Distal Radius Fracture Trauma Case for FRCS (Tr & Orth) Oral Examination

These are an AP and lateral radiograph of the right wrist, which show a dorsally angulated and displaced fracture of the distal radius.

Assuming that this is a closed injury without neurovascular deficit, my treatment would depend on a number of patient-related factors and injury or fracture-related factors. Relevant patient factors include patient biological and physiological age, functional demands of the patient, comorbidities, and fitness for surgery. Injury-related factors include any associated neurovascular deficit, open wounds, comminution, and potential for instability. This is an unstable injury with marked radial shortening as well as dorsal and metaphyseal comminution. I would discuss the benefits of operative versus non-operative treatment with the patient, but my advice would be that, for an active patient with reasonable functional demands, I should perform a careful closed manipulation under Bier’s block or sedation would restore length, alignment, and also reduce tension on the soft tissues, as well as swelling and tension on local nerves. I would place the patient in a below elbow backslab and check the post-manipulation position with radiographs, and if a satisfactory reduction is achieved, then I would review the patient at 1 week in the fracture clinic with repeat radiographs. If the position is maintained, I would complete the cast, but I would warn the patient that this injury has a considerable risk of instability, and I would review the patient in the fracture clinic after another week in clinic with further radiographs. If the position is maintained, I would treat the patient in a plaster cast for a total of 6 weeks. I would treat the loss of position in the first 2 weeks with surgery, and in this situation, I would use a volar locking plate.

I would have a discussion with the patient about the risks and benefits of surgery. In a patient of this age, the bone quality is likely to be osteoporotic, and fixation with Kirschner wires is less reliable, especially for comminuted fractures. I would choose to treat this fracture with locked volar plating through a modified Henry’s approach, which would allow early movement and remove the need for plaster cast treatment.

Various studies have examined a number of radiographic and patient-related predictors of instability. Patient age is consistently agreed as an important patient-related factor. This may be representative of bone quality. Radiographic factors include fracture comminution, radial shortening or ulna variance, and an associated fracture of the distal ulna.