HOW TO CLASSIFY DISTAL RADIAL FRACTURES

The IFSSH Board of Directors wished to examine the potential for a universal classification of fractures and dislocations of the hand and wrist. If this could be accomplished, classifications could be standardized as a constant. The method of treatment would then be the variable. Scientific method would then be applied to analyze different outcome parameters. This would allow a comparative assessment of treatment methods between two or more groups throughout the world. It would allow the accumulation of data by the addition of related series of cases. This would add power to the validity of the conclusions reached by statistical analysis.

Our charge was to initiate the classification process in the targeted area of distal radial fractures. We were asked to examine existing classifications and select one, or modify, combine, or otherwise formulate and endorse a classification system for distal radial fractures. The classification system selected must be sufficiently simple so that it could be applied in undeveloped countries, and yet allow for the contribution of sophisticated analytical technology where it exists. It must provide intra-observer and inter-observer reliability. It should serve as a discriminator for treatment and outcome expectations.

Classification of distal radial fractures has largely occurred in the past two hundred years. Fracture eponyms pay tribute to those who initiated the process: Pouteau,⁷⁶ Colles,^20,21 Barton,¹¹ Goyrand, and Smith.^{70-72, 94} Each described one or more specific fractures that they characterized by clinical evaluation or laboratory dissection, without the aid of X-rays. With this foundation, many investigators progressively contributed to the breadth and depth of understanding of distal radial fractures based on fracture attributes and severity (Tables 1-15).^{8,16,18,22,25,26,42,44,45,49,56-59,67,73,85,86,88,90} Until the last decade, Frykman's classification ³⁴ was the most popular, but it does not define displacement, shortening, or the extent of comminution. Each method of classification had its champions, who touted its strengths, but always there were critics which identified weaknesses as well.

At two international committee meetings during the fifth and sixth IFSSH Congresses, (May, 1992, Paris, France and July, 1995, Helsinki, Finland), the Bone and Joint Committee reviewed each classification. Three classifications emerged as contemporary finalists. These were: 1) the classification of Rayhack,^78,79 further modified by Cooney and his associates at the Mayo Clinic,^23,24 2) the classification of Fernandez,^30,31 and 3) the classification of Muller and associates.^62,63

After much deliberation, the committee could not reach a consensus, much less unanimity, to support one of these classifications at the expense of the other two. Finally, it was unanimously agreed that a universal system should be generic in nature. It should detail measurable fracture characteristics that would cover the basic patterns and displacement while still allowing for expansive detail. Such a system would avoid individual and geographic controversies and would be dynamic and permit continuous editing with additions, deletions, and updating where appropriate.

The characteristics agreed upon were: 1) location, 2) configuration, 3) displacement, 4) ulnar styloid integrity, 5) distal radioulnar joint integrity, 6) stability, 7) associated injuries, and 8) bone mineralization. The two primary x-ray views of the wrist, a posteroanterior and a lateral view, are almost universally available. They are standardized for wrist position, x-ray beam distance and direction and radiographic technique.^{87, 95} Each of the recommended parameters can be measured on these two x-rays. This information can be supplemented by additional views or special imaging studies when they are necessary and available.

LOCATION

Location would be defined as extraarticular or intraarticular. Intraarticular fractures would be designated as those involving the radiocarpal joint, distal radioulnar joint, or both.

CONFIGURATION

Fracture configuration would be designated as either simple or comminuted. Simple fractures would be either transverse or oblique. The obliquity would be defined as it appeared on posterioanterior and lateral X-rays. Comminution would be defined as involving the dorsal extraarticular cortex, the palmer extraarticular cortex, or both; and/or the articular surface of the distal radius at the radiocarpal joint, the distal radioulnar joint or both. The number of major intraarticular fragments would be defined. Fragments designating the styloid ^28,57-59 and dorsal and volar medial die punch fragments are recognized. The articular surface of the distal radius may be shattered with or without one or more major fragments.^75,93

DISPLACEMENT

Fractures are either undisplaced or displaced. A fracture with an offset of more than 1 mm in any plane or in the articular surface is considered displaced. Axial shortening, radial inclination and radioulnar displacement can be measured on the routine posterior/anterior film (Figure 1). Dorsal inclination and dorsal palmar displacement can be measured on the routine lateral X-ray (Figure 2). Fragment displacement and rotation may be further defined on CAT scan.^{1,19,50,74,97}

ULNAR STYLOID INTEGRITY

The ulnar styloid should be evaluated on routine X-rays. It should be determined whether it is intact or fractured. The fracture should be designated as to its level at the tip, mid portion, or base. Displacement, if any, should be defined. Displacement, again, is any off set of 1 mm or more in any plane. The amount of displacement can be measured on routine films.^34,41

DISTAL RADIOULNAR JOINT INTEGRITY

The distal radioulnar joint should be evaluated both clinically and radiographically for stability. Evaluation can be compared to the opposite and non involved side. Any subluxation or instability should be noted as well as its direction; dorsal or palmar. Similarly, dorsal or palmar dislocation should be noted.^{3,15,41,53,61}

STABILITY

A review of clinical and radiographic criteria for instability led the committee to designate that any one or more of the following criteria is an indication of distal radial fracture instability: 1) greater than 10 degrees loss of angulation, 2) greater than 5 mm of axial radial shortening (Figure 3), 3) greater than 2 mm of articular incongruity, 4) comminution of one cortex across the mid axial line on lateral X-ray (Figure 4), 5) comminution of both dorsal and palmar cortices, 6) an irreducible fracture, and 7) loss of reduction.^{1,2,4,5,9,10,12,14,17,19,29,33,35,37,43,46,50,60,65,69,74,89,92,96,98}

ASSOCIATED INJURIES

Associated injuries should be cataloged. Any laceration, crush, loss or avulsion of skin, muscle, tendon, nerve, artery, ligament, or fracture dislocation of bone should be noted. Lacerations should be cataloged as partial or complete. The extent and direction can be measured. The extent of crush or loss should be measured.

Ligament injuries of the wrist should evaluate the triangular fibrocartilage complex, as well as the intrinsic and extrinsic wrist ligaments. Location and extent can classify each of these.^{6,13,36,40,48,51,52,55,80,82} A well recognized classification of triangular fibrocartilage complex injury exists.⁶⁸ The peripheral tears can be further classified by the arcs and the number of degrees subtended. Wrist intrinsic and extrinsic tears can be classified as in continuity, partial and complete. Carpal instability can be defined by classically measured intracarpal angles. Carpal fractures, especially those of the scaphoid,³⁸ can also be classified by location, configuration, displacement and stability.

BONE MINERALIZATION

Bone mineral density influences the fracture pattern, displacement, the ability of fixation implants to purchase the fragments; and, consequently the outcome.^27,83,84 The presence of osteopenia can be categorized by measurement of metacarpal cortical indices or by photon densometry. Single photonabsorptiometry is the preferred method for highest precision and accuracy in the distal radius.^54,65,91

The purpose of a classification is to create standards so that treatment can be recommended and outcomes compared.^7,32 Although an extensive treatment and outcome evaluation was beyond the purview of the committee, we could agree on some basic guidelines. These guidelines are: Distal radial fractures with unacceptable displacement should be reduced. Another alternative, especially in the osteopenic patient, is to accept the displacement and reconstruct later if symptomatic.

Finger traction is extremely helpful in reducing and maintaining reduction in distal radius fractures. If the reduced fracture is stable, it is protected with a cast, splint, or brace while healing. If the reduced fracture is unstable, any of a number of methods, including percutaneous pins, external fixation or a combination of these techniques can maintain the reduction during fracture healing.^{4,5,12,23,39,64}

If the distal radius fracture can not be reduced by closed manipulation, open reduction is recommended.^{10,14,17,23,30,33,44,56,77,81,101} The reduced fracture is stabilized by any of a number of pinning, plating, external fixation or combined techniques. No fixation technique has been demonstrated to have such a clear advantage that it could be recommended to the exclusion of others. The method of stabilization is not so important as it is that it accomplishes its goal of maintaining the reduction until the fracture is healed. Bone graft, synthetic bone graft or bone graft substitutes should be used to fill destabilizing defects and defects representing significant structural loss.¹⁰⁰ Ultrasound has been used in some cases to accelerate, assure, or achieve union.⁴⁷ Rare cases of irreparable fractures can be treated by primary, early or secondary reconstruction.⁹³

At the conclusion of treatment it is preferred (although not always possible) the distal radius fracture be sufficiently stable that the wrist can be placed and supported in a functional position of slight extension (10-20 degrees). This allows optimal digital rehabilitation during distal radial fracture healing. Under optimal circumstances, wrist rehabilitation (motion) can be initiated 3-4 weeks after treatment (sometimes earlier when reduction and stability are assured). In less favorable circumstances, rehabilitation is initiated as soon as it is safely possible.

The Bone and Joint Committee unanimously agreed on a generic and descriptive classification of distal radial fractures that includes the measurable fracture characteristics of location, configuration, displacement, ulnar styloid integrity, distal radial ulnar joint integrity, stability, associated injuries, and mineralization. Such a classification avoids individual and geographic controversy and allows for continuing amendment and updating. All previous and future classifications are encompassed within these criteria. A flow sheet suitable for use on a computerized spread sheet software program is appended (Table 16). The parameters selected allow statistical analysis to evaluate treatment and outcome discriminators.^7,32,35 Basic guidelines are provided for treatment and rehabilitation.

Respectfully submitted by The IFSSH Bone and Joint Committee:

Figure 1: This illustrates the standard method of measuring: a) axial shortening, b) radial inclination, and c) radioulnar displacement of the distal radius on posteroanterior x-ray.¹

Figure 2: This illustrates the standard method of measuring: d) dorsal inclination, and e) dorsal palmar displacement of the distal radius on lateral x-ray.¹

Figure 3: Extra-articular distal radial fractures start to lose inherent stability with over two millimeters of shortening. A high percentage of distal radial fractures with 5 or more millimeters of shortening are unstable and will require fixation, bone grafting, or both to prevent collapse.¹

Figure 4: Fractures with extra-articular comminution beyond the midaxial line on lateral x-ray are unstable and vulnerable to collapse.100 Seventy percent of extra-articular distal radial fractures with more than three millimeters of shortening and over thirty percent of dorsal comminution on lateral x-ray will be unstable, tending to collapse into an unacceptable position.⁵ Of those fractures with less than two millimeters of shortening, those with displacement of the width of the volar cortex or more (positive shelf sign) are unstable with a tendency to collapse.¹²

Tables 1-14 These tables are self-explanatory and were provided by Phillippe Safar [and are from his excellent book, Fractures of the Distal Radius, which he edited with Bill Cooney - comment by David Nelson, MD, webmaster of eRadius and not part of IFSSH report].(⁸⁵⁾ Table 15 Provided by Rober Schenck. Table 16: Distal radial fracture spreadsheet/worksheet.

TABLE 1
Classification of Gartland
From: Gartland, J.J. and Werley, C.W.; J Bone Joint Surg, 33A:4:895-907, 1951 ^{(35, 85)}

Group 1 Simple Colles' fracture
Group 2 Comminuted Colles' fracture with undisplaced intraarticular fragments
Group 3 Comminuted Colles' fracture with displaced intraarticular fragments.

TABLE 2
Classification of Lidstrom
From: Lindstron, A. Acta Orthop Scand (SUPP 41), 1959 (^{50, 85)}

Group 1 Undisplaced
Group 2a Dorsal angulation, extraarticular
Group 2b Dorsal angulation, intraarticular but without gross separation of fragments
Group 2c Dorsal angulation plus dorsal displacement, extraarticular
Group 2d Dorsal angulation plus dorsal displacement, intraarticular but without gross separation of fragments
Group 2e Dorsal angulation plus dorsal displacement, intraarticular with separation of fragments

TABLE 3 Classification of Older, T.M. Et Cassebaum, T.M. J Trauma 5:469-476, 1965 ^{67, 85} Group 1 Non displaced - up to 5° dorsal angulation, radial articular surface at least 2 mm distal ulnar head, Group 2 Displaced with minimal comminution - dorsal angulation or displacement, radial articular surface no lower than 3 m proximal to the ulnar head, minimal comminution of dorsal radius, Group 3 Displaced with comminution of dorsal radius - comminution of dorsal radius; radial articular surface proximal to ulnar head; minimal comminution of distal fragment, Group 4 Displaced with severe comminution of radial head - marked comminution of dorsal and distal radius; radial articular surface 2-8 mm proximal to ulnar head

TABLE 4 Classification of Frykman, G. Acta Orthop Scand 108:7-31, 1967 ^{34, 85} Groups 1 & 2 Extraarticular without and with fracture of the distal ulna, Groups 3 & 4 Intraarticular involving the radiocarpal joint without and with fracture of the distal ulna, Groups 5 & 6 Intraarticular involving the distal radioulnar joint without and with fracture of the distal ulna, Groups 7 & 8 Intraarticular involving both radiocarpal and distal radioulnar joints without and with fracture of the distal ulna

TABLE 5 Classification of Jenkins, N.H. J Hand Surgery 14B:149-154, 1989 ^{43, 85} Group 1 No radiographically visible comminution, Group 2 Comminution of the dorsal radial cortex without comminution of the fracture fragment, Group 3 Comminution of the fracture fragment without significant involvement of the dorsal cortex, Group 4 Comminution of both the distal fragment and the dorsal cortex. As the fracture line involves the distal fracture fragment in Groups 3 & 4, intraarticular involvement is not, however, inevitable, nor does it affect the fracture's placement within the classification.

TABLE 6 Classification of Sarmiento, A., Pratt, G.N., Berry, N.C. And Sinclair, W.F. J Bone Joint Surg, 57:311-317, 1975 ^85,86 Group 1 Non displaced fractures without radiocarpal joint involvement, Group 2 Displaced fractures without radiocarpal joint involvement, Group 3 Non displaced fractures with radiocarpal joint involvement, Group 4 Displaced fractures with radiocarpal joint involvement

TABLE 7 Classification of Fernandez, D.L.^{30,31, 85} Bending: Type 1 One cortex of the metaphysis fails due to tensile stress (Colles and Smith fractures) an the opposite undergoes a certain degree of comminution Shearing: Type 2 Fracture of the joint surface - Barton's, reversed Barton's, styloid process fractures, simple articular fracture Compression: Type 3 Fracture of the surface of the joint with impaction of subchondral and metaphyseal bone (die-punch fracture), intraarticular comminuted fracture Avulsion: Type 4 Fracture of the ligament attachments ulnar and radial styloid process, radiocarpal fracture dislocation Combinations: Type 5 Combination of types, high velocity injuries

TABLE 8 Classification of McMurtry, R.Y. and Jupiter, J.B. In: Skeletal Trauma (Eds: Browner, B., Jupiter, J.B., Levine, A. and Trafton, P. - Philadelphia, W.B. Saunders) ^56,85 Group 1 2 Parts: the opposite portion of the radiocarpal joint remains intact dorsal Barton, palmar Barton, Chauffeur, die punch Group 2 3 Parts: the lunate and scaphoid facets separate from each other and the proximal portion of the radius Group 3 4 Parts: The same plus lunate facet fractured in dorsal and volar fragment Group 4 5 Parts or more

TABLE 9 Classification AO.^62,63,85 Group 1 Extraarticular, Group 2 Partial articular, Group 3 Complete articular: C1 - simple articular and metaphyseal, C2 - simple articular and complex metaphyseal, C3 - Complex articular and complex metaphyseal + fracture distal end

TABLE 10 Classification of Mayo, Intraarticular Fractures.^23,24,85 Type 1 Extraarticular radiocarpal, intraarticular radioulnar, Type 2 Intraarticular scaphoid fossa of distal radius, Type 3 Intraarticular lunate fossa of distal radius +/- sigmoid fossa, Type 4 Intraarticular, scaphoid fossa, lunate fossa and a sigmoid fossa of the distal radius

TABLE 11 Classification of Melone, Ch.P. Intraarticular Fractures. Clin Orthop 202:103-111, 1986 ^42,57-59,85 Type 1 Minimal comminution, stable, Type 2 Comminuted - Stable, displacement of medial complex: ® post: die punch Barton ® ant: Smith 2, Type 3 Displacement of medial complex as a unit + anterior spike, Type 4 Wide separation or rotation of the dorsal fragment and palmar fragment rotation ,Type 1 and 2: Reducible Type 3: Percutaneous pinning or external fixation Type 4: Open reduction

TABLE 12 Classification of Castaing and Le Club. Des Dix Rev Chir Orthop 50, 5:581-696, and 1964 ^16,85 Type 1 Compression - extension (posterior displacement) *Pouteau, Colles *With posteromedial fragment complex a) Sagittal T b) with medial component c) with lateral component d) posterolateral rim isolated or complex e) frontal T f) cross lines in two planes g) comminuted h) undisplaced, Type 2 Compression - flexion *Goyrand-Smith *Anterior rim isolated or anterolateral *Complex anterior rim, Type 3 Associated osteoarticular injuries *Ulnar styloid *Ulnar head *Ulnar neck *Radioulnar dislocation *Radioulnar diastasis *Carpal injuries *Other injuries of the upper limb *Open fracture *Bilateral, Type 4 Non classified

TABLE 13 Classification of Cooney, Universal Classification of Distal Radius Fractures.^23,24,85 Type 1 Articular Un-displaced, Type 2 Non articular* Reducible ** Reducible * Irreducible DisplacedStableUnstable, Type 3 Articular Non-displaced, Type 4 Non articular* Reducible ** Reducible * Irreducible Displaced StableUnstable * (by ligamentotaxis only)

TABLE 14 Classification of Mathoulin, C., Lestrsne, E., Saffar, P.⁸⁵ Type 1 1 Articular line in the coronal plane - Barton, reverse Barton's Type 2 1 Articular line in the sagittal plane involving: a) scaphoid facet b) lunate facet c) radioulnar joint Type 3 2 Lines associated: a) One extraarticular horizontal b) One intraarticular = type 2a,b +/- other fragments or dorsal comminution (T- fractures, die punch) Type 4 3 Lines associated: a) one extraarticular horizontal b) two articular, one coronal, one sagittal (posteromedial fragments, T-frontal and sagittal)

TABLE 15 Classification Of Distal Radial Fracture. Shin, R.D and Schenck, R.R. (personal communication) Type I Extra-articular, Non-displaced X:IF1. Ulnar Fracture2. DRUJ Injury3. Carpal Injury4. Bone Loss5. Soft Tissue Injury S: Skin M: Muscle T: Tendon N: Nerve A: Artery L: Ligament6. Other Type II Intra-articular, Non-displaced, Type III Extra-articular, Displaced A. Reducible **, Stable B. Reducible **, Unstable C. Irreducible, Type IV Intra-articular, DisplacedArticular Line(s) in Sagittal Plane RS = Scaphoid Facet (RoS Joint) RL = Lunate Facet (RoL Joint) SL = Both (RoSoL Joint) A. Reducible **, Stable B. Reducible **, Unstable C. Irreducible **, Type V Intra-articular, DisplacedArticular Line(s) in Cornal Plane A. Reducible **, Stable B. Reducible **, Unstable C. Irreducible **, Type VI Intra-articular, DisplacedArticular Line(s) A. Reducible **, Stable B. Reducible **, Unstable C. Irreducible ** Type VII Other ** By ligamentotaxis only

TABLE 16 Distal Radial Fracture Characteristics Location. Extraarticular Intraarticular Radiocarpal joint Distal radioulnar joint Combined radiocarpal and distal radioulnar joints, CONFIGURATION Simple Transverse Oblique Comminuted Dorsal cortex Palmar cortex Dorsal and palmar cortices Intraarticular Number of major pieces, DISPLACEMENT Undisplaced Displaced (direction) Axial shortening Radial inclination Radial/ulnar displacement Dorsal inclincation Dorsal/palmar displacement Rotation Pronation Supination, ULNAR STYLOID Intact Fractured Level Tip Middle Base Displacement Undisplaced Displaced, DISTAL RADIOULNAR JOINT Stable Unstable Dorsal Palmar Dislocated Dorsal Palmar, STABILITY > 10 degrees angulation > 5 mm shortening > 2 mm articular incongruity Comminution of one cortex across the mid axial line Comminution of dorsal and palmar cortices Irreducible Loss of reduction, ASSOCIATED INJURIES Tissue Laceration Crush or Loss Skin Partial Complete Extent in cms Muscle Tendon Nerve Artery Ligament, TFCC Classification Wrist-intrinsic Classification Wrist-extrinsic Classification Bone Dislocation Fracture Carpal Scaphoid Classification Other Classification, BONE MINERALIZATION Normal Osteopenic Other

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* eRadius editor's note: The original bibliography numbering scheme had duplicates numbers for 37-39.