Indications for Reduction in Distal Radius Fractures

David L. Nelson, MD

This paper is based on a presentation given at the AAOS Summer Institute, San Diego, September, 1996, and at the International Distal Radius Fracture Conference, San Francisco, May 8-10, 1998. The last literature citations were added on 12/30/99, and there have not been any changes in the thresholds for reduction in the literature up to May, 2006. The highlighted summary sections are still those advocated by most authorities.

Many authors suggest that distal radial fractures be reduced anatomically, but few of them define what "anatomical" means, to the frustration to the student of distal radial fractures. This is a review of the scientific literature, both laboratory and clinical, with respect to what "anatomical" really means. Four different but interrelated characteristics have been examined.

A VOLAR TILT

1 BIOMECHANICAL STUDIES

a Short, Palmer, Werner (1987, JHS)

• method: six cadavers, pressure-sensitive film, examine loads
• results: 10° dorsal tilt caused a statistically significant change in the area of  maximum load, moved load more dorsally, and load was more concentrated

b Pogue, Viegas, Patterson, et al. (1990, JHS)

• method: five cadavers, pressure-sensitive film, examine contact areas and pressures
• results: >25° volar tilt or >15° dorsal tilt caused a shift in the scaphoid and lunate high pressure areas and the load were more concentrated

c Kihara, Palmer, and Werner (1996, JHS)

• method: six cadavers, motion tracked by motion sensor system, malunion simulated osteotomy in 10° increments
• results: pronation and supination decreased significantly with 20° dorsal angulation (30° change)
  

2 CLINICAL STUDIES

a Gartland and Werley (1951, JBJS)

• review of 2132 WC cases
• dorsal angle had greatest effect on functional result
• no threshold data given or distractable from data

b Taleisnik and Watson (JHS, 1984)

• retrospective review of 13 patients with midcarpal instability and radial malunion
• average dorsal tilt of 23, but occurred with as little as 8° and 10° in 2 pts
• resolution of midcarpal instability with corrective osteotomy

c Ekenstam (1985, Scan J P & Recon)

• significant improvement in function, the extent of which was dependant on the dorsal tilt
• no threshold data given or distractable from data

d Jenkins (1988, JHS)

• prospective study of 61 consecutive patients treated with closed reduction, cast immobilization
• statistical significant correlation with function and dorsal tilt
• no threshold data given or distractable from data

e McQueen (1988, JBJS[B])

• 30 patients with Colles' fracture, four year follow-up
• as little as 10° dorsal tilt patients much more likely to have pain, stiffness, weakness, and poor function

f Bickerstaff (1989, JBJS[B])

• 32 patients with Colles' fracture managed with closed reduction
• rated for pain, ROM, strength, ADL's
• statistically significant correlation between dorsal tilt and outcome
• no threshold data given or distractable from data

g Kopylov (1993, JHS[B])

• retrospective review of 76 patients, 26-36 years after distal radius fracture
• F statistically significant correlation with DJD and dorsal tilt
• no threshold data given or distractable from data
  

3 RECOMMENDATIONS

• Weiland (OKU-Trauma, AAOS, 1996)
  • Accept no > than 0° dorsal tilt or no > than 20° volar tilt
• ASSH Regional Review Course (1994)
  • Accept no > than 5° dorsal tilt
• Trumble (ASSH Specialty Day at AAOS 1999)
  • Accept no > than 10° dorsal tilt
• Kopylov (1993, JHS[B], 30 year follow-up study)
  • 0° tilt increased risk of DJD by 80%

Nelson: based on all of the basic science and clincal studies cited above, as well as the consensus recommendations noted above:

• Accept no > than 10° dorsal tilt

B INTRA-ARTICULAR INCONGRUITY

1 BIOMECHANICAL STUDIES

a Baratz and Wroblewski (1996, JHS)

• method: cadaver study of contact stresses with pressure sensitive film
• results: increases in contact stresses with stepoff as small as 1 mm
• results: carpal alignment shifts and lunate flexion reduces with stepoffs

b Wagner, et al. (1996, JHS)

• method: cadaver study of contact stresses with pressure sensitive film
• results: lunate fossa depression of 3 mm caused significant pressure in scaphoid fossa
• results: scaphoid fossa depression of 1 mm caused increased pressure in lunate fossa
• limitations of both studies: pressure sensitive film can alter joint characteristics, is quasi-static, does not account for shear forces that occur during rotation of wrist, cannot account for changes over time

2 CLINICAL STUDIES

a Knirk and Jupiter (1986, JBJS)

• retrospective study of 43 fractures with intraarticular displacement, with mean follow-up of 6.7 years
• stepoff > 2 mm (8 of 8): 100% radiographic DJD
• any radiographic stepoff (22 of 24): 91% radiographic DJD
• (but see Dr. Jupiter's current [1999] opinion at Intra-articular fractures of the distal end of the radius in young adults, and scroll down to "Comment by Dr. Jupiter")

b Bradway, Amadio, and Cooney (1989, JBJS)

• retrospective study of 16 patients, mean follow-up of 4.8 years
• 4/4 patients with > 2 mm stepoff had DJD
• 3/12 patients with < 2 mm stepoff had DJD

c Fernandez and Geissler (1991, JHS)

• retrospective radiographic review of 40 patients, but only 31with clinical follow-up
• follow-up averaged 4 years (range 2-8)
• no patient with a step-off of 1 mm or less had DJD
• all three patients with a step-off of 2 mm or more had pain; only 1 with no step-off had pain

d Missakian, Cooney, and Amadio (1992, JHS)

• retrospective review of 650 patients with distal radial fractures
• 32 patients had intraarticular fractures treated with ORIF
• all patient who had > 2 mm stepoff had post-traumatic arthritis and only fair results

e Kopylov (1993, JHS[B])

• retrospective review of 76 patients, 26-36 years after distal radius fracture
• F articular incongruity was the main factor in the development of radiographic DJD and was frequently associated with pain and stiffness clinically
• F incongruity of > 1 mm had 250% increased risk of DRUJ DJD
• F incongruity of > 1 mm had 237% increased risk of RC DJD

f Trumble (1994, JHS)

• retrospective study of 52 intraarticular fractures
• strongest correlation with outcome was with articular incongruity (both stepoff and gap)
• no threshold data given or distractable from data, but would not accept > 1 mm

g Fernandez and Jupiter (1996, Fractures of the Distal Radius )

• retrospective study of 40 patients with intraarticular fracture, average follow-up of 4 years
• 25 of 40: no step-off and no radiographic DJD or clinical pain
• 5 of 6 patients with step-off had pain (3 moderate, 2 severe)

h Catalano, Gelberman, Gilula, et al. (1997, JHS)

• retrospective study of 21 patients with intra-articular fracture, average follow-up of 7.1 years
• follow-up included plain xrays, CT scans, and outcomes questionnaire
• there was a strong association between development of DJD and step-off
• there was no association between functional status and radiographic DJD

3 RECOMMENDATIONS

• Weiland (OKU-Trauma, AAOS, 1996)
  • Accept no > than 1 mm or 2 mm step-off
• ASSH Regional Review Course (1994)
  • Accept no > than 1 mm step-off
• ASSH Specialty Day at AAOS (Trumble, 1999)
  • Accept no > than 1 to 2 mm step-off
  • ("If you can see it, fix it")
• Kopylov (1993, JHS[B], 30 year follow-up study)
  • Accept no > than 1 mm step-off
• Baratz (ASSH Specialty Day at AAOS, 1998)
  • Consider reduction if step-off visible on xray

4 CAVEAT: WE CANNOT RELIABLY MEASURE AT THE 1 MM LEVEL

a Nelson (1995, AAOS)

• method: one cadaver, simulated die punch fracture, with stepoffs of 0.0mm, 0.5 mm, 1.0 mm, and 2.0 mm; plain radiographs and CT's performed; 16 blinded reviewers
• results: cannot reliable measure with an accuracy of 1 mm, CT not more reliable than plain films, and reviewer is not able to tell when his readings are off by more than 1 mm
• weakness of method: used model of die punch, not actual fracture; model may have been easier to evaluate

b Kreder, et al. (J Hand Surg, 1996)

• method: 16 observers examined 6 plain xrays
• results: two experienced observers would be expected to disagree by 3 mm 10% of the time, and repeat measurements by the same observer would be expected to differ by 2 mm 10% of the time
• weakness of method: could not tell what actual measurement was and therefore true accuracy of readings

c Cole, et al. (J Hand Surg, 1997)

• method: 5 observers examined 19 sets of xrays, including plain films and CT scans
• results: more reproducible values were produced by CT scans, but a poor correlation between CT and plain xray measurements
• thirty percent of measurement from plain xrays significantly underestimated or overestimated displacement compared to CT scan measurement
• weakness of method: could not tell whether CT or plain film was actually more accurate
• weakness of method: could not tell what actual measurement was and therefore true accuracy of readings

C RADIAL SHORTENING

1 BIOMECHANICAL STUDIES

a Pogue, Viegas, Patterson, et al. (1990, JHS)

• method: five cadavers, pressure-sensitive film, examine contact areas and pressures
• results: 2 mm shortening created statistically significant increase in the lunate contact areas

b Adams (1993, JHS)

• method: six cadavers
• results: radial shortening was the most significant change affecting the kinematics of the DRUJ and the TFC

2 CLINICAL STUDIES

a Jupiter and Masem (1988, Hand Clinics)

• review article, Reconstruction of Post-Traumatic Deformity of the Distal Radius
• > 6 mm of shortening caused DRUJ pain, decreased pro- and supination
• radial shortening most disabling of malunited fractures

b McQueen (1988, JBJS[B])

• 30 patients with Colles' fracture, four year follow-up
• > 2 mm shortening statistically significant increase in symptoms in terms of strength, ADL, ROM, and pain

c Jenkins (1988, JHS)

• prospective study of 61 consecutive patients treated with closed reduction, cast immobilization
• mean shortening was 4.0 mm
• strong correlation between radial length and strength and ROM
• mean radial shortening in patients with pain: 4.7 mm
• mean radial shortening in patient without pain: 2.3 mm (statistically significant)

d Kopylov (1993, JHS[B])

• retrospective review of 76 patients, 26-36 years after distal radius fracture, average follow-up of 30 years
• radial shortening most important factor after intraarticular step-off
• 1 mm radial shortening had a 50% increased risk of DJD in the DRUJ
• 1 mm radial shortening had a 20% increased risk of DJD in the RC joint
• 2 mm radial shortening had a 0% increased risk of DJD in the RC joint

3 RECOMMENDATIONS

• Weiland (OKU-Trauma, AAOS, 1996)
  • Accept no > than 2 mm radial shortening
• ASSH Regional Review Course (1994)
  • Accept no > than 3 mm radial shortening
• ASSH Specialty Day at AAOS (Trumble, 1999)
  • Accept no > than 2 mm radial shortening
• Kopylov (1993, JHS[B], 30 year follow-up study)
  • Goal: no > than 1 mm radial shortening
• Baratz (ASSH Specialty Day at AAOS, 1998)
  • Accept no > 5 mm radial shortening
    3 mm or less is optimal

D RADIAL ANGLE

1 BIOMECHANICAL STUDIES

a Pogue, Viegas, Patterson, et al. (1990, JHS)

• method: five cadavers, pressure-sensitive film, examine contact areas and pressures
• results: decreased radial angle increased the load on the TFC and ulna

b Adams (1993, JHS)

• method: six cadavers
• results: decreased radial angle disturbed the TFC and DRUJ kinematics

2 CLINICAL STUDIES

a Jenkins (1988, JHS)

• prospective study of 61 consecutive patients treated with closed reduction, cast immobilization
• mean loss of radial angle was 7.8°
• statistically sig. correlation with decreased angle and grip strength
• strong correlation (but short of statistical significance) with decreased angle and decreased flexion

b Kopylov (1993, JHS[B])

• retrospective review of 76 patients, 26-36 years after distal radius fracture, average follow-up of 30 years
• F loss of radial angle of 5° increased the risk of symptoms by 90%

3 RECOMMENDATIONS

• Weiland (OKU-Trauma, AAOS, 1996)
  • Accept no > than 5° loss radial angle
• ASSH Specialty Day at AAOS (Trumble, 1999)
  • Accept no < than 15° radial inclination
• Kopylov (1993, JHS[B], 30 year follow-up study)
  • Goal: no loss of radial angle
• Baratz (ASSH Specialty Day at AAOS, 1998)
  • Goal: no loss of radial angle

Diego Fernandez and Jesse Jupiter, Fractures of the Distal Radius, Springer, New York, 1995.

An invaluable book for any serious student of distal radius fractures. Highly readable, well organized, authors are foremost thinkers in this area. You can either use it to manage a specific fracture when you have a problem case, or read from beginning to end for a comprehensive understanding of the topic.

Trumble, Schmitt, and Vedder, Factors Affecting Functional Outcome of Displaced Intra-articular Distal Radius Fractures, JHS 1994;19A:325-340.

Excellent review article that separated the radiographic results from the clinical results and correlated them, and proposed a classification scheme that will predict results.

Kopylov, Johnell, Redlund-Johnell and Bengner, Fractures of the Distal End of the Radius in Young Adults: A 30-year Follow-up, JHS(B) 1993: 18B:45-49.

A real long-term study, instead of the usual two or five year study. We have needed this kind of long-term study for some time; could only be done in Sweden. The results are not as bad as might have been expected after Knirk and Jupiter's 1986 paper, but the increase in risk is very real.