What are the types of distal fractures?

Types of Distal Fractures

Distal radius fractures include a broad spectrum of injuries ranging from simple isolated fractures of the distal radius to comminuted fractures with associated injuries, with the fracture pattern typically determined by the mechanism of injury, energy imparted, and bone quality. 1

Distal Radius Fractures

Distal radius fractures are one of the most common fracture types, accounting for:

• Approximately 25% of fractures in the pediatric population 1
• Approximately 18% of fractures in the elderly population 1
• Over 640,000 cases annually in the United States 1

These fractures show a bimodal distribution:

• Higher rates in younger individuals (<18 years) typically from sports or vehicular accidents 1
• Higher rates in older individuals (>65 years) typically from falls onto outstretched hands 1

Classification of Distal Radius Fractures

Several classification systems exist for distal radius fractures, including:

• Based on fracture pattern and complexity:

  • Simple isolated fractures of the distal radius 1
  • Comminuted fractures with associated injuries 1
  • Intra-articular vs. extra-articular fractures 1

• Based on articular involvement:

  • Presence of coronally oriented fracture lines 1
  • Die-punch depression 1
  • More than three articular fracture fragments 1

• Contemporary classification systems include:

  • Older classification system 2
  • Comprehensive Classification of fractures 2
  • Melone intra-articular classification system 2
  • Fernandez classification 2

Other Types of Distal Fractures

Distal Femur Fractures

• Supracondylar distal femur fractures:

  • Most common among periprosthetic fractures 1
  • Occur in 0.3% to 2.5% of total knee arthroplasties 1
  • Usually occur within 2-4 years after surgery 1
  • Often result from low-energy trauma 1

• Treatment options:

  • Distal femur locking compression plate (DFLCP) - preferred for intra-articular fractures 3
  • Intramedullary supracondylar nail (IMSCN) - associated with less blood loss 3

Distal Humerus Fractures

• Proximal humeral fractures:
  • Most can be treated non-operatively with good functional outcomes 1
  • Displaced three-part and four-part fractures have controversial treatment approaches 1

Diagnostic Imaging for Distal Fractures

Radiographic Assessment

• For distal radius fractures:

  • Standard 3-view examination includes posteroanterior (PA), lateral, and 45° semipronated oblique view 1
  • A fourth projection (semisupinated oblique) may increase diagnostic yield 1
  • Radiographs should assess radial length, inclination, and tilt 1

• For ankle fractures:

  • Three standard views: anteroposterior, lateral, and mortise views 1
  • Weight-bearing radiographs provide important information for fractures of uncertain stability 1

Advanced Imaging

• CT and MRI:
  • May detect radiographically occult fractures 1
  • Particularly useful when metal artifact reduction techniques are employed 1

Treatment Considerations

Distal Radius Fractures

• Conservative management:

  • Cast immobilization with or without closed reduction 1
  • Most common approach in older population (>65 years) 1

• Surgical options:

  • Locking plates 1
  • Kirschner wires 1
  • External fixation 1
  • Volar plate fixation - becoming increasingly popular as it minimizes tendon irritation, reduces immobilization time, and decreases complication risk 4

Common Complications

• Following operative treatment of distal radius fractures:
  • Tendon irritation and rupture 5
  • Chronic regional pain syndrome (CRPS) 5
  • Carpal tunnel syndrome 5
  • Ulnar or radial neuropathy 5
  • Compartment syndrome 5
  • Malunion or inadequate fixation 5
  • Post-traumatic arthritis and stiffness 5

Clinical Pearls and Pitfalls

• Articular step-off:

  • Operative fixation resulting in <2 mm of residual articular surface step-off is usually necessary to avoid long-term complications such as osteoarthritis 1

• Fracture stability:

  • Medial clear space of <4 mm confirms stability in ankle fractures 1
  • Increased risk of instability with medial tenderness, bruising, swelling, fibular fracture above the syndesmosis, bi- or trimalleolar fractures, open fracture, or high-energy injury 1

• Rehabilitation:

  • Early referral to hand therapy is important for improving functional outcomes following distal radius fractures 4
  • Rehabilitation should focus on restoring mobility, reducing pain, and improving function 4