Distal Radius Fracture Notes:

• Plan to use IV sedation or via hematoma block (A hematoma block is where you inject lidocaine into the fracture site)
  • Regardless of what future surgical management the patient may require (if it all), you should perform a reduction in the ED in order to provide pain relief, reduce swelling, and alleviate potential compression of the median nerve (which could cause acute carpal tunnel syndrome) if a reduction is required.
    • When to reduce?
      • As a general rule consider reduction and splinting with any loss of radial height or volar tilt
      • Give your patient the best shot at non-operative treatment possible
      • Decision-making varies based on personal preferences, age, fracture, and goals.

Confirming Appropriate Reduction

Use these numbers to evaluate your reduction. Also, always get a new set of formal xrays after your reduction (fluoro is not saved at our institution, take a picture on your phone if you want to demonstrate that you were able to obtain your reduction).

Evaluating key anatomical landmarks will help determine if the reduction is set appropriately. Again, normal is defined as:

• Radial inclination should be around 22 degrees (normal range 21-25 degrees)
  • Radial inclination should be within 5 degrees of normal
• Radial height should be around 11 mm (normal range 10 – 17mm)
• Volar tilt should be around 11 degrees (normal range 2-20 degrees)
  • Remember 11+11=22):

(Orthobullets)

Note: this is the book answer, not always the practical one, we do NOT commonly get x-rays of the contralateral side for reference.

Memorize this: LaFontaine Criteria of instability

These criteria tell you when a distal radius fracture is more likely to be unstable, failing non-operative management and subsequently requiring surgery.

• Dorsal angulation > 20 degrees
• Initial radial shortening >5mm
• Associated ulnar fracture
• Dorsal comminution >50%
• Palmar comminution
• Intraarticular comminution
• Osteoporosis

Of these factors, radial shortening, followed by dorsal comminution, are the most predictive of instability.

IV Sedation:

• This can be achieved with either ketamine or propofol. To note, propofol is generally used for everyone except children and patients with low blood pressure.
• The main problem with propofol is its side effect of decreasing blood pressure and patients going apneic. If patients stop breathing on propofol that means their muscles are perfectly relaxed for you to be able to reduce to your heart’s content. Oftentimes ED doctors will be slow to give patients enough propofol for you to effectively perform the reduction, so it can be a struggle to get enough sedation (this is often a problem with hip reductions because there is much more muscle mass in the hip than the distal radius).
• Ketamine, on the other hand, can dissociate patients without decreasing blood pressure. So in trauma situations, some doctors will do ketamine or ketamine and propofol (sometimes they will ask you what you want depending on your institution).
• When to use sedation?
  • Allergies to lidocaine (can’t hematoma block safely) – don’t waste time trying to track down unique versions of lidocaine, just jump to sedation
  • Stiff patients (muscle tension etiology)
  • Highly anxious patients
  • Open fractures
  • Multiple fractures on the same limb
  • Polytraumas

Hematoma Block

• Hematoma blocks are when you inject lidocaine or another nerve-blocking derivative into the fracture hematoma
• When to use hematoma blocks?
  • The elderly typically do well with hematoma blocks
  • Hematoma blocks are more time efficient when it comes to performing multiple hematoma blocks and deploy fingertraps, rather than waiting for the sedation team to follow you to the next room. (Block 3-4 at a time, hang in traps, then go start applying splints)
  • Floor consults (sedations are possible on the floor, but difficult to mobilize)
  • When patients aren’t safe for sedation
• Poor candidates for hematoma block
  • Allergies to lidocaine/ available derivatives
  • Subacute fractures (>1-2 days old) may not do well with hematoma blocks because blood at the fracture site is clotted.
  • Stiff patients that can’t relax: Parkinson’s, strokes (stiffness, muscle rigidity, and/or contractures can make the reduction quite difficult), sometimes direct muscle relaxation via propofol could help (it won’t help contractures)
  • Highly anxious patients: Young men and women <30-40 years old
    • Some are fine, this is when you need to just talk to the patient and see how they are doing
    • If highly anxious I like using Versed (midazolam) or Ativan (Lorazepam, safer for patients with liver problems) with my hematoma blocks more than short-acting opiates like fentanyl (often you can’t use both because it can be too sedating and fits the criteria for an official sedation if you use both) – this is likely hospital dependent
  • Subacute fractures (if the fracture is over 1-2 days old, poor lidocaine distribution due to clotting at fracture site)
  • Open fractures/ Polytrauma patients
  • Summary: If there are any snags with getting someone a hematoma block such as local anesthetic allergies, extremely anxious, or uncooperative, just jump to a sedation.

Operative Indications for Distal Radius Fractures

There are many indications for surgery and several operative techniques. Indications include (Commit these to memory):

• Admit for surgery
  • Open fractures
  • Associated neurovascular or tendon injury
  • High-energy polytraumas
  • Acute carpal tunnel syndrome (emergent)
  • Volar Bartons (unless specified by attending, some are sent home)
    • Posterior cortex must be intact for a true volar barton. When it is intact it allows for a radiocarpal dislocation (carpal bones follow the volar distal radius cortex piece)

• Other indications
  • Associated fracture of the carpal bones (depends on which carpal bones, scaphoid waist maybe, not dorsal triquetrum)
  • Radiographic findings indicating instability (see factors above)
    • Volar or dorsal comminution
    • Displaced intra-articular fractures >2mm
    • Radial shortening >5mm
    • Associated ulnar fracture (not ulnar styloid)
    • Severe osteoporosis (often depends on displacement)
• Articular margin fractures (dorsal and volar Barton’s fractures)
• Comminuted and displaced extra-articular fractures (Smith’s fractures)
• Die-punch fractures
• Progressive loss of volar tilt and radial length following closed reduction and casting

Equipment:

Mobilize any teams that you might need, tech for assistance or ED sedation team (if doing propofol sedation).

Gather your supplies.

• 10ml of 1%lidocaine (okay for it to be with epi, but not necessary) – Not depicted here
• 10 cc synringe with 18g blunt tip fill needle
  • Draw up all 10ml of lidocaine with your blunt tip needle and replace it with the sterile 18g sharp tip needle
• 18g 1.5inch needle with no filter
• 3 – Rolls of 4in. Plaster
• 3 – Rolls of 4in. Webril
• 2 – 4in. Ace Wraps (1 Flexmaster ace if you have it)
• Bucket for water
• Chlorhexadine brush (or iodine, or alcohol swab)
• Gauze
• Fingertraps (if desired) – this method is shown as an alternative to fingertrap use

Ask for the plaster splint cart and C arm (or go get it yourself if you don’t want to wait). (Specific to Trinity Health Hospital)

Position:

• Move bed to allow for ample room to work (move chairs if you have to)
• C-arm comes in from foot of bed with screen in ample viewing position. Plug in C-arm, and ensure it is on and working.
• Patient to edge of bed with shoulder barely off edge to allow the arm to drop while keeping the elbow bent at 90 deg
• Bed should be elevated to desired working height
• Get any tape ready ahead of time.
• Get water running to allow for hot water (baby bath warm is target, as hot water could make the plaster too hot while its curing causing burns)
• Instruct assistants where you want them ahead of time.

Hematoma Block:

• Get your hematoma block in as soon as possible in the patient interaction. This will give the lidocaine time to set up and really numb the area. (Full block activity takes ~10-15 minutes). Start setting up your splint after your block is complete.
• A good working hematoma block will help your patient relax allowing for a better reduction. If your patient is screaming in pain during your reduction, your block was not effective.
• Feel the fracture and start ~1-1.5 finger breadths proximal to the fracture on the dorsal wrist
• Mark your spot on the skin for your target point. The target point should be centered over the distal radius. (You can use c-arm for help localizing, but try to avoid C-arm use if possible).
• The dorsal approach with the needle works for dorsally displaced fractures, if you have a volar sheer fracture, you can perform a block through the dorsal wrist joint block (Just ulnar and distal to Lister’s tubercle, entry matching the volar title of the radius).

• Do not attempt to go volar with your needle (radial and ulnar neurovscular bundles) or lateral (superficial radial nerve).

• This is what your start point on C-arm would look like on an AP image. We are pointing towards a theoretical fracture location, you want to start 1-1.5 finger breadth proximal to your fracture so you have an optimal angle of entry into the fracture site.

• Sterilize the skin prior to needle insertion (chlorhexadine, alcohol, or iodine).
• The needle will enter at 45degrees from the skin surface.
• The red arrow shows a more ideal trajectory in the image below

• You can get an fluoro shot in the lateral position to help you visualize your needle location (try to avoid this step unless needed as it will slow you down).

• You push your needle in at the 45 deg angle until until you gently hit bone, and then you “walk” the needle tip distal until you fall into the fracture site.
• When you fall into the fracture site, pull back on the plunger and visualize the blush of blood mixing with your lidocaine. If you do not see this blush of blood you are likely not in the correct location. Push your lidocaine into the hematoma if you see the “blush” and pull the needle out. The lidocaine should flow freely (this can be done swiftly once you know you are in the correct location). Sometimes cycling the plunger in and out to mix the blood/lidocaine can help but takes longer and is more painful for the patient (mixing is likely an unnecessary step). Pull your needle out and place some gauze.
  • We do not recommend leaving bandaides on underneath a splint, the bleeding will stop soon with pressure over the gauze.
  • If you have skin wounds, wash them before splint application, place a nonstick dressing prior to splint application (xeroform or telfa for example).

Sugartong Splint Set Up:

• Measure your splint length with webril. Ensure not to stretch webril when measuring at your splint could end up too short. The patient’s arm must be at 90 degrees. You have to measure long to get the appropriate length splint (plaster contracts when wet). One target measurement is from index DIP volar to DIP dorsal. The volar index distal interphalangeal joint (DIP) is able to be seen in the image below).

• Measure from DIP to DIP of the index finger.
  • You can also measure from finger tips to finger tips (find what works best for you, target should be not having to fold excess splint material, but if you have to, fold the excess on the dorsal side).

• Lay out 5 layers of webril staggered to increase width slightly.
  • (Some do not stagger their webril, just ensure the posterior upper arm is padded well. This posterior proximal skin of the upper arm where the sugar tong splint wraps around the elbow, is where skin breakdown occurs, especially in ICU patients that can’t keep their elbows bent).
    • For ICU patients do a modified Sugartong splint with separate volar and dorsal slabs (Clamshell), this way they can extend their elbows and it won’t cause a pressure sore.

• Add one layer on its own next to your stack of 5, this will cover your plaster prior to placing the splint on the patient to make it easier to take off the ace wrap and keep the process clean.

• Roll out your 4 inch plaster. Place three rolls in a bucket. (This keeps the process as clean as possible and saves you time).

• Use your webril template to measure out the length of your plaster. Make the plaster the same length as your webril (when the plaster is dipped in water its length with contract slightly allowing overlap of webril to protect the patient’s skin on both ends).

• Make 10 layers of plaster (more than 10-12 layers can make the cumulative exothermic reaction process too hot, causing burns. Less than 10 may be too weak to hold your reduction). Fold your plaster twice until you have 9 layers, and then just add 1 more to make 10 total. Rip the plaster stack to match your webril template.

• Remember the length of your plaster should match your Webril template, so your splint does not end up too short. (Remember: The plaster will contract in length when it gets wet).

Reduction:

• Coach your patient on what you are going to do.
• Coach them into relaxing their muscles. When they stiffen up, their brachioradialis is pulling the distal radius fracture fragment causing you to lose your reduction.
  • This is why with good hematoma blocks you can often maintain more perfect reductions (from my experience), because patients waking up from sedation often flex their upper extremity muscles and move around and displace their fracture even when you hold the splint/reduction during the wake up process
• Ensure your hematoma block is adequate, with good hematoma blocks, patients usually have minimal pain
• Instruct your assistant to stand at the patient’s head, holding the arm at 90 deg. One hand on upper arm, the other holding the thumb so that the assistant’s thumb is pointing to the floor.
  • Pulling at the thumb can give you more leverage to restore radial height when compared to pulling the index or long finger
    • If you are reducing a both bone fracture where you need to restore radial and ulnar length, having your finger traps or assistant pulling the index and long fingers can be more helpful

• One method we call the “Bro Handshake”, you hold the patient’s hand as depicted below in the standard bro handshake custom, while placing your thumb over the distal radius fracture fragment.

Reduction Maneuver

• The xray shows an example of a dorsally displaced distal radius fracture, the drawn image shows the maneuver step by step in reference to this type of fracture.

• Step 1 above, shows the initial fracture
• Hyperextend the fracture fragment to dissociate it from the radial metaphysis to “recreate the fracture”, which is essentially bending the distal fragment more dorsally.
  1. Use your thumb to help lever it in this dorsally displaced orientation
• Then apply aggressive longitudinal traction while keeping this recreation angle until the dorsal cortices are lined up and out length while you are holding it in a dorsally tilted orientation

• Hold the fracture out to length and keep volar pressure

• While holding your reduction as depicted above, get a lateral and AP shot with fluoro to ensure you have obtained your reduction Confirming Appropriate Reduction (Remember to always keep the elbow bent a 90deg and hold your reduction through traction/ pushing the fragment in place.
  • If the fracture is a physeal fracture in a pediatric patient, you don’t want to manipulate the fracture too much (because you can cause physeal arrest) and physeal fractures should slide back in place, so you should not need as much recreation and traction. 1-2 reduction attempts with physeal fractures.
• In the reduction maneuver, a common mistake is that people don’t recreate the fracture (bending the bone in the direction it was broken), and when you do that you want to keep the bone bent or in recreation angle while pulling longitudinal traction until you get it out to length and then you lever it over into alignment. People commonly recreate, pull traction and lose their recreation angle too early or they do not pull with enough force.
  • Also, be careful in elderly patients with fragile skin to prevent skin tearing. Gloves are also more likely to tear skin, more aggressive forces in small surface areas, (like pushing really hard with your thumb) are more likely to cause skin tears.
    • Fingertraps are a more gentle alternative
• Never let go of the thumb with traction to evaluate your reduction with an AP and Lateral view.

• Very carefully hand off your reduction to your holder, like previously stated, the assistant will hold the thumb in traction pointing straight up to the ceiling and slightly volar. This will allow you to place your splint while they are maintaining your reduction
  • Using finger traps is also an option here if accessible. Instruct your assistant to tell you if they are losing their grip, having their thumb pointed down can help keep their arm out of the way while you are placing your splint. (They can also hold the patient’s thumb with their thumb pointed up).

Splint Application:

• Dip your plaster, squeeze out excess water, with two fingers squeegee out water to laminate plaster layers together. Then lay it on your laid out webril.

• The padded side goes against the skin. Do not place the single layer side against the skin, as it can burn the skin during the drying process (exothermic reaction).

• The plaster must end at the distal palmar crease, this allows fingers to fully flex. In the image below the webril is folded down over the edge of the plaster, when placing the splint, know where your plaster edge is beneath the webril and place it on the distal palmar crease.
• On the dorsal side the plaster should end just short of the metacarpal heads as depicted below

• Wrap your ace wrap, starting proximally and working your distally. (It is possible to wrap ace too tight)

• Notice that the splint is pulled down slightly in this image, the volar end of the plaster should be at the distal palmar crease across the palm. Ensure that your ace wrap does not displace your desired splint length and that it stays low at the level of the distal palmar crease as to not block finger motion.

Molding the Splint (Three-point-mold):

• Perform a three-point mold (crooked splints make straight bones). By molding the splint you can keep the fracture fragments from displacing.
• We are pointing to the dorsal aspect of the distal radius fracture fragment. Place the ulnar side of your palm over this location. This is where most of the force will go.
• You know that because the fracture displaced dorsally upon injury, the force you apply will be pushing from dorsal to volar.

• Ideally, your assistant or finger traps will never let go of longitudinal traction of the thumb, pulling straight up and slightly volar, always keeping the elbow at 90 degrees
  • Pulling at the thumb can give you more leverage to restore radial height
• Your other hand will go just proximal to the fracture site.
• Your knee (same side as your hand on the distal fragment) will be placed at the patient’s elbow on the same side as your hand on the distal fragment

• Keep your palms flat, while applying the optimal pressure (commonly more than you think, and if you’re not sweating you may not be pushing hard enough)
• Be careful to not flex the wrist in this step (avoiding a severely flexed and ulnar deviated position which can cause acute carpal tunnel syndrome)
• Again, having the assistant pull the thumb during this step is necessary to help maintain radial height
• You can check your reduction in the splint before the splint hardens to allow for minor adjustments to the reduction, this is how to do this: Evaluate: 
• You should hold the mold until the splint is fully hardened (until you can’t bend the corner of the splint). This holding process is often longer than you think.
  • Hotter water = faster hardening, also increases risk of burns
  • “Hold ‘till it’s cold”. (Don’t actually hold until it is cold because this could take way too long, but often this is a good thought process because reductions are often lost because the splint is not held long enough)

Evaluate:

• Ensure that you are maintaining the reduction in the splint, one method is to get xrays before your splint has fully hardened so you can dial in the amount of pressure you use in your reduction
  • It is possible to over reduce some distal radius fractures
  • Note: Some choose to not use fluoro, and just assess with a flat plate xray.
• Get your lateral first to assess that you restored your posterior cortex and volar tilt.
  • Ensure that you keep the elbow bent at 90degrees at all times. The brachioradialis crosses the elbow joint and attaches to the radial styloid. If you extend your elbow it tensions the brachioradialis pulling the distal radius fracture fragment causing you to lose your reduction.
  • I usually perform this step after the splint has had a few minutes to set up, but prior to becoming stiff to allow for optimizing the reduction
  • Note: You can not change your splint once it is hard. If you push on your splint after it is hardened you can fracture the plaster (broken plaster will not hold a reduction).

• You can lift the distal aspect of the radius to allow you to see down the joint by matching the radial inclination

• Assess your AP xray

Confirming Appropriate Reduction

Use these numbers to evaluate your reduction. Also, always get a new set of formal xrays after your reduction (fluoro is not saved at our institution, take a picture on your phone if you want to demonstrate that you were able to obtain your reduction).

Evaluating key anatomical landmarks will help determine if the reduction is set appropriately. Again, normal is defined as:

• Radial inclination should be around 22 degrees (normal range 21-25 degrees)
  • Radial inclination should be within 5 degrees of normal
• Radial height should be around 11 mm (normal range 10 – 17mm)
• Volar tilt should be around 11 degrees (normal range 2-20 degrees)
  • Remember 11+11=22):

(Orthobullets)

Note: this is the book answer, not always the practical one, we do NOT commonly get xrays of the contralateral side for reference.

• Overall, you are shooting for getting the cortices lined up as perfectly as you can (even though it is debatable whether it will truly affect long term functional outcomes).
• This is an example of a reduction that was inadequate, there is a loss of volar tilt of the distal radius as well as length, and you can see that the posterior cortex of the distal radius is not lined up.

The hematoma block was reperformed under fluoro and this fracture was reduced and splinted correctly the second time. Do you see the posterior cortex of the distal radius and how it is lined up?

Here are the two reductions side by side so you can compare.

Some fractures will become displaced again after closed reduction. Use LaFontaine’s Criteria to help predict how unstable a fracture will be.

LaFontaine Criteria of instability:

• Dorsal angulation > 20 degrees
• Initial radial shortening >5mm
• Associated ulnar fracture
• Dorsal comminution >50%
• Palmar comminution
• Intraarticular comminution
• Osteoporosis

Of these factors, radial shortening, followed by dorsal comminution, are the most predictive of instability.

Volar Sheer (Volar Barton) Reduction/Mold:

Plan:

NWB. Patients should move fingers and keep elevated to help with swelling.

Keep splint clean, dry, intact.

Repeat xrays in splint on weekly basis in clinic (prone to displacement, so needs close follow up.

If treating with continued non op treatment. Switch to short arm cast in 2 weeks.

Volar sheer/ volar barton fractures should be communicated to attending on call prior to sending out, if great reduction/mold, okay to send out for close follow up ~2-3 days for outpatient surgery (not all attendings will be okay with this plan)

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