Distal radial fractures are a heterogeneous group of fractures that occur at the distal radius and are the dominant fracture type at the wrist. These common fractures usually occur when significant force is applied to the distal radial metaphysis.
Distal radial fractures can be seen in any group of patients and there is a bimodal age and sex distribution. Younger patients tending to be male and older patients tending to be female.
The majority of patients with a distal radial fracture present following a fall onto an outstretched hand. They are in pain and have a reduced range of motion. There may be an associated deformity and in severe cases, distal neurovascular compromise.
Trauma is almost always the cause of distal radial fractures and is often the result of a fall onto an outstretched hand (FOOSH).
In young adults, the long bones tend to be strong and the force required to break the bone is significant. Thus, distal radial fractures in younger patients require much greater force, e.g. falling from a significant height, severe road traffic accident.
In the elderly, the bones tend to have a much lower bone density and are consequently much weaker. Fracture of the distal radius can occur with injuries that exert much less force, e.g. falling from standing height.
Force applied longitudinally or obliquely to the hand and wrist is absorbed by the distal radius because it is the load-bearing bone in the forearm. If this force is greater than the strength of the bone, a fracture occurs.
When most people fall, they do not axially load the forearm, but apply an oblique force longitudinally and dorsally. If a fracture does occur, there is usually associated dorsal angulation.
They are best described in terms of their fracture type, location, displacement and joint involvement. Traditionally, eponymous names were given to the common fracture types of the distal radius:
- Colles fracture: transverse extra-articular fracture with dorsal angulation
- Smith fracture: transverse fracture with palmar angulation
- Barton fracture
- chauffeur fracture
There are many radiological classification systems, e.g. Frykman classification. However, it is more important to recognise what makes the fracture more severe:
- oblique, spiral or comminuted configuration
- greater degree of angulation
- intra-articular involvement
- additional fractures
- associated dislocation
- associated ligamentous injury
Diagnosis usually only requires a standard wrist x-ray series. In some complex cases, additional cross-sectional imaging (usually CT) is required to accurately assess the fracture. This is especially true when there is a multi-part fracture with joint involvement.
Plain radiograph / CT
Most distal radial fractures in adult patients are transverse metaphyseal fractures. They are often extra-articular, but some may extend into the joint and when they do, it is important to recognise. The degree of displacement (usually dorsal) is important because it will be a determining factor for treatment (whether to reduce or not before immobilisation).
When describing the fracture, think about:
- what type of fracture is it?
- is there displacement?
- is there joint involvement?
- is there an accompanying ulnar styloid fracture?
Treatment and prognosis
Treatment is dependant on the type of fracture (as determined by the x-ray). The vast majority of distal radial fractures are relatively uncomplicated and do not require a trip to theatre and can be managed as an outpatient with review in fracture clinic.
Fractures with significant displacement require manipulation (under sedation or anaesthetic). A small number will require internal fixation following manipulation.
A small proportion of patients treated conservatively need to be followed up. If a fracture is stable and treated in cast it must be reviewed regularly because of the risk of displacement. This is particularly true if the cast becomes loose once the wrist swelling subsides. Late displacement warrants surgical consideration.
- 1. Goldfarb CA, Yin Y, Gilula LA et-al. Wrist fractures: what the clinician wants to know. Radiology. 2001;219 (1): 11-28. doi:10.1148/radiology.219.1.r01ap1311 - Pubmed citation
- 2. Rutgers M, Mudgal CS, Shin R. Combined fractures of the distal radius and scaphoid. J Hand Surg Eur Vol. 2008;33 (4): 478-83. doi:10.1177/1753193408090099 - Pubmed citation
- 3. Meena S, Sharma P, Sambharia AK et-al. Fractures of distal radius: an overview. J Family Med Prim Care. 2014;3 (4): 325-32. doi:10.4103/2249-4863.148101 - Free text at pubmed - Pubmed citation
- fracture location
- fracture types
- avulsion fracture
- articular surface injuries
- complete fracture
- incomplete fracture
- compound fracture
- pathological fracture
- stress fracture
- fracture displacement
- skull fractures
- fractures involving a single facial buttress
- complex fractures
cervical spine fracture classification systems
- AO classification of subaxial injuries
- Anderson and D'Alonzo classification (odontoid fracture)
- Levine and Edwards classification (hangman fracture)
- Roy-Camille classification (odontoid process fracture )
- Allen and Ferguson classification (subaxial spine injuries)
- thoracolumbar spinal fracture classification systems
- three column concept of spinal fractures (Denis classification)
- classification of sacral fractures
- cervical spine fracture classification systems
- spinal fractures by region
- cervical spine fractures
- thoracic spine fractures
- lumbar spine fractures
- sacral fractures
- spinal fracture types
- rib fractures
- sternal fractures
upper limb fractures
- Rockwood classification (acromioclavicular joint injury)
- Neer classification (proximal humeral fracture)
- AO classification (proximal humeral fracture)
- Milch classification (lateral humeral condyle fracture)
- Weiss classification (lateral humeral condyle fracture)
- Bado classification of Monteggia fracture-dislocations (radius-ulna)
- Mason classification (radial head fracture)
- Frykman classification (distal radial fracture)
- Mayo classification (scaphoid fracture)
- Hintermann classification (gamekeeper's thumb)
- Eaton classification (volar plate avulsion injury)
- Keifhaber-Stern classification (volar plate avulsion injuries of hand)
- upper limb fractures by region
- carpal bones
- metacarpal fractures
- fractures of the thumb
- phalanx fractures
- lower limb fractures
- classification by region
- Pipkin classification (femoral head fracture)
- Garden classification (hip fracture)
- American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
- Cooke and Newman classification (periprosthetic hip fracture)
- Johansson classification (periprosthetic hip fracture)
- Vancouver classification (periprosthetic hip fracture)
- Schatzker classification (tibial plateau fracture)
- Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)
- Watson-Jones classification (tibial tuberosity avulsion fracture)
- Berndt and Harty classification (osteochondral lesions of the talus)
- Sanders CT classification (calcaneal fracture)
- Hawkins classification (talar neck fracture)
- Myerson classification (Lisfranc injury)
- Nunley-Vertullo classification (Lisfranc injury)
- lower limb fractures by region
- pelvic fractures
- sacral fractures
- mid-shaft fracture
- bisphosphonate-related fracture
- avulsion fractures
- Segond fracture
- reverse Segond fracture
- anterior cruciate ligament avulsion fracture
- posterior cruciate ligament avulsion fracture
- arcuate complex avulsion fracture (arcuate sign)
- biceps femoris avulsion fracture
- iliotibial band avulsion fracture
- semimembranosus tendon avulsion fracture
- Stieda fracture (MCL avulsion fracture)
- patella fracture
- tibial plateau fracture
- avulsion fractures
- tarsal bones
- Chopart fracture
- calcaneal fracture
- talus fracture
- navicular fracture
- medial cuneiform fracture
- intermediate cuneiform fracture
- lateral cuneiform fracture
- cuboid fracture
- metatarsal bones
- tarsal bones
- classification by region