CASE REPORT

CLOSED FRACTURE OF DISTAL RADIUS

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian

Ilmu Bedah RSUD Kendal

Disusun oleh :
Vicky Novitasari
01.211.6549

Pembimbing :
dr. Wisnu Murti Sp.OT

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015
 HALAMAN PENGESAHAN

Nama : Vicky Novitasari

NIM : 012116549
Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Bedah
Judul : Closed Fracture Radius Distal

Semarang, 23 November 2015

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

 CHAPTER I
BACKGROUND

In the times of Hippocrates and Galen, distal radius fractures (DRFs) were thought to be
wrist dislocations. Pouteau first varied from this tradition when he described a varied of forearm
fractures in the French literature, including a DRF. As a result, DRFs are termed pouteau
fractures in the French-speaking world. However, politics and communications being what they
were, the English-speaking world did not recognize the Pouteau description.

The Irish surgeon Abraham Colles described DRFs in the 1814 volume of the Edinburgh
Medical Surgical Journal. Although his description was based on clinical examination alone
(because radiography had not yet been invented), it is quite accurate, and it is Colles name that
is most often associated with this fracture in the English-speaking world. Colles stated, Pne
consolation only remains, that the limb will at some remote period again enjoy perfect freedom
in all of its motions and be completely exempt from pain This claim that all DRFs, despite
displacement, will fare well has been a source of criticism.

Over time, other eponyms have been added to the various subclassifications of DRFs,
such as the Smith fracture, Barton fracture, and volar Barton fracture. The fractures are also
referred to as various stages of classification systems, such as a Melone IV os an AO (ie,
Arbeitsgemeinschaft fur Osteosynthese [Association for the Study of Osteosynthesis]) C3
fracture, or are referred to the region of the fracture (eg, a radial styloid or a lunate facet
fracture), or have a historical explanation (chauffeurs fracture, so called because a chauffeur
sustained this injury when he tried to crank-start a car and it backfired).

In current practice, as a result of greater knowledge of the varieties of fracture

configurations, eponymstend to be avoided, and a direct description of the fracture is preferred.
The term of DRFs properly covers all fractures of the distal articular and metaphyseal areas.
Although all classification systems have serious problems, there is general agreement on the
meaning of at least some of the classification terms (eg, Melone IV or AO C3 fracture), and these
terms do add some degree of specificity and understanding to the generic designation DRF.
 Distal radius fractures (DRFs) are among the most common type of fracture, and many
authors state that they are the most common type of fracture. DRFs have a bimodal distribution,
with a peak in younger persons (aged 18-25 years) and a second peak in older persons (aged >65
years). The mechanism of injury is unique to each group, with high-energy injuries being more
common in the younger group and low-energy injuries being more common in the older group.

The ultimate aim of treatment is to restore each patient to his or her prior level of
functioning. The specific goals, therefore, will not be the same in all patients. For example, a 21-
year-old athlete wants to resume competition, but a 82-year-old person usually only wants to
return to activities of daily living (ADLs).

Because goals differ, treatment options differ as well. In addition, because people now
remain active until an older age, the definition of the phrase prior level of functioning is
changing. For example, a 92-year-old patient who was being treated in the emergency
department had only one concern when conversing with his physician : how soon he could return
to playing golf (he had a tournament the next week). Treatment goals, therefore, must be tailored
to each patient. Specifically, treatment should be determined not by age but by activity level.
 CHAPTER II
PATIENTS STATUS

I. IDENTITY
a. Name : Mr. M
b. Age : 45 years old
c. Sex : Male
d. Religion : Islam
e. Job : Laborer
f. Address : Langenharjo Rt 04/01, Kendal
g. Room : Kenanga
h. Register number : 484599
i. Date of in patient : November 2nd, 2015

II. ANAMNESA
Autoanamnesa and alloanamnesa with the patient and the patients wife held on
November 2nd, 2015 in IGD and also supported by medical records.
Primary Survey :
A (Airway) : Airway and cervical spine stabilisation (Cleared)
B (Breathing) : Adequate breathing (respiration rate : 26x/minutes )
nothing abnormality
Circulation (C) : Adequate circulation
Disability (D) : E4V5M6 , pupil refleks +/+ isokor
Exposure (E) : Abnormality on upper lefl wrist
Chief complaints: Pain in the left hand

Present status:
Patient come to emergency room accompanied by his wife after had job accident.
Patient was climbing a ladder when he got slip and fall down from high with aslant
position. Patient complained a pain on his left hand, swollen and hard to move it.
Medical condition history:
- History of asthma and allergies : denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Family history:
- History of asthma and allergies : denied
- History of heart disease : denied
- History of hypertension : denied
 - History of diabetes : denied

Socioeconomic status :
Patients working as an laborer. The cost of treatment using BPJS.
Impression: enough in socioeconomic.

III. Physical Examination

Held on November 2nd, 2015 at 14:00 pm in IGD of Kendal Hospital
General Condition : Good enough
Awareness : Composmentis, GCS 15
Vital Signs
1. Blood pressure : 120/70 mmHg
2. Heart rate : 88 x / minute, regular
3. Temperature : 36oC
4. Breathing : 20 x / min

Physical Assessment
General Appearance : slightly untidy with discomfort ( due to previous fall)
Skin : brown, skin turgor normal
Head : mesocephal form, injuries (-)
Eyes : isokor pupil (d : 3mm/3mm), light reflex (+/+), palpebral
conjungtival pallor (-/-), sclera jaundice (-/-)
Ears : Discharge (-/-)
Nose : septal deviation (-), discharge (-/-)
Mouth : Normal , cyanosis (-)
Neck : symmetrical, deviation of the trachea (-), enlarged lymph nodes
clear (-), an enlarged thyroid gland (-)
Chest : normochest, symmetrical
Abdomen : lesion (-), tenderness (-)
Extremities : left hand : edema and covered by unsterile bandage, warm and
the skin was wrinkeled and paled
Motor Sensorik
5 3 N N
5 5 N N

Localized Status of lower extremities in right femoral region:

Look :
o Skin color : normal
o Edema : (+)
o Pale and wrinkled : (-)
o Vulnus : (-)
 o Deformity : (+) eksorotasi, fleksi
Feel :
o Skin temperature : warm
o Tenderness : (+)
o Krepitation : difficult to evaluate
o Artery pulsation : (+)
Move of femoral dextra :
Aktif :
o Suppination : (-)
o Pronation : (-)
Pasif :
o Suppination : (-)
o Pronation : (-)
Neurovascular Distal (NVD) :
Neurological :
o Physiological reflex : difficult to evaluate
o Pathological reflexes : (-)
o Motor : 3/5 (because of left hand pain)
o Sensory : touch (+), tenderness (+), temperature (+)
Vaskular : CRT : >2 seconds

IV. Laboratory Results

1. Blood laboratory

Examines Results Normal Results

Hb 11,4 gr% 13 18 gr%
Leucosite 10.600 cell/mm3 4.000 10.000 cell/mm3
Trombosite 181.000 cell/mm3 150.000 500.000 cell/mm3
Ht 37,5 % 39 54 %
PT - -
APTT H 27,4 39,3 seconds
GDS 91 75-115 mg/dl
Ureum 18 10-50 mg/dl
Creatinin 1 0,5-1,10 mg/dl

2. Radiology
X- ray Wrist Joint Left AP-lateral
 Interpretation : fracture of left radius distal

V. DIAGNOSE
Close fracture left radius distal

VI. PLANNING THERAPY

Medical
IVFD RL 20 drops per minute
Antibiotic : Cefotaxim 2 x 1 gr IV
Non-Medical :
Conservative :
Close reduction casting
NVD evaluation
Vital Sign evaluation
Operative :
Consul to orthopedic
Can be performed ORIF

BAB III
 CONTENTS REVIEW

3.1 Anatomy
The forearm contains two bones : the radius and the ulna.

RADIUS

The radius is the lateral bone of the forearm. Its proximal end ariticulates with the
humerus at the elbow joint and with the ulna at the proximal radioulnar joint. Its distal end
articulates with the scaphoid and lunate bones of the hand at the wrist joint and with the ulna
at the distal radioulnar joint.

At the proximal end of the radius is the small circular head. The upper surface of the
head is concave and articulates with the convex capitulum of the humerus. The
circumference of the head articulates with the radial notch of the ulna. Below the head, the
bone is constricted to form the neck. Below the neck is the bicipital tuberosity for the
insertion of the biceps muscle.

The shaft of the radius, in contradistinction to that of the ulna, is wder below than
above. It has a sharp interosseous border medially for the attachment of the interosseous
membrane that binds the radius and ulna together. The pronator tubercle, for the insertion of
the pronator teres muscle, lies halfway down on its lateral side.

At the distal end of the radius is the styloid process; this projects distally from its lateral
margin. On the medial surface is the ulnar notch, which articulates with the round head of
the ulna. The inferior articular surface articulates with the scaphoid and lunate bones. On the
posterior aspect of the distal end is a small tubercle, the dorsal tubercle, which is grooved on
its medial side by the tendon of the extensor pollicis longus.

The important muscles and ligaments attached to the radius are shown in below.
3.2 Etiology
Younger patients have stronger bone, and thus, more energy is required to create a
fracture in these individuals. Motorcycle accidents, falls from a height, and similar situation
are common causes of a distal radius fracture (DRF). Trauma is the leading cause of death in
the 15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas.
Older patients have much weaker bones and can sustain a DRF from simply falling on an
outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to
these injuries being termed fragility fractures, with the implication that a workup for
osteoporosis should be a standard part of treatment. As the population lives longer, the
frequency of this type of fracture will increase.

3.3 Pathophysiology
The pathophysiology of a fracture is rather obvious: more load is imparted to a bone than
the bone can sustain. Osteoporotic bone can break with very low impact. However, the
patient should always be questioned regarding the circumstances of the injury, especially if
 he or she is older. Heart attacks or transient ischemic attacks can cause a distal radius
fracture (DRF) and should not be overlocked.
In addition, more problems may be involved with the injury than just the fracture. A
useful perspective is that a DRF is a soft-tissue injury surrounding a broken bone, and the
immediacy of the radiographic diagnosis should not distract the surgeon from carefully
assessing systemic issues or forearm soft-tissue issues.

3.4 Presentation
The history should be directed toward ascertaining the probable amount of energy
involved. A fall from 20 feet can be associated with a larger and more complex constellation
of injuries (ie, beyond the fracture seen on the radiograph) than would be seen with a fall
from a standing position. A history of prior fractures should be sought. A history of fragility
fractures helps predict the ability of the patient to comply with directions.
The median nerve is always compressed after a fall on the palmar aspect of the hand that
results in a distal radius fracture (DRF), and the chart note should specifically document the
quality (not just the presence or absence) of median nerve function.
Most therapies for DRF have implications for the median nerve. A cast or splint without a
reduction may result in median nerve compromise due to pressure. A reduction, whether
closed or open, involves some level of anesthesia, temporarily compromising the ability to
assess the median nerve function at the first assessment is critical to planning and assessing
treatment, not to mention protecting the surgeon from subsequent claims. DRFs are
overrepresented in orthopedic malpractice suits.

3.5 Indications
No consensus has been reached on classification systems, indications for surgery, or a
particular choice of surgery since the orthopedic community first rejected Colles contention
that all DRFs heal well. Gartland and Werley are generally credited with starting the
revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought
the discussion into modern era with his 1986 paper in the Journal of Bone and Joint Surgery
that emphasized the importance of reduction.
Despite the parge number of papers published each year on DRFs, no consensus has been
reached on treatment, and there is nothing in the literature to suggest that a consensus might
be developing. Indeed, with one approach advocating immediate motion using a fixed-angle
volar plaate and another advocating immobilization fir 3 months using an internal joint-
spanning plate, treatment options seem to be diverging rather than converging.
One area of agreement is that fractures in active adults should be reduced anatomically.
Unfortunately, however, no consensus has yet been reached on precisely how the term
anatomically should be interpreted. That is a 0,5-mm displacement of an intra-articular
fragment anatomic? What if it is extra-articular? Is the same definition of anatomic
appropriate both for young, active patients and for older, inactive patients?
Even with classification, no consensus has been reached. The International Federation of
Societies for Surgery of the Hand formed a working group of the most distinguished minds
in DRF management to investigate for the existence of a consensus on the best classification
system or, if one did not exist, to develop one. This working group concluded that no
available system was universally useful or accepted and that the group could not develop a
system that would be.
There is, however, a consensus that the goal of treatment is to restore the patient to the
prior level of functioning. This is the starting point for all discussion.
The goals of any classification system are as follows :
To stratify the injuries
To guide treatment
To facilitate discussion
To predict outcome
Each classification system has its merits and weakness with respect to each goal, and
often, more than one classification system is needed.
The classification system used most frequently are the Frykman, Melone, AO
(Arbeitsgemeinschaft fur Osteosyntthese [Association for the Study of Osteosynthesis]), and
Fernandez systems. Their key characteristics are follows :
The Frykman classification highlights the injury to the distal radioulnar joint (DRUJ)
The Melne classification, based on the paper by Scheck, highlights the fragmentation of
the articular surface, especially the dorsoulnar corner of the distal radius
The AO classification emphasizes the location as extra-articular, partial articular and
completely articular
The Fernandez classification is based on the mechanism of injury, deduced from the
displacement of the bone and the location of the fracture lines
A classification system that approaches the topic from another rangle categorizes fracture
patterns according to the three-column concept of the wrist and proposes treatment
accordingly. This approach was independently developed by Medoff in 1994 (personal
communication) and by Rikli and Rigazzoni. The three column are as follows :
Lateral column (the radial half of the radius, including the radial styloid and the scaphoid
facet, though Medoff differentiates these two)
Central column (the ulnar half of the radius, including the lunat facet)
Medial column (the ulna, the triangular fibrocartilage [TFC], and the DRUJ)
Each column is considered separately as to its need for reduction and stabilization. It
should be noted that this conceptual approach does not exclude any other approaches but,
rather, is complementary to them.

Most authors advocate an anatomic reduction. This admonition, however, has two
problems. First, not all patients need an anatomic reduction to be able to resume their normal
activities. Second, the concept of anatomic reduction is not defined, as noted above. No
authorities advocate operative reduction if the stepoff is 0,5 mm; however, a stepoff of 0,5
mm is obviously not anatomic. On the other hand, a 20 dorsal tilt is not anatomic, yet
inactive elderly adults can easily return to their previous level of functioning with this
alignment.
The indications for reduction or operative treatment are not based solely on age but must
be tailored to the individual patient. It is also important, however, not to err in the opposite
direction that is, by considering that any patient who is old does not require an anatomic
reduction (one paper defined old as 50 years old!) balanced judgement is required.
Most authors would recommend anatomic reduction in a patient who is active in
recreation (remembering that golf and tennis are common activities for persons older than 70
years) or engages in forceful activities at work.
Conversely, if the patient is sedentary, a less reduction may allow return to full activities.
Usually, three parameters are relevant :
Intra-articular stepoff Most authors would accept less than 1 mm of intra-articular
stepoff but not more than 2 mm
Dorsal tilt Most authors would accept neutral dorsal tilt but not more than 10 (the
range is quite large in the literature, with some authors not accepting more than neutral)
Radial length Most authors would accept 2 mm of radial shortening but not more than 5
mm
Radial tilt is generally considered a lesser parameter.
Defining anatomic reduction in terms of intra-articular stepoff is challenging. The main
challenge lies in making a reliable determination of the relevant parameters that is, how to
distinguish between less than 1 mm and greater than 1 mm. The difficulty is that opinions
are based on studies using routine plain radiographs, which cannot accurately measure
stepoffs with an accuracy of 1 mm.
The threshold of 1 mm for intra-articular displacement is commonly cited, referencing a
1986 landmark paper by Knirk and Jupiter. However, Jupiter has repeatedly stated that this
threshold is not the benchmark that subsequent authors have used, that the 1986 study had
methodologic flaws, and that ligamentous injuries may account for functional limitations
better than intra-articular stepoff does. Surgeons must review the literature with this in mind,
because it changes the reliability of the conclusions reached by many authors after 1986.
Fewer comparative studies (either basic science or clinical) have been published on
dorsal tilt, but this has not kept authors from making pronouncement. The range of anatomic
alignment for dorsal tilt has reportedly been from 0 to 10, with no proviso for less
active patients. Given that a neutral (0) alignment represent an 11 loss of volar angulation,
even the most conservative figure is not truly anatomic.
Commonly, some older, inactive patients are able to achieve full resumption of their
activities with dorsal tilts of 45 or more. Although orthopedic surgeons may find the
radiographs of these patients disturbing and the clinical deformity not much better, some
patients are quite satisfied and able to function in all of the ADLs. This calls into question
 any rigid threshold of dorsal tilt, whether it be 0 or 10. Most authors recommend no more
than 0-10of dorsal tilt in healthy, active individuals.
The basic science of radial length is clear. Shortening radial length by 2 mm doubles the
load through the TFC and the ulna. The clinical relevance of this fact in the context of distal
radius fracture (DRFs) is unclear. Additionally, altering the radius length relative to the ulna
affects the function and forces associated with the DRUJ. On the basic of less well-defined
clinical grounds, most authors would not accept more than 2-5 mm of shortening.
Another issue that has not been resolved is the stability of the reduction if it is performed
in a closed procedure and without operative support to the fracture fragments. Some authors
believe that a 30 dorsal tilt or any radial shortening will not be stable and will subside. If
function requires that reduction be achieved, surgery is needed to maintain it.
Agreement has been reached that weekly radiographic assessment is required for
approximately 3 weeks. Fractures do not commonly subside after 3 weeks, but this is not a
certainly. Care must be taken to compare the current radiograph because subsidence is
gradual and can be difficult to detect.

3.6 Relevant Anatomy

Treatment depends on a solid understanding of the anatomy of the radius.
On the volar surface of the radius, the large lunate
facet is see on the left, projecting out from the surface of
the radius. The volar radial tuberosity is at the right margin
of the bone. The surface is covered with the pronator
quadrates (PQ). The cortical bone is quite thick and is
strong, even in osteoporotic patients.

On the dorsal surface of the radius, the Lister tubercle is seen in the center. This bone is a
thin cortical shell, with little structural strength.
 The ulnar surface of the radius, with the sigmoid notch for articulating with the ulna. On
the distal articular surface of the radius, the scaphoid facet is to the right, and the lunate
facet is to the left. This bone is the strongest of all the surfaces, and even if it is osteoporotic,
it is quite strong.

A normal posteroanterior radiograph of the radius is shown in the image below. The ulna
is generally within (plus or minus) 2 mm of the radius. Several anatomic landmarks are
important for the volar approach to the radius.
3.7 Bone healing
Bone healing process (cortical bone on bone length) consists of five phases, there are :
1. Hematoma phase (within 24 hours arising bleeding)
If a fracture occurs, the small blood vessels that pass through the canaliculi in
system suffered a tear in the area of the fracture and hematoma will form between the
two sides of the fracture. Large hematoma covered by the periosteum. Periosteum
will be motivated and able to experience tears hematoma that occurred as a result of
pressure that can occur extravasation of blood into soft tissue. Osteocytes with the
lacuna, located one millimeter from that area of blood loss and fractures will die,
which would lead to an avascular area dead bone on the sides of the fracture
immediately after the trauma.
2. Proliferation / inflammation Phase (Occurs 1-5 days after trauma)
Soft tissue reaction occurs around the fracture as a healing reaction. Healing
occurs because of osteogenic cells which proliferate from perosteum to form callus on
the external and internal callus in endosteum areas as cellular activity in the canal
 medullaris. In the event of severe laceration in the periosteum of the healing cells
derived from mesenchymal cells that are not differentiated into soft tissue. In the
early stages of fracture healing by an additional amount of osteogenic cells which
provides rapid growth of malignant tumors.
Soft tissue are not formed from freezing hematoma organization of a region of
the fracture. After a few weeks of the fracture callus will form as a mass of tissue
covering the osteogenic. On radiological examination contains bone callus yet so it is
still a radiolucent area.
3. Callus formation Phase (occurring 6-10 days after trauma)
After the formation of the cellular tissue that grew from each fragment based on
derived from osteoblasts and then on chondroblasts form the cartilage. Osteoblasts
place occupied by the intercellular matrix of collagen and attachment of
polysaccharide by calcium salts formed immature bones. This bone forms called
"woven bone" (an indication of the first radiological fracture healing).
4. Consolidation phase (2-3 weeks after the fracture to heal)
Woven bone callus will form the primary and gradually transformed into a more
mature bone by the osteoblasts activity and excess callus lamellar structure can be
gradually resorbed.
5. The remodeling phase (time over 10 weeks)
Slowly happening in osteoclastic resorption and osteoblastic process persists on
external callus is slowly disappearing. Intermediates turned into a bone callus is
compact and contains haversian systems and callus inside will experience to form a
marrow space.
3.8 Definition of Fracture
A fracture is a break, usually in a bone. If the broken bone punctures the skin, it is called
an open or compound fracture. Fractures commonly happen because of car
accidents, falls or sports injuries. Other causes are low bone density and osteoporosis, which
cause weakening of the bones. Overuse can cause stress fractures, which are very small
cracks in the bone.
A femoral shaft fracture is a fracture of the femoral diaphysis occurring between 5 cm
distal to the lesser trochanter and 5 cm proximal to the adductor tubercle.
Types of Fractures
a. closed fracture
Closed fracture is a fracture without complications, the skin is intact, the bone
does not protrude through the skin.
b. open fracture
Open fractures are fractures that damage skin tissue, because of the relationship
with the outside environment, thus potentially open fractures infection osteomyelitis.

3.9 Mechanism of injury/traumatic

high-energy
o most common in younger population

o often a result of high-speed motor vehicle accidents

low-energy
 o more common in elderly

o often a result of a fall from standing

o gunshot

3.10 Classification

Oestern and Tscherne classification of soft tissue injury in closed fractures

Grade 0 Minimal soft tissue damage

indirect injury to limb (torsion)

simple fracture pattern

Grade 1 Superficial abrasion or contusion

mild fracture pattern

Grade 2 Deep abrasion

skin or muscle contusion

severe fracture pattern

direct trauma to limb

Grade 3 Extensive skin contusion or crush injury

severe damage to underlying muscle

compartment syndrome

subcutaneous avulsion

Winquist and Hansen Classification

Type 0 No comminution
Type I Insignificant amount of comminution
 Type II Greater than 50% cortical contact
Type III Less than 50% cortical contact
Type Segmental fracture with no contact between proximal and distal
IV fragment

3.11 Imaging Study

Plain radiographs are the foundation of treatment and are all the needed for most distal
radius fracture (DRFs). If the DRF is placed in traction as an early plan of treatment, traction
radiographs are very helpful. Often, the fragments cannot be adequately identified or
assessed on the injury films; the traction views are often the first radiographs that define the
fragments. Final reduction films must be evaluated for adequacy of reduction and for an
assessment of stability, even though this is an area with no clear guidelines.
 Computed tomography (CT) is useful for evaluating the articular fracture lines and
degree of cumminution, and it is sometimes helpful for planning the approach. It should be
kept in mind that plain films underestimate the number of fracture lines and that CT
overestimates the number. CT is necessary in planning intra-articular osteotomies for
nascent malunions and mature malunions.three-dimensional reconstructions may look
impressive in presentations, but to date, they have not been very helpful in preoperative
planning or postoperative assessment.
One study examined whether the locations of DRFs correlate with the areas of attachment
of the wrist ligaments. Using data from CT scans of acute intra-articular DRFs, the study
noted that articular DRFs were statistically more likely to occur at the intervals between the
ligament attachments than at the ligament attachments. The most common fracture sites
were the center of the sigmoid notch, the area between the short and long radioulnate
ligaments, and the central and ulnar aspects of the scaphoid fossa dorsally.
These result suggest that CT may be used for identify the subsequent propogation of the
fracture and the likely site of the impaction of the carpus on the dista radius articular surface.
This is a very interesting approach that will likely become a standard part of understanding
DRFs in the future, especially if the method can be refined.
 The threshold for treatment, though not clearly defined, often involves assessing the
degree of displacement (measured in millimeters). Both plain films and CT scans have been
evaluated for their accuracy at the 1-mm level. Neither modality can reliably be read at this
level, which adds to the challenge of the treating distal radius fractures.
Magnetic resonance imaging (MRI) is not indicated for evaluation of bony anatomy.

3.12 Medical Therapy

In the treatment of distal radius fractures (DRFs), the goal is to return the patient to his or
her prior level of functioning. The physicians role is to discuss the option with the patient
and the patients role is to choose the option that best serves his or her needs and wishes.
This treatment paradigm can be illustrated by a case discussion of an approach to the
surgical treatment of stable fractures that are in acceptable alignment.
Many DRFs can be treated nonoperatively. Those that are undisplaced or minimally
displaced (the definition of minimally displaced is controversial and varies with age and
activity level) can be treated in a cast for 6 weeks. In most instances, unless the distal ulna is
fractured and unstable (type I and II ulna fractures are usually stable), it can be treated in
short arm cast.long arm casts are not required if the ulna is stable; additionally, these casts
significantly disable the patient during the treatment of the fracture.
Some fracture in elderly persons that are compressed dorsally can be minimally painful
and can appear to be clinically stable. These fractures may be treated with a splint only. This
variant is somewhat rare.
Elderly, low-activity patients can have very high function and return to prior activities
even with a significantly displaced fracture. A 45 dorsal tilt can be highly functional in a
patient who drives and is active out of the home but does not sports. Clinically, such patients
have an unsightly wrist (with a prominent ulnar head) that has limited supination and
flexion, but they do not have symptoms with activities of daily living (ADLs). Success in
theses cases strongly depends on the patient, not the surgeon, making the treatment choice.
A systematic review concluded that, in patients with DRFs who are aged 60 years and
older, cast immobilization provided functional outcomes similar to those achieved with
surgical treatments (volar locking plate system, nonbridging external fixation, bridging
external fixation, or percutaneous Kirschner wire [K-wire] fixation). Cast immobilization
had the worst radiographic outcome yet the lowest complication rate. Additional studies are
needed to evaluate the recovery rate, cost and outcomes of these treatment methods.
 In 2009, the American Academy of Orthopedic Surgeons (AAOS) issued a clinical
guideline on the treatment of DRFs. Many of the recommendations in the guideline lacked
strong supporting evidence and were considered inconclusive. However, the following
recommendations were supported by moderately strong evidence :
Rigid immobilization is suggested in preference to removable splints in nonoperative
treatment for the management of displaced DRFs
For all patients with DRFs, a postreduction true lateral x-ray of the carpus is suggested
for assessment of distal radial ulnar joint alignment
Operative fixation is suggested in preference to cast fixation for fractures with
postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10, or intra-
articular displacement or stepoff greater than 2 mm
Patient probably do not need to begin early wrist motion routinely after stable fracture
fixation
Adjuvant treatment of DRFs with vitamin C is suggested for the prevention of
disproportionate pain
On the basis of the available evidence, the AAOS was unable to make a recommendation
for or against casting as definitive treatment after initial adequate reduction or to
recommend any specific surgical method over another.

3.13 Surgical Therapy

Traditionally, surgical treatment has been reserved for displaced, irreducible DRFs or
reducible but unstable DRFs. One approach that is becoming more popular is to provide the
surgical treatment to patients who cannot or do not want to accept the constrains of cast
treatment because of ADL, work, or recreational concerns.
No consensus has been reached as to which surgical treatment is best. Several options are
available, each with its own variations.
Closed reduction and percutaneous pinning has been popular for many years and
continues to be one of the most popular techniques internationally. The pinning can be of
several varieties, including Clancey pinning (ie, 0,062-in wires into radial styloid and the
dorsal ulnar corner of the radius, crossing the fracture site) and Kapandji pinning (ie, wires
or arum pins placed into the fracture site dorsally and used as levels to reduce the fracture
and then to stabilize it).
 External fixation became the most popular treatment throughout much of the world in the
decades after the development of a radius-specific fixator by Anderason in 1944. The proper
application technique, however, was not defined until 1990 by Seitz. Small open incisions
are used to avoid injuring the sensory branches of the radial nerve and to ensure central
placement in the second metacarpal and the radial shaft. This technique continues, to be one
of the most popular approaches internationally.
Many variations of external fixation have been
developed. One variation of the fixator allowed early
motion with the fixator still in place. The concept was
originated by Clyburn and popularized internationally by
Penning. The axis of motion of the fixator was placed over
the center of motion of the wrist, thought to reside in the
center of the head of the capitates.
This approach has largely been abandoned because of theoretical criticisms and clinical
experience. The theoretical criticisms are related to the location of the rotation that is,
whether it is an instant center or a constant center and whether it is possible to place the
center of motion of the fixator reliably over the center of motion of the wrist. An additional
practical consideration is the impossibility of having a center of motion of the fixator not
coaxial with the center of the wrist.
Clinical studies also noted a decrease in final range of motion and an increase in
complications related to the device; thus, early motion in external fixation has largely been
abandoned. Nevertheless, some researchers are still investigating this technique, and it is
still used clinically in some regions of the world.
In a study of patients with DRFs that compared complication rates after external fixation
and after volar plating, the volar plate group experienced more tendon and median nerve
complications; however, the external fixation group had a significantly higher overall
complication rate. Whereas there were no significant differences between the groups in the
scapholunate angle or palmar tilt measurements, the volar plate group had significantly
better ars of motion in pronation-supination and flexion-extension and better grip strength.
The author is a proponent of external fixators; however, it should be noted that at this
time, most surgeons would place a volar plate rather than an external fixator when feasible.
The rate of complications after volar plating (tendon irritation, tendon rupture, loss of
fixation, inadequate fixation, or plate removal) has dramatically decreased.
Some studies have shown that open reduction and internal fixation resulted in better grip
strength and range of motion than closedreduction and bridging external fixation in the
treatment of nonreducible DRFs. The results from one study noted that these benefits
diminished with time; after a mean of 5 years both groups had approach normal values.
Dorsal plating had its greatest popularity in the 1990s, with the development of plates
specifically for the distal radius. Because of tendon irritation problems, this technique has
lost most of its appeal for most fractures.

Fragment-specific fixation was originated by Fernandez, who called it the limited open
approach, and was developed and popularized by Medoff, who coined the term fragment-
specific. Fragment-specific fixation uses very small, low-profile plates that are specifically
designed for the radial column, the central column, or the ulnar column of the radius. This
approach lends itself to many types of fractures, but it is difficult to learn, and often the
plates must be removed.
 Nonspanning external fixation was popularized by
McQueen and capitalized in the strength of the subchondral
bone and the volar cortex. Although the proponents of this
procedure touted the possibility of early motion, others
found that the range of motion was poor.

Volar plating, especially for dorsally unstable fractures, was independently developed by
Orbay, Jennings, and Drobetz. However, Orbaysuccessfully developed a practical device,
promoted it internationally, and was the first to publish information on it; thus, he is
properly considered the grandfather of the technique. Volar plating is gaining in popularity,
but its complications, particularly the incidens of tendon rupture, are now becoming
recognized.

As noted earlier, a study of external fixation versus volar plating of DRFs found that the
latter led to more tendon and median nerve complications but the former to a significantly
 higher overall complication rate. At present, most surgeons would place a volar plate rather
than an external fixator when feasible (the author is a proponent of external fixators).
The result from another study noted that extra-articular and simple intra-articular DRFs
realized similar outcomes in motion, grip strength, Gartland and Werley scores, and
disabilities of the Arm, Shoulder and Hand (DASH) scores at 2 years when treated with
open reduction and internal fixation with a volar locking plate.
In a 2014 meta-analysis of six trials that included 445 patients with unstable DRFs, Li-
Hai et al. determined that whereas external fixation had a lower rate of reoperation due to
complications, volar locking plating yielded better functional recovery in the early
postoperative period. However, the two methods resulted in comparable functional recovery
at 1 year after the procedure.
Spanning internal fixation plates were originated by Becton and popularized by Ruch,
and several companies make such plates. The screws are placed into the metacarpals and the
midradial shaft, and the plates are removed at 3 months. This technique is relatively new,
and only a few series have been published to date.
Despite the many techniques and the large number of studies on DRFs, no consensus has
been reached on the best surgical approach. Strong regional tendencies exist, such as volar
plating in the United States, Kapandji pinning in France, and traditionally external fixation
in the United Kingdom and in Italy. In some regions (eg; Japan, Germany), the plates are
tipically removed; however, in others (eg, the United States), they are rarely removed.

3.14 Postoperative Details

Postoperative management varies. Most casts are kept on for 6 weeks, but some
compressed fractures require only a splint. Most external fixators are kept in place for 6
weeks, but 8 weeks is also common; and some fractures are not bone-grafted still collapse at
3 months. Volar fixed-angle plates are moved at anywhere from 3 days to 3 weeks. Spanning
internal fixation plates are usually removed at 3 months, and therapy is initiated at that time.
It is difficult to make useful generalizations.
It is important that volar plates be evaluated via facet views, not standard PA and lateral
views. For both the PA facet view and the lateral facet view, the right amount of tilt can be
achieved by placing a roll of cast padding under the wrist.
It is advantageous to discuss postoperative hand therapy with the patient and arrange the
appropriate appointments before surgical treatment; this includes obtaining the required
 authorization. Otherwise, the full benefits of the procedure may be lost because of
paperwork issues.

3.15 Outcome and Prognosis

Unresolved treatment controversies not with standing, most patients can resume their
previous level of activity, including competitive sports. Although many cases has been
reported in which return to function was not limited by malunion or complications, patients
are, in general, living longer and continuing to be active longer than in previous
penetrations, and this places demands on the distal radius that were not seen previously.
Consequently, even with apparently good-quality care, some patients are unable to resume
their prior level of functioning.
All treatment approaches have a percentage of poor results, with decreased supination,
prominent ulnar heads, ligamentous problems, distal radioulnar problems (usually
instability), and degenerative joint disease being common problems. These are the cases that
prompt researchers to continue to refine the techniques and devices.
Patients, however, want more concrete prognostic statements. To this end, the following
may be stated :
Most patients treated with a volar fixed-angle plate can resume nonforceful activities of
daily living (ADLs) within 3 days to 2 weeks
Patient treated with a cast have the cast removed at 6 weeks and can then start ADLs
Grip strengthening can often be started at 2 months after any type of treatment, but
forceful use of the hand should be delayed for 3 months
Contact sports or activities in which the likelihood of falling on an outstretched hand is
high should be delayed for approximately 4 months
It should be kept in mind that these are just general guidelines, and great variation exists
among specific cases and specific physicians.
The long-term prognosis for a properly treated DRF is good, even with an intra-articular
fracture. If the articular surface is not comminuted and can be reconstructed, osteoarthritis is
rare. Wrist range of motion will continue to increase, and wrist tenderness with forceful use
will continue to decrease even beyond 2 years.
 CHAPTER IV
DISCUSSION

Diagnose for the closed fracture in left radius distal in this patient enforced from the
history that the patient complains of pain in the left hand after had job accident. Patient was
climbing a ladder when he got slip and fall down from high with aslant position. Patient
complained a pain on his left hand, swollen and hard to move it.

From the results of physical examination, we found abnormalities in the left hand. Localist
status check on hand below the visible presence of edema, deformity, pale and wrinkled skin
around and the wound has been bandaged with unclean. There is tenderness on palpation, the
arterial pulsation is normal. In the active movement of patients were not able to minimal
supination, minimal pronation. At the neurovascular distal examination (NVD) it was not
obtained for pathological reflexes, motor examination by 3/5 (because of left hand pain), there is
no sensory disturbances, and CRT> 2 seconds.
Definitive diagnosis of fracture on the left radius distal established based on the results of
the x-ray region of the left AP and lateral wrist jont indicating simple fracture of radius distal
sinistra.
Electrocardiograph, laboratory tests Hb, leucosite, trombosite, Ht, PT, APTT, GDS,
ureum, creatinin intended as preparation if conducted operative intervention in these patients.
Medical management of the case are: IVFD RL 20 drops per minute, antibiotics:
cefotaxim 2 x 1 g IV. Cefotaxim given as an antibiotic to prevent infection in these patients.
Non medical therapy consists of conservative and operative therapy. Conservative
therapy: do immobilization as first aid with close reduction casting, NVD evaluation to monitor
the presence of pain and fracture complications, and also vital sign. In the operative therapy can
do the open reduction internal fixation (ORIF).
 CHAPTER V
CONCLUSION

The term of distal radius fractures (DRFs) properly covers all fracture of the distal
articular and metaphyseal areas, with a peak in younger persons (aged 18-25 years) and a
second peak in older persons (aged >65 years). The ultimate aim of treatment is to restore
each patient to his or her prior level of functioning. For a treatment, some studies have
shown that open reduction and internal fixation resulted in better grip strength and range
of motion than close reduction and bridging external fixation in the treatment of
nonreducible DRFs.
Fracture is the loss of continuity of bone, joint cartilage, epiphyseal cartilage is both total
and partial. Fracture classification is divided into, etiological classification, clinical
classification, and radiological classification. Fracture diagnose is made by history,
physical examination, and local checks in the form of inspection, palpation, movement,
neurological examination, vascular examination and radiological examination. Fracture
treatment principle is the recognition, reduction, retention, and rehabilitation. This
treatment will be divided based on closed fractures and open fractures. In the closed
fracture treatment is divided into conservative and operative treatment. The fracture
healing process consists of five phases, there are hematoma phase, cellular proliferative
subperiosteal and endosteal phase, callus formation phase, the consolidation phase and
remodeling phase.
REFERENCES

1. Medscape Journal

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3. Diktat Anatomi Muskuloskeletal FK Unissula

4. Buku Ajar Ilmu Bedah, Wim de Jong