Recommendations

Key Recommendations

A thorough history and comprehensive clinical examination are critical to a clinical diagnosis, which is then confirmed by radiographs.

History

A history of trauma is almost always present. A fall on the outstretched hand (FOOSH) is often the cause and may occur from a simple slip or trip. This mechanism is more common in the older age groups.[14] In such patients the possibility of osteoporosis as a predisposing factor for fractures should be considered. In the younger patient, there is often a history of a fall on the outstretched hand during a sporting activity, or a history of a vehicular trauma.[11][14]

Often the details of the exact cause/mechanism can be limited.

Physical examination

Nondisplaced fractures

Nondisplaced fractures usually present with localized swelling but no deformity. Tenderness over the distal radius is the hallmark.

Displaced fractures

Displaced fractures often present with the classic "dinner fork" deformity with dorsal angulation at the fracture site (resulting from dorsal displacement from falling on a pronated hand). The wrist is tender and range of motion is limited by pain.

The carpus, especially the scaphoid, should be carefully palpated in the anatomic snuff-box distal to the distal radius. Tenderness in this area is suggestive of a scaphoid fracture, either as an isolated injury or associated with concomitant fractures of the distal radius.[2]

Open fractures

Fractures of the distal radius can sometimes be associated with open wounds. Irrespective of age, an open wound usually suggests a high-energy injury.[6] In these fractures patients may experience numbness affecting the radial three digits, suggesting acute median nerve compression (carpal tunnel syndrome).[6] Numbness of the ulnar two digits, suggesting ulnar nerve compression, is less common. Signs of a vascular injury include lack of a palpable pulse, continued blood loss, and an expanding hematoma.[29] The key clinical findings of compartment syndrome are pain out of proportion to the associated injury and pain on passive movement of the muscles of the involved compartments.[30] Pulses are normally present in compartment syndrome. Absent pulses are usually due to systemic hypotension, arterial occlusion, or vascular injury.[30] See Compartment syndrome of extremities.

Imaging

X-ray

An initial radiographic examination is required to make a conclusive diagnosis of a distal radius fracture.[31]

Typically posteroanterior, lateral, and carpal views should be obtained.[31] Fractures may be minimal cracks, extra-articular fractures, or intra-articular fractures. Radiographs also suggest the degree of osteopenia, and may offer some information about the degree of articular involvement or comminution.

Although uncommon, combined injuries of the distal radius and scaphoid are seen. Scaphoid fractures can be missed and radiographs must be carefully examined for these fractures.[2] In patients where there is pain or tenderness in the anatomic snuff-box a clinical diagnosis of a scaphoid fracture should be considered. 

For fractures of the distal radius, radiographic features that suggest the need for surgical treatment include:[13][32][33][34][35]

  • Initial loss of radial length in excess of 15 mm

  • Angulation apex-volar of >20°

  • Postreduction radial shortening of >3 mm

  • Dorsal tilt of >10°

  • Intra-articular step-off of >2 mm.

Computed tomography (CT) scan

Do not order CT scans for children until physical exam has been completed and plain radiographs have been obtained. CT scans deliver a significant dose of radiation to a child, so their utility needs to be confirmed prior to ordering.[36]​ However, in patients where surgical fixation is considered, a CT scan of the distal radius is beneficial for the analysis of extra- and intra-articular fracture geometry and preoperative planning.[31] A CT scan may also reveal any occult fractures around the carpus.

Magnetic resonance imaging (MRI)

Do not order MRI scans for children until physical exam has been completed and plain radiographs have been obtained. MRI scans may not be correctly interpreted without all of the necessary clinical information and frequently require sedation in a young child.[36]​ However, scaphoid fractures can be missed on x-ray; consider an MRI (without contrast) as first-line imaging if an occult fracture of the scaphoid is suspected.[37]​ It may also be used to define associated ligamentous injuries.​[38][39]

Bone mineral density (BMD) / Dual-energy x-ray absorptiometry (DXA)

Assessment of bone mineral density should be performed as part of the follow-up in all patients over the age of 50 years.[16]

DXA is considered the standard for measurement of bone density; the World Health Organization considers BMD measurements diagnostic for osteoporosis.[40]​​​​​[Figure caption and citation for the preceding image starts]: Type A extra-articular fracture of the distal radius: lateral viewFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].Type A extra-articular fracture of the distal radius: lateral view[Figure caption and citation for the preceding image starts]: Type B (simple) intra-articular fracture of the distal radius: lateral viewFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].Type B (simple) intra-articular fracture of the distal radius: lateral view[Figure caption and citation for the preceding image starts]: Type C (complex) intra-articular fracture of the distal radius: lateral viewFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].Type C (complex) intra-articular fracture of the distal radius: lateral view[Figure caption and citation for the preceding image starts]: CT scans of the wrist provide excellent detail to assess fracture geometry and articular involvement, as well as degree of comminutionFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].CT scans of the wrist provide excellent detail to assess fracture geometry and articular involvement, as well as degree of comminution

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