RADIOLOGICAL EVALUATION OF DR #

1. RADIOGRAPHIC EVALUATION OF
VARIOUS TYPES OF DISTAL RADIUS
FRACTURES AND THEIR SIGNIFICANS
DR CHIRANJEEVI

2. PROBLEMS OF DISTAL RADIUS FRACTURES
• Common injury
• High potential for functional impairment and frequent
complications
• Risk factors include increasing age, decreased bone mineral
density, female sex, white race, family history and early
menopause

3. INCIDENCE
• Children do well (10%)
• Middle age- high velocity injuries, high functional demands
(60%)
• Old age- less functional demands (30%)

4. Introduction
• Distal radius fractures occur through the distal metaphysis of the
radius
• May involve articular surface
• frequently involving the ulnar styloid
• Most often result from a fall on the outstretched hand.
• forced extension of the carpus,
• impact loading of the distal radius.
• Associated injuries may accompany distal radius fractures.

5. Introduction
• Classified by:
• presence or absence of intra-articular
involvement,
• degree of comminution,
• dorsal vs. volar displacement,
• involvement of the distal radioulnar
joint.

6. Diagnosis: History and Physical Findings
• History of a fall on the outstretched hand or an episode of trauma
• A visible deformity of the wrist is usually noted, with the hand most
commonly displaced in the dorsal direction.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the neurovascular status of the
hand is imperative, before any treatment is carried out.

7. Diagnosis: Diagnostic Tests and Examination
• General physical exam of the patient, including an evaluation of the injured
joint, and a joint above and below
• Radiographs of the injured wrist
• Radiographs of other areas, if symptoms warrant.
• CT scan of the distal radius in selected instances.

8. Treatment Goals
• Preserve hand and wrist function
• Realign normal osseous anatomy
• promote bony healing
• Avoid complications
• Allow early finger and elbow ROM

9. Osseous Anatomy
• Distal radius – 80% of axial load
• Scaphoid fossa
• Lunate fossa
• Sigmoid notch – DRUJ
• Distal ulna

10. Anatomy
• Scaphoid and lunate fossa :
• Ridge normally exists between these two
• Sigmoid notch :
second important articular surface
• Triangular fibrocartilage
complex(TFCC): distal edge of radius
to base of ulnar styloid

11. Radiology
• Radial inclination = 22°
• Radial length = 12mm
• ulnar neutral
• Palmar tilt = 11-14°
• Scapho-lunate angle = 47° +/- 15°

12. Radial height
• normal 9-12 mm
• shortening of upto 3-5 mm can be
associated with satisfactory result, as
long as there is an accurate articular
restoration
• >10 mm of shortening is associated
with symptoms, including
involvement of DRUJ

13. Radial Inclination(ulnar slant)
• On the PA view the radius inclines towards the ulna
 Radial inclination: averages 23 degrees (range, 13 to 30
degrees)

14. Palmar (volar) tilt
• Palmar (volar) tilt: avg 11-12°
• normally ranges from 11° of volar tilt to
4° of dorsal tilt

15. MEASUREMENT OF RADIAL LENGTH AND INCLINATION

16. 1: Line connecting dorsal
and volar tip of lunate
2: Line perpendicular
to lunate
3: Line along axis of
scaphoid
Scapholunate angle measured between lines 2 and 3
(normal 47 ± 15 degrees)

17. Teardrop angle
• The teardrop of distal radius articular surface refers to the U-shaped outline
of the volar rim of the lunate facet
• normally 70°
• depressed teardrop angle may be the only evidence that reduction is
incomplete and articular incongruity remains
• The AP distance is defined by the distance between the apices of the dorsal
and volar rims of the lunate facet

19. fractures of the
distal radius
On PA radiograph
Radial height, ulnar variance, radial inclination, dorsal/palmar tilt
On lateral radiograph
carpal alignment, teardrop angle, AP distance
Articular step off should be 2mm or less

20. • Overall alignment of the fracture was considered
‘unacceptable’ if
• dorsal tilt was > 10°
• radial inclination was < 15°
• if there was ≥ 3 mm of positive ulnar variance

22. Computed Tomography
Indications:
• Intra-articular fractures with multiple fragments
• centrally impacted fragments
• DRUJ incongruity

23. Classification of
Distal Radius Fractures
• Ideal system should describe:
• Type of injury
• Severity
• Evaluation
• Treatment
• Prognosis

24. ABRAHAM COLLES (1773-1843)
professor of Surgery at
the College of Surgeons
in Dublin (Ireland) from
the age of 29
• first to tie the
subclavian artery
• best known for his
description of Colles'
fracture, in 1814

25. Classification
Originally named after surgeons who described it-
• Colles’ fracture
• Smith’s fracture
• Barton’s fracture
• Chaufeur’s fracture

26. Common Classifications
1. Gartland/Werley
2. Frykman
3. AO/ Weber
4. Melone
5. Column theory
6. Fernandez (mechanism)
7. Universal classification.

27. Gartland and werley
Grp 1- simple distal radius fracture with no involvement of radial articular
surfaces
Grp 2 - comminuted distal radius fractures with intraarticular extension
without displacement
Grp 3 - comminuted distal radius fracture with intraarticular extension with
displacement
 Grp4 - Extra articular , undisplaced

28. Frykman Classification
Extra-articular
Radio-carpal joint
Radio-ulnar joint
Both joints
Same pattern as odd
numbers, except ulnar
styloid also fractured

29. AO/ OTA Classification
Group A:
Extra-articular
Group B:
Partial Intra-
articular
Group C:
Complete
Intra-articular
Volar and dorsal
Barton fxs

30. Melone classification
• Type 1 – stable fracture without displacement.
This pattern has characteristic fragments of
radial styloid and a palmar and dorsal lunate
facet.
• Type 2 – unstable “die punch” with
displacement of the characteristic fragments
and comminution of the anterior and posterior
cortices.type 2 a is reducible ,type 2b is
irreducible

31. • Type 3 – “spike fracture” unstable. Displacement of the articular
surface and also of the proximal spike of the radius.
• Type 4 – “split fracture” unstable medial complex that is severely
comminuted with seperation or rotation of the distal and palmar
fragments.
• type 5 – explosion injury.

32. Column Theory
3 Columns: radial, intermediate, medial

33. Classification – Fernandez (1997)
• I. Bending-metaphysis fails under
tensile stress (Colles, Smith)
II. Shearing-fractures of
joint surface (Barton, radial
styloid)

34. • III. Compression-intraarticular
fracture with impaction of
subchondral and metaphyseal bone
(die-punch)
• IV. Avulsion-fractures of ligament
attachments (ulna, radial styloid)
• V. Combined/complex - high velocity
injuries

35. • Based on simple concept and
principle of extra articular versus
intraarticular fracture and stable versus unstable
fracture

36. Universal Classification
• Type I extraarticular, undisplaced
• Type II extraarticular,displaced
A. Reducible, stable
B. Reducible, unstable
C.Irreducible

37. • Type III Intraarticular, undisplaced
• Type IV Intraarticular,displaced
A)Reducible,stable
B)Reducible,unstable
C) Irreducible
D)Complex

38. Assessment of X-rays
• Assess involvement of dorsal or volar rim
• Is comminution mainly volar or dorsal?
• is one of four cortices intact?
• Look for “die-punch” lesions of the scaphoid or lunate fossa.
• Assess amount of shortening
• Look for DRUJ involvement

39. Dorsal angulation and comminution

40. Volar subluxation of carpus with fracture fragment