a

 

 

 

DEFINITION

Distal radius fractures occur at the distal end of the bone, originating in the metaphyseal region and often extending to the radiocarpal and distal radioulnar joints (DRUJ).

Distal radius fractures can be classified as stable or unstable and extra- or intra-articular to assist in treatment decisions.

Fractures may angulate dorsally or volarly and may have significant comminution depending on the energy of the injury and the quality of the bone.

Percutaneous pins or K-wires, typically 0.062 or 0.045 inches, can be used for treatment of simple intra-articular or extra-articular fractures with mild comminution and no osteoporosis.

Percutaneous pins can aid reduction and stabilize the fragments in a minimally invasive manner.

Percutaneous pins can support the subchondral area of the distal radius and maintain the articular reduction in highly comminuted fractures, which is useful when combined with other fixation methods.

Smooth percutaneous pins may also be placed across the physis to maintain a reduction in children with minimal risk of a growth arrest.

Highly comminuted fractures are more difficult to fix rigidly and often require external and/or internal fixation to maintain alignment during healing.

External fixators can be hinged or static and may or may not bridge the wrist joint.

K-wire fixation of extra-articular and simple intra-articular fractures has received more support over the last few years after several prospective randomized trials comparing K-wire fixation to volar plating has shown no difference in outcome at 1 year.

FIG 1 • Anatomy surrounding the radial sensory nerve branch in the forearm.

 

 

ANATOMY

 

The distal radius consists of three articular surfaces: the scaphoid fossa, the lunate fossa, and the sigmoid notch.

 

Ligamentotaxis aids in the reduction of intra-articular and comminuted fractures.

 

 

Volar extrinsic ligamentous attachments include the radioscaphocapitate, long radiolunate, and short radiolunate ligaments.

 

Dorsal extrinsic ligamentous attachments include the radiotriquetral ligament.

 

Dorsal and radial to the second metacarpal lie the first dorsal interosseous muscle and the terminal branches of the radial sensory nerve.

 

The distal radial sensory nerve branches lie superficial to the distal radius and should be protected during dissection and pin placement.

 

The radial sensory nerve emerges between the brachioradialis and the extensor carpi radialis longus (ECRL) muscle bellies (FIG 1).

 

The terminal branches of the lateral antebrachial cutaneous nerve lie superficial to the forearm fascia at the radial wrist.

 

There is a bare spot of bone between the first and second dorsal compartments in the region of the radial styloid.

 

The brachioradialis tendon inserts onto the radial styloid deep to the first dorsal compartment.

 

The ECRL and the extensor carpi radialis brevis (ECRB) lie dorsal to the brachioradialis in the second dorsal compartment.

 

Lister tubercle is dorsal, with the extensor pollicis longus (EPL) tendon on its ulnar side, in the third dorsal compartment.

 

 

P.32

 

The extensor digitorum communis tendons lie over the dorsal ulnar half of the distal radius in the fourth dorsal compartment.

 

The extensor digiti minimi lies over the DRUJ in the fifth dorsal compartment.

 

PATHOGENESIS

 

Distal radius fractures are the most common fractures of the upper extremity in adults, representing about 20% of all fractures seen in the emergency room.22

 

Mechanism of injury typically is a fall on an outstretched hand with axial loading, but other common histories include motor vehicle accidents or pathologic fractures.

 

Higher energy injuries cause increased comminution, angulation, and displacement.

 

Osteoporosis, tumors, and metabolic bone diseases are risk factors for sustaining pathologic distal radius fractures.

 

In children, fractures typically occur along the physis due to its relative weakness compared to the surrounding

ligaments.

 

NATURAL HISTORY

 

Distal radius fractures needing no reduction and those that are stable after reduction typically recover functional range of motion with minimal long-term sequelae.

 

Three parameters that affect outcome include articular congruity, angulation, and shortening.21, 26

 

 

Two millimeters or more of articular surface incongruity of the distal radius can lead to degenerative changes, pain and stiffness.

 

 

Dorsal angulation can lead to decreased range of motion and increased load transfer to the ulna. Radial shortening can lead to decreased range of motion, pain, and ulnar impaction of the carpus.

PATIENT HISTORY AND PHYSICAL FINDINGS

 

The history of a fall on an outstretched hand is the most common presentation for a patient with a distal radius fracture.

 

 

Motor vehicle or motorcycle accidents and osteoporosis account for most comminuted fractures. It may be clinically indicated to implement a workup for osteoporosis.

 

Pain, tenderness, swelling, crepitus, deformity, ecchymosis, and decreased range of motion at the wrist are typical symptoms and warrant radiographic evaluation.

 

Physical examination should include the following:

 

 

Inspection: Evaluate the integrity of the skin, cascade of the digits, direction of displacement, and presence of any swelling.

 

Identify points of maximal tenderness to differentiate between distal radius injuries and carpal or ligamentous injuries.

 

Palpate specific areas of the wrist and hand to differentiate distal intra-articular, DRUJ, and carpal injuries.

 

Two-point discrimination: Higher than normal (5 mm) results in the form of progressive neurologic deficit may signify an acute carpal tunnel syndrome or ulnar neuropathy.

 

 

Passive finger stretch test to assist with diagnosis of compartment syndrome. EPL tendon function should be evaluated.

 

EPL assessment: Assess the resting position of the thumb interphalangeal joint and the patient's ability to lift the thumb off of a flat surface to determine the continuity of the EPL tendon.

 

 

Palpation of forearm and elbow to assess for concomitant injury proximally The DRUJ must be assessed for displacement and instability.

 

The bony anatomy must be carefully evaluated to avoid missing minimally displaced fractures, which may displace without treatment.

 

Skin should be assessed to avoid missing an open fracture.

 

Swelling should be monitored to allow for early diagnosis of compartment syndrome.

 

Sensory examination should be monitored for progressive changes, which may represent acute carpal tunnel syndrome.

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Radiographic evaluation should include posteroanterior (PA), lateral, and oblique views to assess displacement, angulation, comminution, and intra-articular involvement and allow for radiologic measurements.18, 22 Often, comparison x-rays of the uninjured wrist are helpful.

 

Lateral articular (volar) tilt is the angle between the radial shaft and a tangential line parallel to the articular margin as seen on the lateral view (FIG 2A). The normal angle is 11 degrees.

 

Radial inclination, measured on the PA view (FIG 2B), is the angle between a line perpendicular to the shaft of the radius at the ulnar articular margin and the tangential line along the radial styloid to the ulnar articular margin. The normal angle is 22 degrees.

 

Ulnar variance, also measured on the PA view (see FIG 2B), is the distance between the radial and ulnar articular surfaces. Ulnar variance is compared to the contralateral side.

 

 

 

FIG 2 • A. Lateral radiograph of the wrist demonstrating volar tilt (black lines). B. PA radiograph demonstrating radial inclination (black lines), ulnar variance (red bracket), and radial height (white bracket).

 

 

P.33

 

Traction radiographs help assess intra-articular involvement, intercarpal ligamentous injury, and potential

fracture reduction through ligamentotaxis.

 

Computed tomography (CT) scans are useful in fully elucidating the anatomy of the fracture, including impaction, comminution, and size of the fragments.

 

 

CT scans often significantly alter the original treatment plan.14

 

Magnetic resonance imaging (MRI) is rarely performed acutely but can diagnose concomitant ligamentous injuries, triangular fibrocartilage complex injuries, and occult carpal fractures.

 

DIFFERENTIAL DIAGNOSIS

Bony contusion Radiocarpal dislocation

Scaphoid or other carpal fracture Perilunate or lunate fracture-dislocation Distal ulnar fracture

Wrist ligament or triangular fibrocartilage complex injury DRUJ injury

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment consists of splinting or casting for stable fracture patterns using a three-point mold.

 

Fractures amenable to nonoperative treatment include fractures that are stable after reduction with minimal metaphyseal comminution, shortening, angulation, and displacement.

 

 

Evaluation for secondary displacement weekly for 2 to 3 weeks is critical as the swelling subsides.

 

Unstable patterns will displace if not surgically stabilized.

 

 

There is little role for nonoperative treatment in highly comminuted fractures.

 

The physiologic age, medical comorbidities, and functional level of the patient should be considered in determining the need for surgical treatment.

 

Early range of motion of the nonimmobilized joints is essential in the nonoperative treatment of all fractures near the wrist to prevent contracture.

 

 

The cast or splint must not extend past the metacarpophalangeal joints so as to allow digital motion.

 

SURGICAL MANAGEMENT

 

Surgical treatments are indicated to prevent malunion and improve pain control, function, range of motion, and to decrease the time of return to function.

 

Surgery is reserved for unstable fractures, including displaced, intra-articular, comminuted, or severely angulated injuries and fractures that displace following attempted closed management.

 

Percutaneous pinning can assist in obtaining and maintaining reduction of displaced fractures with limited comminution in a minimally invasive manner.

 

External fixators maintain radius length but cannot always control angulation and displacement; therefore,

supplementation with percutaneous pins is typically performed.2

 

Conversely, external fixators may augment percutaneous pins and plate fixation when extensive comminution is present.

 

 

Supplemental external fixation should be considered for fractures with comminution of over 50% of the diameter of the radius on a lateral view or when significant volar cortical comminution is present.

 

External fixation may be used as a neutralization device because the distraction forces decrease soon after fracture reduction.

 

External fixators also are useful for “damage control orthopaedics” to temporarily stabilize wrist fractures, especially for complex, combined, open injuries.

 

For nonbridging external fixation, there must be at least 1 cm of volar cortex intact and adequate fragment sizes to allow proper pin placement.

 

A relative contraindication to pin fixation with or without external fixation is a volar shear injury, which should be reduced and stabilized using a volar plate and screws.

 

Preoperative Planning

 

All radiographs should be reviewed before surgery and brought into the operating room.

 

Analysis of the pattern and presumed stability of the fracture fragments determines whether percutaneous fixation, with or without external fixation, is suitable.

 

For intra-articular fractures, the specific fragments to be reduced and fixed must be identified preoperatively to avoid incomplete reduction of the joint surface.

 

The surgeon must be prepared to change his or her management decision intraoperatively if the fracture behavior is different from anticipated. A variety of fixation devices should be available in the operating room.

 

Positioning

 

 

The patient is positioned supine on the operating table with a radiolucent arm board. A tourniquet is applied near the axilla with the splint still in place (FIG 3).

 

Fluoroscopy should be used for confirmation of reduction and fixation throughout the procedure.

 

There must be enough range of motion of the shoulder and elbow to allow standard anteroposterior (AP), lateral, and oblique images.

 

Approach

 

Various approaches can be used in the application of external fixators and the insertion of percutaneous pins.

 

 

 

FIG 3 • Positioning of patient supine on the hand table with tourniquet in place.

 

 

Distal external fixator half-pins may be placed directly into the second metacarpal or into other carpal bones (for injuries

 

P.34

including the second metacarpal). Wires and half-pins from nonbridging fixators may be placed in the distal radius itself.

 

Percutaneous pins can be inserted through the radial styloid between the first and second dorsal compartments, through Lister tubercle, through the interval between the fourth and fifth dorsal compartments, and across the DRUJ (FIG 4).

 

 

Caution is taken to avoid skewering tendons and nerves and to avoid penetrating the articular surface.

 

 

 

FIG 4 • Areas for K-wire insertion at the distal radius.

 

TECHNIQUES

• Closed Reduction of a Distal Radius Fracture

Closed reduction should be performed before fixation using a combination of distraction and palmar translation of the distal radius fragment and carpus.1

Use of a padded bump or towel roll will aid in the reduction (TECH FIG 1).

Overdistraction will cause increased dorsal angulation due to the intact short, stout volar ligaments.1 Excessive palmar flexion of the wrist can restore volar tilt but leads to an increased incidence of stiffness and carpal tunnel syndrome.7, 8

Overdistraction can be assessed by measuring the carpal height index, measuring the radioscaphoid and midcarpal joint spaces, checking full finger flexion into the palm, or evaluating index finger extrinsic

extensor tightness.9

 

 

 

 

TECH FIG 1 • Closed reduction over a towel bump using traction and palmar translation.

• Kapandji Technique for Percutaneous Pinning

   

  Closed reduction is obtained using a bump, and the reduction is confirmed using fluoroscopy.

   

  This technique should be employed in patients younger than 55 years of age with minimal comminution. It should not be used in osteoporotic, elderly patients or those with comminution secondary to a higher risk

  of reduction loss. External fixation should be used to supplement pinning in these patient populations.27

   

  An incision is made radially and a 0.062-inch pin is manually inserted into the fracture site, taking care to protect the sensory nerve branches and the first dorsal compartment tendons (TECH FIG 2A).

   

  The pin is angled distally, levering the bone back into its normal position and restoring the radial inclination (TECH FIG 2B). The pin is advanced proximally and ulnarly through the far cortex using power. This pin act as a buttress to maintain radial inclination (TECH FIG 2C).

   

  A second incision is placed dorsally, and a second pin is manually inserted into the fracture (TECH FIG 2D).

   

  The pin is angled distally, levering the bone back into its normal position and restoring the volar tilt (TECH FIG 2E). This pin act as a buttress to maintain volar tilt (TECH FIG 2F).

   

  Using the modified technique, a third pin is inserted retrograde using power, starting at the radial styloid and proceeding into the ulnar cortex of the radius, proximal to the fracture line.

   

  The pins are buried and cut just below the skin, and the skin is sutured.

   

  Alternatively, the pins may be bent using two needle drivers and left outside the skin.

   

   

  The pins are then cut and covered with pin caps or antibiotic gauze. A sterile dressing is applied, followed by a splint.

   

  P.35

   

   

   

  TECH FIG 2 • A. An incision is made over the radial styloid, and a K-wire is manually inserted into the fracture site. B. The wire is levered distally to correct the radial inclination. C. The wire is advanced proximally, using power, into cortical bone. D. An incision is made over Lister tubercle, and a wire is inserted into the fracture site. E,F. The wire is levered distally to correct the dorsal angulation and advanced proximally using power into cortical bone.

• Author's Preferred Technique for Percutaneous Pinning

   

  Closed reduction is obtained using a bump, and the reduction is confirmed using fluoroscopy (TECH FIG 3A,B).

   

  A small incision is placed over the bare spot on the radial styloid between the first and second dorsal compartments (TECH FIG 3C).

   

   

   

  TECH FIG 3 • A,B. PA and lateral views demonstrating reduction of distal radius fracture. C. The incision

  is made over the radial styloid. (continued)

   

   

  P.36

   

  Two 0.062-inch smooth K-wires are placed retrograde from the radial styloid across the reduced fracture, engaging the opposite cortex in a divergent fashion (TECH FIG 3D,E).

   

  A small incision is placed over the interval between the fourth and fifth dorsal compartments.

   

  One or two K-wires are placed retrograde from the dorsoulnar corner of the distal radius across the reduced fracture, engaging the opposite cortex in a divergent fashion (TECH FIG 3F-H).

   

   

   

  The pins are cut just beneath the skin, which is closed with a 5-0 nylon suture. Alternatively, the pins are bent and cut and left outside the skin (TECH FIG 3I). A dressing and splint are then applied.

   

   

   

  TECH FIG 3 • (continued) D. A pin is inserted retrograde into the radial styloid. E. PA radiograph demonstrating the course of the radial styloid wire. F. Two radial styloid wires and two dorsoulnar wires are in place. G. PA view showing fixation and the path of the wires. H. Lateral view showing fixation and path of wires. I. Pins are bent, cut, and covered above the skin.

• Bridging External Fixator Application

  Distal Pin Placement

   

  A 3-cm incision is made over the dorsal index metacarpal, exposing the proximal two-thirds.

   

  The distal sensory nerve branches are retracted, and the first dorsal interosseous muscle is elevated from the metacarpal to identify the insertion of the ECRL (TECH FIG 4A).

   

  The index metacarpophalangeal joint is flexed to protect the sagittal band and first dorsal interosseous aponeurosis.

   

  The metacarpal drill guide is placed on the radial base of the index metacarpal at the flare of the metaphysis. Partially threaded 3- to 4-mm pins are used, with or without predrilling.

   

  A long-threaded pin is placed through the index and long metacarpal bases, obtaining three cortices of fixation.

   

  Care is taken not to enter the carpometacarpal joint.

   

  The double drill guide is then placed over the first pin, and the distal short-threaded pin is placed through both cortices of the index metacarpal shaft (TECH FIG 4B,C).

   

  Fluoroscopy confirms placement and length of the pins.

   

   

  P.37

   

   

   

  TECH FIG 4 • A. An incision is made over the second metacarpal base, with reflection of the first dorsal interosseous muscle and radial sensory nerve terminal branches. (The thumb is at the top of the photograph.) B. Diagram showing placement of fixator pins in the shaft of the index and the base of the index and long metacarpals. C. Parallel placement of two metacarpal pins.

  Proximal Pin Placement and Frame Construction

   

  A 4- to 5-cm incision is made over the radial forearm, proximal to the first dorsal compartment musculature, through skin and subcutaneous tissue, avoiding the lateral antebrachial cutaneous nerve branches.

   

  The fascia overlying the interval between the brachioradialis and the ECRL is divided, and the radial sensory nerve is identified and retracted (TECH FIG 5A).

   

  The interval between the ECRL and ECRB may also be used to avoid the radial sensory branch.

   

  The double drill guide is placed onto the diaphysis of the radius between the brachioradialis and the radial wrist extensors or between the ECRL and ECRB (TECH FIG 5B).

   

  Threaded 3- to 4-mm pins are placed, with or without predrilling.

   

  The fracture should be reduced, and the pins placed parallel to the metacarpal pins to facilitate alignment of the fracture.

   

   

  The proximal pin should be placed bicortically, just distal to the tendon of the pronator teres. The distal pin is then drilled bicortically through the double drill guide.

   

  Pin placement is confirmed using fluoroscopy.

   

  The incisions are closed using nylon suture, ensuring no tension is on the skin at the pin sites.

   

  Clamps and rods or adjustable fixators may then be applied to the pins to achieve and maintain final reduction (TECH FIG 5C).

   

  Supplementary K-wire fixation is added before or after external fixation (TECH FIG 5D).

   

   

   

  TECH FIG 5 • A. Incision over the radial forearm demonstrating the radial sensory nerve branch deep to the fascia. (The hand is to the right.) B. The double drill guide is placed onto the radius. (continued)

   

   

  P.38

   

   

   

  TECH FIG 5 • (continued) C. Final reduction is maintained by the addition of clamps and rods. D. K-wires are used for supplemental fixation when necessary.

• Nonbridging External Fixator Application

   

  Fracture reduction can be performed after insertion of the distal pins, allowing direct control of the distal fragment.

   

  The wrist is placed for a lateral fluoroscopic view, and a marker is used to determine the level of incision halfway between the radiocarpal joint and the fracture. A short transverse skin incision is made just proximal to the radiocarpal joint.

   

  A longitudinal incision is then made through the retinaculum on either side of Lister tubercle, and the EPL is protected.

   

  The first distal pin is drilled using power, parallel to the radiocarpal joint on the lateral view, halfway between the fracture and the joint surface (TECH FIG 6A).

   

  The second distal pin is placed between the second and third dorsal compartments, between the radial wrist extensors and the EPL tendon.

   

  This pin should be placed parallel to the first pin in both planes, with the starting point halfway between the radiocarpal joint and the fracture.

   

  The two proximal radius pins are placed using the technique described for placement of a bridging external fixator.

   

   

  The incisions are closed, after which the clamps are applied but not tightened. Reduction is achieved by manipulation of the distal pins and clamps.

   

   

  Pushing the pins in the dorsal/volar plane corrects dorsal tilt. Adjusting the pin clamp can correct radial inclination.

   

  Reduction is confirmed using fluoroscopy, and the clamps are tightened (TECH FIG 6B).

   

  TECH FIG 6 • A. Distal pin placement. B. Final reduction with nonbridged external fixator in place.

   

   

   

   

  P.39

   

  PEARLS AND PITFALLS
  	Indications ▪ Determine stability   Surgical ▪ Make skin incisions for pin placement to avoid sensory nerves, tendons, and approach crossing veins.   Hardware ▪ Choose pins of appropriate diameter. placement ▪ Supplement fixation with pins using external or internal fixation as necessary.

  • Determine comminution and supplement fixation with external or internal fixation as necessary.

  • Obtain adequate exposure of the radial sensory branch at forearm and hand to avoid injury.

  • Do not leave pins more than 1 to 2 mm out of the cortex, and keep all pins extra-articular.

  • If placing the proximal metacarpal pin in metaphyseal bone, ensure that three

   

  cortices are penetrated.

  • Do not back out conical pins because fixation will be lost.

  • Evaluate the DRUJ after fixation to determine stability.

  • Subcutaneous pins are more costly to remove because that requires a second procedure, but they have a lower infection rate. Therefore, if fixation is needed for an extended period, bury the pins.

  • Overdistraction of the carpus must be avoided because it is associated with chronic pain-mediated syndromes and nonunion.

   

  Postoperative management

• Allow for adequate immobilization.

• Encourage early range of motion of the fingers, elbow, and shoulder whenever possible.

• Educate the patient regarding appropriate pin care.

• Begin strengthening only after healing is complete and range of motion is maximized.

 

POSTOPERATIVE CARE

 

After fixation with percutaneous pins, the wrist is immobilized alone in a short-arm splint to allow for swelling but provide stability. A cast is applied after the swelling goes down.

 

Isolated radial styloid fractures fixed with pins can be placed in a volar wrist splint.

 

External fixation devices typically require no additional immobilization, although a volar forearm-based Orthoplast (Johnson & Johnson, Langhorne, PA) splint may be used for support and patient comfort.

 

The splint or cast is continued for 4 to 8 weeks until healing occurs and the pins are removed.

 

K-wires and half-pins should be inspected and cleaned regularly using either soap and water or half-strength hydrogen peroxide and water.

 

Finger, elbow, and shoulder range of motion are begun immediately, and wrist range of motion is begun as the fracture heals.

 

OUTCOMES

Multiple prospective randomized trials comparing volar plate fixation to closed reduction and percutaneous pinning have demonstrated quicker return to functional recovery with volar plate fixation but no difference in function at 1 year.12, 13, 20, 28

Functional and cost comparison of extra-articular and simple intra-articular fractures treated with volar plate fixation versus closed reduction and percutaneous fixation showed only a significant cost increase with volar plate fixation and no difference in function. This study calls into question the extra cost associated with volar plate fixation. No external fixation was used to augment the percutaneous fixation which would increase the cost of this treatment method and may negate the cost benefit of percutaneous

fixation.5

A prospective randomized trial comparing percutaneous pinning and casting versus external fixation with augmentation (eg, pins, screws, bone graft) found no difference in clinical outcomes for fractures with minimal articular displacement.10

 

 

In patients older than 60 years of age, percutaneous pinning has been shown to provide only marginal radiographic improvement over cast immobilization alone, with no correlation with clinical outcome.4

 

Ebraheim et al6 reported excellent outcomes for restoration of radiographic parameters and functional outcomes with intrafocal pinning and trans-styloid augmentation.

 

An evaluation of percutaneous pinning outcomes found the best results for metaphyseal fractures. Good results were found for intra-articular fractures. The worst results were seen in fractures with associated

ulnar styloid fractures and fractures in elderly persons.19

 

A retrospective review of radiographic and clinical outcomes of open reduction internal fixation (volar and dorsal) versus external fixation revealed no significant differences, except that palmar tilt was more effectively restored with dorsal plating.29

 

A meta-analysis found no evidence for the use of internal fixation over external fixation for unstable distal radius fractures.16

 

Women older than 55 years of age with unstable intra-articular distal radius fractures treated with external fixation have a high rate of secondary displacement but can have acceptable functional

outcomes.11

 

Patients older than the age of 55 years have better results with external fixation and pinning than with pinning alone. Younger patients with two or more sides having comminution also have better results with supplemental external fixation.27

 

Nonbridging external fixation has been shown to maintain volar tilt and carpal alignment better than bridging external fixation while having significantly better function during the first year.17

 

Nonbridging external fixation was shown to have no clinical advantage in patients older than 60 years of age with moderately or severely displaced distal radius fractures.3

 

 

A prospective, randomized comparison of bridging versus nonbridging external fixation revealed more complications in the nonbridging fixators and better outcomes in the bridged fixator group.23

P.40

 

A prospective study compared unrepaired ulnar styloid fractures to those without ulnar styloid fractures and found no significant differences in clinical outcome. However, DRUJ instability was not evaluated.24

 

 

COMPLICATIONS

Infection (pin tract or deep). Pin tract infections occur in 10% to 30% of patients and historically have been a major problem with this treatment method.9, 10

Pin tract infections can be minimized by reducing the time pins are left in place or by burying the pins beneath the skin.15, 25

One study showed that pin tract infections can be reduced to a 2% incidence if they are only left in place for 30 days, then removed in the office, and the wrist then casted for another 2 weeks without the pins in place.

If K-wires are going to be left in place for longer than 30 days, they should be buried under the skin at the time of surgery to help prevent pin tract infections.

Injury to tendons, vessels, and nerves due to percutaneous technique. Stiffness may result if tendons are

 

inadvertently skewered, and the radial sensory branch can be injured.

Injury to the radial sensory branch can cause a painful neuroma and should be avoided. Loss of range of motion

Posttraumatic arthritis Weakness in grip or pinch

Tenosynovitis and tendon rupture Malunion or nonunion Compartment syndrome

Carpal tunnel syndrome Hardware failure

Nonunion (associated with overdistraction with an external fixator) Complex regional pain syndrome (CRPS)30

Vitamin C should be prescribed to prevent CRPS (500 mg once a day for 50 days)

 

 

REFERENCES

1. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 1993;9(4):577-585.

    

    

2. Anderson JT, Lucas GL, Buhr BR. Complications of treating distal radius fractures with external fixation: a community experience. Iowa Orthop J 2004;24:53-59.

    

    

3. Atroshi I, Brogren E, Larsson GU, et al. Wrist-bridging versus nonbridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. Acta Orthop 2006;77(3):445-453.

    

    

4. Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br 2005;87(6):837-840.

    

    

5. Dzaja I, MacDermind JC, Roth J, et al. Functional outcomes and cost estimation for extra-articular and simple intra-articular distal radius fractures treated with open reduction and internal fixation versus closed reduction and percutaneous Kirschner wire fixation. Can J Surg 2013;56(6):378-384.

    

    

6. Ebraheim NA, Ali SS, Gove NK. Fixation of unstable distal radius fractures with intrafocal pins and trans-styloid augmentation: a retrospective review and radiographic analysis. Am J Orthop 2006;35(8):362-368.

    

    

7. Gupta A. The treatment of Colles' fracture. Immobilisation with the wrist dorsiflexed. J Bone Joint Surg Br 1991;73(2):312-315.

    

    

8. Gupta R, Bozentka DJ, Bora FW. The evaluation of tension in an experimental model of external fixation of distal radius fractures. J Hand Surg Am 1999;24:108-112.

    

    

9. Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled

   trial between percutaneous and buried wires. J Hand Surg Br 2004;29(4):374-376.

    

    

10. Harley BJ, Scharfenberger A, Beaupre LA, et al. Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial. J Hand Surg Am 2004;29(5):815-824.

     

     

11. Hegeman JH, Oskam J, Vierhout PA, et al. External fixation for unstable intra-articular distal radial fractures in women older than 55 years. Acceptable functional end results in the majority of the patients despite significant secondary displacement. Injury 2005;36(2):339-344.

     

     

12. Jeudy J, Steiger V, Boyer P, et al. Treatment of complex fractures of the distal radius: a prospective randomized comparison of external fixation “versus” locked volar plating. Injury 2012;43(2):174-179.

     

     

13. Karantana A, Downing ND, Forward DP, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am 2013;95(19):1737-1744.

     

     

14. Katz MA, Beredjiklian PK, Bozentka DJ, et al. Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment? J Hand Surg Am 2001;26(3):415-421.

     

     

15. Lakshmanan P, Dixit V, Reed MR, et al. Infection rate of percutaneous Kirschner wire fixation for distal radius fractures. J Orthop Surg 2010;18:85-86.

     

     

16. Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am 2005;30(6):1185-1199.

     

     

17. McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised, prospective study of bridging versus nonbridging external fixation. J Bone Joint Surg Br 1998;80(4):665-669.

     

     

18. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg 2005;13(3):159-171.

     

     

19. Rosati M, Bertagnini S, Digrandi G, et al. Percutaneous pinning for fractures of the distal radius. Acta Orthop Belg 2006;72(2):138-146.

     

     

20. Rozental TD, Blazar PE, Franko OI, et al. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am 2009;91(8):1837-1846.

     

     

21. Short WH, Palmer AK, Werner FW, et al. A biomechanical study of distal radial fractures. J Hand Surg Am 1987;12(4):529-534.

     

     

22. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. Instr Course Lect 2003;52:185-195.

     

     

23. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fixation of unstable fractures of the

    distal part of the radius. A prospective, randomized comparison with static external fixation. J Bone Joint Surg Am 1994;76(8):1149-1161.

     

     

24. Souer JS, Ring D, Matschke S, et al. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate and screw fixation of a distal radius fracture. J Bone Joint Surg Am 2009;91(4):830-838.

     

     

25. Subramanian P, Kantharuban S, Shilston S, et al. Complications of Kirschner-wire fixation in distal radius fractures. Tech Hand Up Extrem Surg 2012;16(3):120-123.

     

     

26. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19(2):325-340.

     

     

27. Trumble TE, Wagner W, Hanel DP, et al. Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23(3):381-394.

     

     

28. Wei DH, Raizman NM, Bottino CJ, et al. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am 2009;81(7):1568-1577.

     

     

29. Westphal T, Piatek S, Schubert S, et al. Outcome after surgery of distal radius fractures: no differences between external fixation and ORIF. Arch Orthop Trauma Surg 2005;125(8):507-514.

     

     

30. Zollinger PE, Tuinebreijer WE, Breederveld RS, et al. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am 2007;89(7):1424-1431.