Keywords

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Description

Frykman Classification

In 1967 Frykman presented this classification which has been one of the most popular among the number of classifications existing for distal radius fractures [1]. It distinguishes between radial articular and ulnar styloid involvement (Fig. 23.1). The Frykman classification has been considered to be the easiest and most straight-forward to use. Nonetheless it does not define direction of displacement, shortening, or the extent of comminution thus making this scheme less helpful for treatment and prognosis, particularly with high-energy injuries and articular impaction fractures. The Frykman classification although considered good for tabulation of different fracture types it does not specifically direct the surgeon toward treatment decision.

Fig. 23.1
figure 1

The eight types of fractures according to the Frykman classification: type I extra-articular distal radial fracture; type II extra-articular distal radial fracture with fracture of the ulnar styloid; type III involvement of the radio-carpal joint; type IV involvement of the radio-carpal joint with fracture of the ulnar styloid; type V involvement of the distal radio-ulnar joint; type VI involvement of the radio-ulnar joint with fracture of the ulnar styloid; type VII involvement of the distal radio-ulnar and radio-carpal joints; type VIII involvement of the distal radio-ulnar and radio-carpal joints with fracture of the ulnar styloid

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  • Type I: Extra-articular

  • Type II: Type I with ulnar styloid fracture

  • Type III: Involvement of the radiocarpal joint

  • Type IV: Type III with ulnar styloid fracture

  • Type V: Involvement of the distal radio-ulnar joint

  • Type VI: Type V with ulnar styloid fracture

  • Type VII: Involvement of the radiocarpal and radio-ulnar joints

  • Type VIII: Type VII with ulnar styloid fracture

Fernandez Classification

The Fernandez classification system was developed in 1993 by Fernandez and consists of five groups based on the mechanism of trauma (Fig. 23.2). This system was designed to determine stability, include associated injuries, and assist treatment recommendations [2,3].

Fig. 23.2
figure 2

The five types of fractures according to the Fernandez classification: type I bending fracture - Colles or Smith’s; type II shearing fracture of the joint surface - Barton’s reverse Barton’s; type III compression fracture - die punch impaction; type IV avulsion fracture of the radial / ulnar styloid; type V combination of types

Full size image
  1. 1.

    Bending

    One Cortex of the metaphysis fails due to tensile stress (Colles and Smith fractures) and the opposite cortex undergoes some comminution

  2. 2.

    Shearing

    Fracture of the joint surface: Barton’s, reversed Barton’s styloid process fracture, simple articular fracture

  3. 3.

    Compression

    Fracture of the joint surface with impaction of subchondral and metaphyseal bone (die punch). Intra articular comminuted fracture

  4. 4.

    Avulsion

    Fracture of the ligament attachments to ulnar and radial styloid process. Radio-carpal fracture dislocation

  5. 5.

    Combinations

    Combination of types

    High energy injuries

Universal Classification

This system meant as a guide for treatment, and addresses intra-articular involvement, ability to achieve reduction based on the concept of ligamentotaxis and post-reduction stability. Fracture severity is thus based on reducibility and stability (Fig. 23.3). The Universal Classification is based on Gartland and Werley’s classification and is similar to the Mayo classification [4,5].

Fig. 23.3
figure 3

The four types of fractures according to the Universal classification: type I non-articular non-displaced; type II non-articular displaced; type III articular non-displaced; type IV articular displaced

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  • Type I

    Non-articular, non-displaced

  • Type II

    Non-articular, displaced

    1. a.

      Reducible, stable

    2. b.

      Reducible, unstable

    3. c.

      Irreducible

  • Type III

    Articular, non-displaced

  • Type IV

    Articular, displaced

    1. a.

      Reducible, stable

    2. b.

      Reducible, unstable

    3. c.

      Irreducible

    4. d.

      Complex (shear, joint depression, fracture/dislocation)

Smith Classification

Smith fracture was named after Robert William Smith, writer of the book: “A Treatise on Fractures in the Vicinity of Joints, and on certain forms of Accidents and Congenital Dislocations” published in 1847 [6].

This book, detailing the different kinds of leg and arm fractures resulting from accidents, has been recognized in the field of medicine as the main reference for this fracture.

Smith fractures of the distal radius are characterized by volar displacement of the distal part (reversed Colles Fracture). A Smith fracture may be extra articular, intra articular, or be part of fracture dislocation of wrist (Fig. 23.4). Their classification is accordingly adjusted to three types [7].

Fig. 23.4
figure 4

The three types of fractures according to the Smith’s classification: type I extra-articular; type II fractures cross into the dorsal joint surface; type III fractures enter the radio-carpal joint (volar Barton’s)

Full size image

  • Type I

    Extra articular fracture

  • Type II

    The fracture crosses into the dorsal articular surface

  • Type III

    The fracture enters the radio-carpal joint. This type is the volar Barton’s fracture. (Both involve volar dislocation of carpus associated with intra articular distal radius component)

Treatment Strategy

Distal Radial Fractures: Frykman Classification

As already mentioned the Frykman classification is not a treatment oriented classification thus no specific treatment guidelines can be offered based on the type of the fracture.

General guidelines include the following:

  • Distal radial fractures with unacceptable displacement should be reduced under either hematoma block or sedation.

  • If the reduced fracture is stable, it is protected with a cast, splint, or brace while healing

  • If the reduced fracture is unstable, any of a number of methods, including percutaneous pins, external fixation or a combination of these techniques can maintain the reduction during fracture healing

  • If the distal radius fracture cannot be reduced by closed manipulation, open reduction is recommended. The reduced fracture is stabilized by any of a number of pinning, plating, external fixation or combined techniques.

  • No fixation technique has been demonstrated to have such a clear advantage that it could be recommended to the exclusion of others. The method of stabilization is not as important as it is that it accomplishes its goal of maintaining the reduction until the fracture is healed [8,9]

Distal Radial Fractures: Fernandez Classification [2,3]

  • Type 1 ( Bending )

    Non-operative (stable fractures)

    Percutaneous pinning (extra- or intrafocal)

    External fixation – Exceptionally: bone graft

  • Type 2 ( Shearing )

    Open reduction – Plate and Screw fixation

  • Type 3 ( Compression )

    Non-operative closed reduction, or limited open reduction, or arthroscopically assisted, or extensile open reduction.

    Percutaneous pins combined with external and internal fixation – Bone graft

  • Type 4 ( Avulsion )

    Closed or open reduction

    Pin or screw fixation

    Tension wiring

  • Type 5 ( Complex )

    Combined methods of fixation

Distal Radial Fractures: Universal Classification [4,5]

Type I

Non-articular, non-displaced

Cast or splint

Type II

Non-articular, displaced

Closed reduction

 Stable

Cast or percutaneous pins

 Unstable

External fixation – ligamentotaxis

Type III

Intra-articular, non-displaced

Cast or splint +/− percutaneous pins

Type IV

Intra-articular, displaced

 Reducible and stable

Closed reduction, cast +/− percutaneous pins

 Reducible and unstable

External fixation +/− pins

 Irreducible and Unstable

Open reduction, percutaneous pins, plate, +/− External

Fixation

 Complex irreducible and unstable

Open reduction, external fixation, bone graft, Pins or plate +/−intercarpal ligament repair

Smith’s Type I

Non-operative treatment is the treatment of choice. The fracture should be closed reduced under proper sedation/anesthesia or hematoma block, by reversing the deformity with longitudinal traction. Immobilization should be applied by long arm cast with the forearm in supination &the wrist in neutral position.

Smith’s Type II and Type III

Surgical Treatment is recommended for volar displaced fractures, especially intra articular types II and III. Open reduction and Internal Fixation with volar plates is the treatment of choice. External fixators are acceptable for wound considerations. Reduction under fluoroscopy & supplementary K wires may be needed for Smith’s type II fractures, to insure anatomic alignment of radiocarpal joint.

Distal radius fractures – evidence according to Smith classification

Classification

Meta-analysis

Systematic review

Cochrane library

 

Not available

Not available

Not available

Distal radius fractures – evidence according to Frykman classification

Classification

Meta-analysis

Systematic review

Cochrane library

 

Not available

Not available

Not available

Distal radius fractures – evidence according to Fernandez classification

Classification

Meta-analysis

Systematic review

Cochrane library

 

Not available

Not available

Not available

Distal radius fractures – evidence according to universal classification

Classification

Meta-analysis

Systematic review

Cochrane library

 

Not available

Not available

Not available

Distal radius fractures – type of anaesthesia

Anaesthesia

Meta-analysis

Systematic review

Cochrane library [10]

IVRA Vs haematoma block

Not available

Not available

Better analgesia during fracture manipulation; better and easier reduction of the fracture, with some indication of a reduced risk of later re-dislocation or need for re-reduction

Haematoma block Vs IVRA

Not available

Not available

Quicker and easier to perform; less resource intensive

Comparisons with other methods of anaesthesia*

Not available

Not available

No sufficient evidence

  1. IVRA intravenous regional anaesthesia
  2. *Nerve block Vs haematoma block; intravenous sedation Vs haematoma block; general anaesthesia Vs haematoma block; general anaesthesia Vs sedation; and general anaesthesia Vs haematoma block and sedation

Distal radius fractures – use of bone substitutes

Type of substitute

Meta-analysis

Systematic review

Cochrane library [11]

 

Not available

Insufficient evidence [12]

There is some evidence that bone scaffolding may improve anatomical outcome compared with plaster cast immobilisation alone. Insufficient evidence on functional outcome and safety; effectiveness of bone scaffolding supplementary to external fixation, or relative to percutaneous pinning or to external fixation; or of different methods of bone scaffolding

Distal radius fractures – type of treatment (adults)

Treatment

Meta-analysis

Systematic review

Cochrane library

Type of closed reduction

Not available

Not available

Insufficient evidence [11]

Type of non-operative intervention

Not available

Not available

Insufficient evidence; practitioners should use an accepted technique with which they are familiar; which is cost-effective; Take into account patient preferences and circumstances; and consider the risk of complications [12]

Type of ex-fix

Some evidences support the use of dynamic ex-fix, which may also have practical advantages over static fixation by allowing earlier limb mobility during the fixation period and enabling such patients to maintain their independence [13]

Dynamic and static ex-fix both achieve good outcomes with comparable complication rates. Non-bridging fixation may result in better functional and radiological results than static wrist-bridging fixation when considering patients of all ages with earlier return of function [14]

Insufficient evidence [15]

Ex-fix Vs non-operative

Not available

Not available

There is some evidence to support the use of ex-fix for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, ex-fix reduces re-displacement, gives improved anatomical results and most of the excess surgically-related complications are minor [16]

Ex-fix Vs ORIF (unstable fractures)

There is some evidence supporting the use of ORIF [17]

ORIF yields significantly better functional outcomes, forearm supination, and restoration of anatomic volar tilt. Ex-fix results in better grip strength, wrist flexion, and remains a viable surgical alternative [19]

Not available

ORIF with plate fixation provides lower DASH scores, better restoration of radial length and reduced infection rates [18]

Percutaneous pinning

Not available

Not available

Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use [20]

Non-operative Vs Operative

Not available

Despite worse radiographic outcomes associated with cast immobilisation, functional outcomes were no different from those of surgically treated groups for patients age 60 and over [21]

Not available

Surgical fixation is recommended for fractures with post-reduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm as opposed to cast fixation [22]

  1. Ex-fix external fixation, ORIF open reduction internal fixation, DASH Disabilities of the Arm, Shoulder and Hand outcome measure

Distal radius fractures – type of treatment (children)

Treatment

Meta-analysis

Systematic review

Cochrane library

Removable splintage Vs plaster casts (buckle fractures)

Not available

Splints were consistently better than plaster immobilisation in terms of clinical outcome, patient preference and cost, with the exceptions of young children or children with special needs who can easily remove the device [23]

Limited evidence supports the use of removable splintage and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents re-displacement, the effects on longer term outcomes including function are not established [24]

Distal radius fractures – type of rehabilitation

Treatment

Meta-analysis

Systematic review

Cochrane library

 

Not available

A home exercise program is an option for patients prescribed therapy after distal radius fracture [22]

Insufficient evidence [25]

Active finger motion exercises are recommended, but patients do not need to begin early wrist motion [22]