurred with severelydisplaced fractures, and as expected (owing to soft tissue attachments), thelunate displaced with the medial complex while the scaphoid remained withthe radial styloid. The carpal diastasis was corrected by reduction of themedial complex, the disrupted soft tissues of the scapholunate articulationhealed during the period of traction, and no cases resulted in chrc~nic carpalinstability. Fractures of the distal ulna with displacement of the ulnar headand scaphoid fracture.’; were also associated with the more severe Wpe IIinjuries. With the exception of one unstable scaphoid that required openreduction and internal fixation so that traction could be continued, concom-itant skeletal injury was treated successfully by an accurate and stable closedreduction of the articular fracture. Significantly, in the entire group of un-

CHARLES ~. NIELONE, JR.

~ngulation, gentle manipula-s the reduction.s are incorporated in a shorte fingers and thumb free forned in slight flexion and thestabilized, neither pronation~ev medial fi-agments becausee plaster is hard, the tractionnt is~strongly urged to begin~ontinued for at least 6 weeks;tely healed. In the office, thened program of therapy begins;, the patient progresses fromises with weights. Steady im-ufter removal of the east.nly 3 of 70 type II fractures’e was one instance of fractureas were removed prematurelyteotomy, following ~vhieh sheo instances of loosening of thet’ter insertion and the other 6red placement of an ulnar pinease, the fracture was healed

:e displacement did not occurreetion, soft tissue injuries, or:aneous pinning and traction.:ion at the time of injury andeeessary to detect nerve injury,fractures (see Table 1). Mediand with a marked displacementof its ulnar artieula.t__ion. Char-

3f sensibility immediately afteron maintained by traction, hasve function over a period of 4

:al injuries have occurred~ with~ciation occurred with severelyto soft tissue attachments), thenile the scaphoid remained withcorrected by reduction of the

3f the scapholunate articulationcases resulted in chronic carpaldisplacement of the ulnar headI with the more severe type IIle scaphoid that required3n could be continued, concom~by an accurate and stable closedln~ly, in the entire group of un-

ARTICULAR FRACTURES OF THE DISTAL, lq~DIUS 231

Figure 9. A, Severely displaced type II fracture with concomitant scapholunate disso-ciation and a displaced ulnar head fracture. B, Correction of the skeletal injuries by reductionof the medial complex. Successful treatment with traction prevented both carpal and radioulnarinstability.

stable fractures, reconstructive su:rg~ry, including excision of the ulnar head,has been necessary in only one case.

Type III Fractures

The displaced spike fragment is usually excised in conjunction with softtissue repair and skeletal fixation of the articular fracture. An anterior ap-proach extending from the proximal palm across the carpal tunnel to theulnar aspect of the wrist provides excellent exposure of the displaced frag-ment and the damaged soft tissues (see Fig. llD). Stabilization of the articularfraeture is achieved by either internal fixation using Kirsehner wires orexternal fixation using pins and plaster.

Concomitant Injury. In all cases, the displaced spike fragment con-tused and continually compressed the median nerve until it was excised

10A and B). In no case was the nerve disrupted, and following thorough decompression and over a period of 4 months, complete recoverywas the rule.

In addition to the acute eases, two malunited type III injuries referredreatment were complicated by median neuropathy, again due

to continuous compression by a displaced spike fragment. Both eases alsorupture of the flexor pollicis longus and flexor digitorum pro-

tendons (Fig. 10C and D). The ruptures occurred at the unreducedspike fragment approximately 3 months after injury. Because of extensive

232

Figure i0. Type III articular fractures. A and B, A displaced spike fragment compressingthe median nerve. C and D, A malunited spike fragment (at tip of forceps) resulting in chronicmedian neuropathy and attrition ruptures of the flexor pollicis longus tendou (FPL) and flexordigitorum profundus tendon (FDP) of the index finger.

Fi~with th~rotation

tendon damage, direct repair was impossible, and transfers ~vere used to C

restore tendon function. Most probably, these tendon injuries could have eeptio

been prevented by excision or replacement of the spike fragment at the time ~ media

of injury, edgemedia

Type IV Fractures sion,

Traction cannot correct the. separation or rotation of the medial frag- juneti~

ments, and open treatment is necessary for repair of the articular surfaces by ste:

as well as the frequently damaged soft tissue (Fig. 11). Typically, the palmar month

medial fragment is most severely displaced, and an anterior approach to the associa

wrist is necessary for reduction and fixation. Extending the incision across sharp

the carpal tunnel provides complete exposure of the articular fragments, ically,

The four-part comminuted fractures are generally not suitable for rigid fix-ation, and stabilization with Kirschner wires is used most frequently. First, rancor:

the medial fragments are reduced and fixed with wires; then they are care-fully aligned with the other fragraents and ~vith the ulnar head. Preservation sion, a

of the radioearpal joint requires precise apposition of the medial fragmentsand the styloid, and preservation of the distal radioulnar joint requires re- !i reeove

location and stabilization of the ulnar head in the sigmoid notch of the : seconc.

reduced medial fragments. Fracture stability is achieved with a minimumof four transfixion wires. Following reduction and fixation, the wrist is im- " .type I

mobilized in a short arm cast for 6 weeks, edge

CHARLES P. MELONE, JR.

A displaced spike fragment compressingmt (at tip of forceps) resulting in chronic¯ pollicis longus tendon (FPL) and flexor

ble, and transfers were used toaese tendon injuries could haveof the spike fragment at the time

~ or rotation of the medial frag-r repair of the articular surfaces~ (Fig. 11). Typically, the palmarand an anterior approach:to the

a. Extending the incision acrosssure of the articular fragments.nerally not suitable for rigid fix-,s is used most frequently. First,t with wires; then they are care-¢ith the ulnar head. Preservationposition of the medial fragmentsstal radioulnar joint requires re-~d in the sigmoid notch ofity is achieved with arrion and fixation, the wrist is

ARTICULAR FRACTURES OF THE DISTAL lq.ADIUS 233

Figure i1. Type IV articular fracture. A and B, Marked disruption of the medial complexwith the palmar medial fragment rotated 180°. C, Traction cannot correct the separation orrotation of the medial fragments.

Concomitant Injury. Median and ulnar neuropathy has been an ex-ceptionally common occurrence with type IV fractures (see Table 1). Themedian nerve invariably has been injured at the level of the comminutededge of the radial shaft, and i~t each case of ulnar neuropathy, the palmarmedial fragment contused the nerve. In all but one case, prompt decompres-sion, epineurotomv, and evacuation of a subepineural hematoma, in con-junction with fracture reduction and internal fixation, have been followedby steady and complete recovery of nerve function over a period of 4 to 5.months. The one case of complete median nerve disruption occurred inassociation with a laceration of the flexor pollicis longus tendon, also at thesharp edge of the radial shaft fragment. The nerve was repaired microscop-ically, and recovery was satisfactory.

In contrast to type II fracture neuropathy, which has improved spon-with successful fracture treatment, neuropathy associated with

~e III and type IV fractures requires thorough exploration and decompres-sion, and possibly even nerve suture. However, all nerve injuries associated

Jar fractures have demonstrated a similar and superiorof nerve function. Interestingly, none of the injuries required arepair or neurolysis during a follow-up period as long as 7 years.

Injury of the flexor pollicis longus tendon is also prone to occur with~e IV fractures. In all cases, the tendon has been lacerated at the sharp

of the comminuted radial shaft fragment and has been repaired pri-

234 CHARLES P. MELONE, JR.

Figure 11 (Continued). D, An anterior approach to the wrist provides excellent exposureof the displaced fragments and the damaged soft tissues. Inset, Derotation and reduction ofthe palmar medial fragment restore biarticular congruity. E and F, Postoperative radiographsfollowing open reduction and internal fixation with multiple Kirschner ~vires demonstrate ex-cellent restoration of the distal radial articulations.

marily at the time of the fracture treatment. All of these tendon injurieshave been associated with an injury, to the adjacent median nerve, and inone case, there was complete laceration of both the radial and ulnar arterieglThe vascular injuries were repaired microscopically, and a fasciotomy wasnecessary to restore adequate circulation in the hand.

Treatment OverviewThe McBride system of disability evaluation and the Lidstr6m radio-

graphic classification are the standard methods of analyzing the results oftreatment,a,5,7,9.1°,14,16 Based on these criteria, a preliminary review of 85unstable articular fractures leads to several conclusions. First, the classifi-cation proposed here serves as a useful guide for successful treatment. Sec-ond, an accurate and st~le reduction of the medial complex consistentlyresults in satisfactory and generally superior wrist function. Finally, despiteextensive comminution and technical problems of internal fixation, the morecomplex articular fractures (type III and type IV) are most effectively treatedby prompt and precise repair of the articular and soft tissue damage.

CHARLES t 9. MELONE, JR.

~vrist provides excellent exposure~set, Derotation and reduction ofand F, Postoperative radiographsKirschner ~vires demonstrate ex-

.11 of these tendon injuriescent median nerve, and inhe radial and ulnar arteries...~ally, and a fasciotomy washand.

~n and the LidstrSm radio-of analyzing the results ofpreliminary review of 85

clusions. First, the classifi-successful treatment. Sec-

aedial complex consistentlyst function. Finally, despite~f internal fixation, the moreare most effectively treated

~d soft tissue damage.

ARTICULAR FRACTURES OF THE DISTAL PtADIUS 235

SUMMARY

Fractures of the distal radius are frequently articular injuries resultingin disruption of both the radiocarpal and distal radioulnar joints. The articularfracture comprises four basic components: (1) radial shaft; (2) radial styloid;(3) dorsal medial fragment; and (4)palmar medial fragment. The medialfragments and their strong ligamentous attachments with the proximal ear-pals and ulnar styloid have been termed the medial complex, and its dis-placement is the basis for a useful classification into four fracture types.

Type I fractures are undisplaced:, or they are stable after closed reduc-tion with preservation of the joint surfimes. Type II fractures are comminutedand unstable, with displacement of the medial complex as a unit, and arebest managed with continuous skeletal traction. Type III spike fi’acturesdemonstrate displacement of the medial complex as a unit as well as dis-placement of an additional fragment fi’om the eomminuted radial shaft. Thespike fragment characteristically causes injury to an adjacent nerve or tendonand requires excision or replacement along with repair of the soft tissue atthe time of skeletal fixation. Type IV split fractures require open reductionand internal fixation for an accurate repair of the disrupted distal radialarticular surfaces.

The unstable articular fractures are frequently associated with seriousconcomitant nerve, tendon, or skeletal injury, which must be recognizedand often repaired at the time of fi:acture treatment. These injuries areusually the result of violent trauma, and contrary to common opinion, theydo not characteristically occur among; the elderly.

Optimal management of distal radial fractures requires early recognitionand repair of articular disruption and any associated soft tissue or skeletalinjury. Precise reduction of the medial complex consistently restoresbiarticular congruity and generally re.s, ults in a superior recovery of wristfunction.

REFEtlENCES

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: 2. Anderson, R., and O’Neill, G.: Comminuted fractures of the distal end of the radius. Surg.Gynecol. Obstet., 78:434, 1944. /

3. Cole, J.M., and Obletz, B.E.: Comminuted fractures of the distal end of the radius treatedby skeletal transfixion in plaster cast. Aa end-result study of thirty-three cases. J. BoneJoint Surg., 48A:931, 1966.

4. Cooney, W.P., III, Dobyns, J.H., and Linscheid, R.L. : Complications of Colles’ fracture.~ii~ ~ J. Bone Joint Surg., 62A:613, 1980.

5. Cooney, W.P., III, Linscheid, R.L., and Dobyns, J.H.: External pin fixation for unstableColles’ fractures. J. Bone Joint Surg., 6:1A:840, 1979.

DePalma, A.F.: Comminuted fractures of the distal end of the radius treated by ulnarpinning. J. Bone Joint Surg., 34A:651, 195’2.

DoMing, J.J., and Swyer, B., Jr.: Comm:inuted Colles’ fractures: Evaluation of a method~ of treatment. J. Bone Joint Surg., 43A:657, 1961.

Ellis, J.: Smith’s and Barton’s fractures. A method of treatment. J. Bone Joint Surg.,47B:724, 1965.

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236 CHARLES P. ~IELONE, JR.

drome, disturbance in the distal radionlnar joint and impairment of nerve function: Aclinical and experimental study. Acta Orthop. Scand. (Suppl.), 108:1-153, 1967.

10. Gartland, J.J., Jr., and Werley, C.W.: Evaluation of healed Coltes’ fractures. J. Bone JointSurg., 33A:895, 1951. ¯

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12. Gelberman, R.H., Salamon, P.B., Jurist, J.M., et al. : Ulnar variance in Kienb6ck’s disease.J. Bone Joint Surg., 57A:67.4, 1975.

13. Green, D.P.: Pins and plaster treatment of comminuted fractnres of the distal end of theradius. J. Bone Joint Surg., 57A:304, 1975.

14. LidstrSm, A.: Fracture of the distal end of the radins. A clinical and statistical study ofend results. Acta Orthop. Scand. (Suppl.), 41:1-118, 1959.

15. McMaster, P.E.: Late ruptures of extensor and flexor pollicis longus tendons followingColles’ fracture. J. Bone Joint Surg., 14:93, I932.

16. Sarmiento. A., Pratt, G.\V., Berry, M.C., et al.: Colles" fractures. Functional bracing insupination. J. Bone Joint Surg., 57A:311, 1975.

17. Scheck, M.: Long-term follow-up of treatment of comminuted fractures of the distal endof the radius by transfixation with Kirschuer wires and cast. J. Bone Joint Surg., 44A:337,1962.

18. Southmayd, W.W., Ivlillendel’, L.H., mad Nalebufl; E.A.: Rupture of the flexor tendonsof the index finger after Col]es’ fracture. Case report. J. Bone Joint Surg., 57A:562, 1975.

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20. Taleisnik, J.: The ligaments of the wrist. J. Hand Surg., 1:110, 1976.21. Thomas, F.B.: Reduction of Smith’s fracture. J. Bone Joint Surg., 39t3:463, 1957.22. Vance, R.M., and Gelberman, R.H.: Acute ulnar neuropathy with fractures at the wrist.

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Colles fracture. A case report. J. Bone Joint Surg., 59A:828, 1977.24. Zo~ga, H.: Fracture of the louver end of the radius with ulnar nerve palsy. J. Bone Joint

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