Distal Radius Fracture Essentials

A snowboard edge catch, a fall on an outstretched hand, and a wrist that instantly looks wrong. We take you step-by-step through a classic distal radius fracture presentation in orthopedic urgent care, featuring a 22-year-old with dorsal displacement and the unmistakable dinner fork deformity often seen in a Colles-type fracture. If you want a practical, real-world framework for evaluating acute wrist injuries, this case is built for you. 

We start with how we describe the fracture correctly on imaging, focusing on the distal fragment, and what we look for on AP, oblique, and lateral X-rays including loss of radial height and radial inclination plus concern for intra-articular involvement near the DRUJ. From there, we shift to what can’t be missed: a careful distal neurovascular exam. With dorsal displacement, traction on volar structures can lead to neuropraxia, and we talk through why leaving a fracture unreduced can put nerves at risk. 

Then we get hands-on with the hematoma block, a useful option when IV sedation is not available. I explain why the dorsal approach is typically safer, where to place the needle relative to the dorsal step-off, how much local anesthetic we commonly use, and why timing and patience matter, especially within the first three to five days. We finish with closed reduction mechanics, the alignment numbers that guide “good enough” reduction (radial inclination, radial length, volar tilt), and how a sugar tong splint with a strong volar three-point mold helps prevent the fracture from drifting back dorsally. 

If you want to follow along visually, check out the YouTube version for the X-rays and illustrations, then subscribe, share this with someone who treats wrist injuries, and leave a review with your go-to reduction and splinting tips.

Transcript

Welcome And Podcast Purpose

SPEAKER_01 0:07

Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves.

SPEAKER_00 0:40

Hello, everyone, and welcome back to the podcast. My name is Chuck Dowell. I'll be the host for today's episode. Um thank you and welcome

Case Setup And YouTube X-Rays

SPEAKER_00 0:48

back. I I hope you enjoy another case presentation. Uh so this is a common thing that I think we all see in our orthopedic clinics andor our urgent care or primary care clinics. I live in the Colorado area, so we're in the middle of winter. So a lot of times we will see patients come in with kind of slip and falls on the ice or a lot of snowboarding and skiing injuries. This gentleman was a 22-year-old gentleman who presented to the orthopedic urgent care complaining of left wrist pain. Now, again, this episode will be a case presentation. There will be, you know, visual presentation as well. You can see all the x-rays and images and other depictions that I discuss on the YouTube channel. So if you want to transfer over to the YouTube channel now, you can follow us along on that channel and be able to look at the x-rays and follow along during the discussion about the images I describe or depict during the podcast itself. So this gentleman was snowboarding uh good conditions, caught an edge. He fell, um, put his arm out to try to catch himself, immediately felt pain within his left wrist, was done snowboarding for that session, tried to treat it conservatively with ice and anti-inflammatories, but woke up the next day andor didn't sleep well that night with significant pain in his wrist, and then Monday morning presented to the urgent care clinic uh or orthopedic urgent care clinic for evaluation of his left

Exam Findings And Dinner Fork Deformity

SPEAKER_00 2:14

wrist. Um, again, the x-rays are seen on the screen now. His physical exam, uh visual deformity uh was noted within the left uh distal radius. There was dorsal displacement of the distal fracture segment, diffusedema is noted throughout the area as well. A couple things when I'm evaluating these, uh number one, obviously we want to look for any visual deformity. This deformity can help us to tell um where the displacement may be. Again, if we remember from our radiological terminology, um anytime we're describing displacement or angulation, we're describing the distal segment and how the distal segment is in alignment with the proximal segment. So if you're looking at the X-rays now, you can see that he has dorsal kind of angulation and 50% dorsal displacement of the distal segment. Uh so again, this is that dinner fork deformity that we commonly see. So you can see on the screen now an image or um illustration uh showing that dinner fork deformity. So that distal radius segment has that dinner fork appearance to it. We often call these the collis type fractures. So again, when I'm looking at the x-rays, I'm looking for the significant amount of displacement. The age of the patient definitely comes into play. This was a 22-year-old gentleman, so he is skeletally mature. Um, we will discuss on part two of this podcast our pediatric patients with these distortius fractures and their ability to continue to grow through this distortius area. But part one, I just wanted to discuss this patient itself.

Reading Films And Describing Displacement

SPEAKER_00 3:46

Um, again, if we're looking at the AP views, you can see there's loss of our radial height here and our radial inclination. There does appear to be some interarticular component within this very ulnar side of that distortius and kind of into that DRUJ section itself. And again, our oblique view shows very similar complete loss of radial height and radial inclination with this dorsal displacement. So when we're looking at these as well, and we know that they have these full dinner fork deformities, we always want to check neurovascularly distally. One of the big concerns is all our neurovascular bundles run on this palmer of volar side of the wrist. And anytime we have this dorsal displacement, we will put some traction onto that area, and it could cause a neuropraxia secondary to that reason. So, again, if we remember anatomy-wise, there's an illustration of the anatomy depicted on the screen now. Our median nerve runs through that carpal tunnel, our ulnar nerve runs onto that ulnar side of the hand as well. And then we obviously have our radial and ulnar vascular structures and arteries

Neurovascular Risk And Neuropraxia

SPEAKER_00 4:50

within that side as well. This gentleman did have a little bit of neuropraxia, a little bit of numbness entangling distally. So we don't want to leave these in this displaced position because if that traction on the nerve remains, it can cause some possible long-term nerve damage to the area. So the goal here is to try to close reduce this fracture and get it into an appropriate position. And if we can hold that closed reduction in a good position, he potentially won't require surgery. If we can't hold the close reduction in a good position, he may require surgery. So he's a 22-year-old gentleman, he's skeletal mature. This is his non-dominant arm. We discussed with him about performing close reduction in the

Hematoma Block Indications And Timing

SPEAKER_00 5:30

orthopedic urgent care clinic. He was agreeable to this plan. Now I don't have the ability for IV sedation. So when I see these patients in with these disturbidous fractures and this displacement, I'll um perform a hematoma block. And oftentimes I can get quite good anesthetics with these hematoma blocks. Majority of the patients that I do the hematoma blocks on will have a one, maybe two out of ten pain after the block is performed with performing this closed manipulation. So again, when we go back to the hematoma block itself, um we want to try to. So if we remember that when we have a fracture that occurs, a hematoma will form around that fracture area. This hematoma provides this encapsulated kind of water balloon that if we can prefer put you know put an anesthetic in the area, um, it can give them quite good pain relief, not only for just pain control from the fracture itself, but also for us to be able to perform this closed reduction uh with minimal discomfort. And so I usually use about 10 cc's of lidocaine for this. Some patients or some providers will use lidocaine and bupivacaine to provide both short-term and long-term pain relief. Our goal here is to go through the dorsal aspect of the wrist, because again, our volar aspect has all of our neurovascular bundles and all of our flexor tendons on it. Our dorsal aspect typically is fairly safe.

Hematoma Block Technique Step By Step

SPEAKER_00 6:59

Again, when we're talking about technique, you can see as the illustration shows at this time, um, the hematoma will form around that area. So I'll palpate. I'll try to find the area where that step-off deformity is at on the dorsal aspect of the wrist. I'll go one centimeter or so proximal to that. That's where I'll enter the skin at. Um, after fully, you know, cleaning the skin with beta dyn or alcohol, whatever your preferred cleaning method is. You'll try to go at about a 30-degree angle with the needle here and go directly into that fracture. So you'll go all the way down to bone until you hit bone and you're trying to go into that step-off deformity itself. You'll pull back on the plunger, trying to see if you can pull off some of the hematoma itself. Oftentimes you can, sometimes you can't. Even if I can't, I oftentimes still get a great block, even though I can't pull back and kind of aspirate some of the blood itself. If I can't aspirate the blood, I'm always encouraged that I'm in the hematoma itself. And um so sometimes if I don't pull back and get a blood filling into the chamber, I will maybe adjust my needle a little bit to see if I can find that area. If I can't, then I'll just try to put the anesthetist in the area. So I'll put about three to five cc's directly into the middle, and then you can see as the illustration depicts here, I'll try to fan out towards the radial and ulnar side itself, both uh times aspirating again, trying to make sure I'm in that hematoma. Um, again, a couple things about these hematoma blocks. Number one, um, ideally you want to perform these pretty acutely. So within the first three to five days of the fracture, if you try to perform this after three to five days, oftentimes some of that hematoma has reabsorbed and we won't get as good of an anesthetic with this. So typically, if it's three days, I will perform the hematoba block. If it's five days, I'll warn the patient it may be an incomplete block. And if that's the case, they may have to go to the emergency room to have IV sedation if we feel like the fracture still needs reduction at that point. Number two, um, you want to give this plenty of time to allow the hematoma block to set in. I give every patient at least 10 minutes. I think oftentimes as providers, we get a little impatient. We try to go and manipulate the fracture itself prior to the full hematoma, you know, the block setting in, and they don't get complete pain relief or anesthetics with it. So full 10 minutes to allow it to set in, and oftentimes patient will do well with this. You can see here as the illustration shows, this is a provider performing a hematoma block, a little bit more of a steep angle with their needle than I would normally perform. Again, I would normally go at about that 30 to 45 degree angle. Um, trying to go proximal to where the step off deformity is at and putting my needle right into that deformity itself. So that's what I did on this gentleman. I performed a hematoma block on him. I gave it 10 minutes. He did quite well. He said his pain was more of a three to four out of ten with the manipulation itself, but he had significant and/or improved pain relief.

Closed Reduction Maneuver And Countertraction

SPEAKER_00 9:56

So again, when we're doing these uh closed reductions technique-wise, um, you can see on the illustration here, andor the description here, um, in younger patients that periosteum is quite thick and that younger that periosteum is intact. And so if we just pull straight longitudinal traction in those patients, we won't unhook that distal fragment and we'll potentially won't get a good um reduction itself. So when we're doing this, we're gonna want to recreate the form deformity. So I take both hands, I put them onto the wrist, I recreate the deformity, so I make the deformity worse. I then pull traction to try to get this dorsal segment up and over that hinge that it's sitting on, and you can see in the depiction here, uh, recreate the deformity uh first, pull traction and try to get that dorsal hinge to sit into place, and then pull the fracture back over into place to hold it. Now, if there's a lot of dorsal comminution, obviously this won't work. So in this patient, there wasn't a significant amount of dorsal commutation. I felt like this method would work quite well. Um, so again, you could see in the depiction here, we recreate the deformity with our thumb right here, kind of pushing on that distal fracture segment. Um, I'll then either have my assistant push down onto the you know biceps area to give me countertraction to allow me to pull against it. There's a lot of different methods. Uh, you know, one of our surgeons puts his arm, his foot or leg around and kind of pushes down with that. You can use finger traps if you have them. I don't I don't specifically have them. But then I'll try to get that dorsal hinge um in place and then I'll try to push it up volarly to try to manipulate that fracture into position. And luckily in this patient, again, with this, you know, come on, I'm minimally comminuted with a slightly uh minimal dorsal comminution fracture segment, I was able to get a good reduction. So you can see here my post-reduction x-rays uh show that the fracture segment is in a good position. There is still some dorsal comminution here, but I was able to improve that dorsal displacement to almost a normal position. And again, you could see here when we're looking at our AP view, I was able to kind of re um maintain our radial height and our radial inclination.

Post Reduction Metrics That Matter

SPEAKER_00 12:22

So again, briefly, and we'll discuss more of this and when we discuss distortius fractures themselves. But three things we're looking for when we're looking at distortius fractures is our radial inclination here. So we want that to be about 22 degrees, and that's this kind of slope of that radius from the ulnar the radial styloid to that DRUJ joint. We want um our radial height to our radial length um to be seen here as well. So it's not depicted here, but normally we want that radial length to be about 10 to 13 millimeters. So again, you can measure from that radial DRUJ joint to that tip of that radial styloid and look for the radial length. And then we're looking at our volar tilt. So we're looking at any tilt that could be present. Um, and we want that distal or dorsal aspect to be higher than that volar aspect, and usually that's approximately 7 to 15 degrees or 11 degrees on average. And you can see here on the screen now an X-ray image with these uh different measurements in place. Uh so again, radial inclination, kind of looking at that tilt to the radius, our radial length, and then our volar tilt. Um, hopefully that uh dorsal volar aspect is a little bit higher. So in this patient, I think we were able to get a lot of those back. Again, typically when they have a nice piece distally that doesn't have a significant amount of comminution, especially inner articular component, uh, these closed reductions will do quite well. So this is my post-reduction. So the second thing about these is you want to make sure that you mold the cast or whatever you're putting on there to not allow this to fall back off.

Sugar Tong Splint And Three Point Mold

SPEAKER_00 14:05

Uh, number one is getting a good reduction. Number two is holding that reduction into place. So usually we're not going to cast these because they will swell afterwards. We're going to put them in some type of splint. We want to put a splint above the elbow to control rotation. And so these um gutter splints. I apologize. These sugar tong splints are what typically work the best. Uh, so this is what a sugar tong splint looks like. Typically, we can provide kind of orthoglasts to go around the elbow. This will provide um support with both rotational and um any dorsal or kind of volar displacement. We want to go at least to the metatarsal heads um and to get kind of a full distal um splinting as well. But again, in this patient, I think the molding of the splint is probably the most important part. We want to have a volar mold. So you can see here there's a little bit of a banana-shaped deformity to this where I'm I'm taking and I'm pushing, you know, on my dorsal aspect here to try to make sure I'm molding that splint. So if it's gonna fall off because of the forces of pull, it's typically gonna fall off dorsally here again. And so I want this volar mold to make sure that it doesn't fall off into that dorsal position. Um, because if it's gonna go anywhere, that's the direction it's gonna want to go. So I'll have this kind of three point mold to you know form the splint. And so