Fractures of the distal radius

Colles` fracture

This fracture is described by Ibraham colles` in 1814 . It is a transverse fracture of the distal end of the radius with posterior displacement of the distal fragment. It is the most common of all fractures in the human being ; mainly in old osteoporotic people , but it occur in all age groups . It is occur due to fall on out stretched hands

X-ray : there is transverse fracture of the Clinically : The deformity of this fracture called dinner – fork deformity . The patient also has the sign and symptoms of any other fracture like pain , tenderness , loss of function , swelling …..etc . X-ray : there is transverse fracture of the radius at the cortico – cancellous junction , and the distal fragment is displaced posteriorly ; some time it is severely comminuted or crushed .

Treatment : It must be reduced under general anesthesia, the reduction will be by traction on the hand in the length of the bone , the distal fragment then pushed into place by pressing on the dorsum while manipulating the wrist into flexion , ulnar deviation and pronation

Then put back slab and check by x-ray . The back slab from below elbow to the neck of the metacarpals . Extreme pronation , flexion and ulnar deviation must be avoided ; 20` in each direction is adequate . Shoulder and fingers exercise then started . After 7-10 days remove the slab and do full p.o.p. . The fracture usually unite in 6 weeks

Complication : early : 1-vascular damage radial artery (rare) . 2- nerve damage median nerve (rare) . Late complication : 1- malunion : it is common due to unreduced fracture or due to redislpacement . 2- delayed union and non union . 3-stiffness of the wrist ,fingers, elbow and shoulder 4-tendon rupture of extensor polices longus . 5- sudeck`s dystrophy (localized sympathetic over activity). 6-carpal- tunnel syndrome . Smith fracture :it is the same as colles` fracture but the distal segment is displaced anteriorly .

Radial styloid process fracture : Here the fracture line extend from the articular surface of the radius laterally . Treatment : If there is displacement , the fracture should be reduced by manipulation under anesthesia , then back slab below elbow tell the neck of the metacarpal ; imperfect reduction will lead to osteoarthritis , so if the fracture not reduced perfectly by manipulation then open reduction and fixation by screw or k wire .

BARTON`S FRACTURE 1- volar Barton's`: called true Barton fracture and It is intra articular fracture of the lower end of the radius with subluxation of the wrist joint . It is of two types : 1- volar Barton's`: called true Barton fracture and it associated with volar subluxation of the carpus . The fracture line run obliquely across the volar lip of the radius into the wrist joint . The distal segment displaced anteriorly carrying the carpus with it . Treatment : the fracture easily reduced but it is unstable so it can easily redisplaced so the treatment will be by open reduction and fixation by special plate called Buttress plate . 2- dorsal Barton`s: it is the reverse of the volar one .

Fracture scaphoid bone It is caused by fall on out stretched hands ; the most important point in scaphoid is its blood supply inter the bone from distal to proximal direction , so the blood supply is decreased from distal to proximal ; this fact explain why only 1% of the fracture in the distal third of scaphoid , 20% of the fract. In the middle third and 40% of the proximal third fract. Will develop avascular necrosis and non union .

Clinically : there is fullness and tenderness in the anatomical snuff box ; other diagnostic sign is that, proximal pressure along the axis of the thumb is painful . X-ray : a-p , lateral and oblique views are all essentials . Some time recent fracture show it self only in oblique view . Usually the fracture is transverse and through the narrowest part of the bone (the waist) , but it could be in the proximal pole or in the tubercle ; few weeks after injury the fracture will be more obvious

Fracture scaphoid

If union is delayed , cavitation appear on either side of the fracture . In old ununited fracture there will be sclerosis at the edge and the appearance will be as there is extra carpal bone . Sclerosis of the proximal fragment is path gnomonic of avascular necrosis of the proximal fragment .

Treatment : Undisplaced fracture : conservative treatment by p.o.p. cast in 90% of the cases will heal ; the cast will be applied from upper forearm to just short of the metacarpophalangeal joint of the fingers but it should incorporating the proximal phalanx of the thumb ; the wrist is held in dorsiflexion and the thumb forward in ( GLASS HOLDING ) position and it should be retained for 6 weeks . After 6 weeks the p.o.p. removed and the wrist examined clinically and radiologically , if there is no tenderness and the x-ray show sign of healing , the wrist is left free

Displaced fracture : treatment by open If there is local tenderness or the fracture is still visible in x-ray , the p.o.p. is reapplied for further 6 weeks and after that either the wrist become painless and the fracture healed so the p.o.p. removed or the x-ray show sign of delayed healing then we should do fixation and bone grafting . Displaced fracture : treatment by open reduction and fixation by compression screw .

Complication 1- avascular necrosis : the proximal fragment may die especially with proximal pole fracture , it will appear dense on x-ray . Treatment : by excision of the proximal fragment . 2- non union : after 3 months if fracture not united it will be obvious that the fracture will not unite at all . Treatment :in old people and in those who are completely asymptomatic , non union may be left untreated . In young patients treatment by fixation and bone grafting .

non union fracture scaphoid

Avascular necrosis of proximal segment of scaphoid frac.

If the graft fail then do excision of the scaphoid and fusion of the carpel bones . 3- osteoarthritis : non union and avascular necrosis may lead to secondary osteoarthritis .