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Distal Radius Fracture

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Other Names

  • Colle's fracture
  • Distal Radius Fracture (DRF)
  • Radius Fracture
  • Wrist Fracture
  • Broken Distal Radius
  • Distal Radius Break
  • Colles Fracture
  • Smith Fracture
  • Barton Fracture
  • Reverse Barton Fracture
  • Chauffeur Fracture
  • Radial Styloid Fracture

Background

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Distal Radius Fractures Review Pod
  • This page refers to fractures of the distal radius

History

  • 1783 – Claude Pouteau described distal radius fractures in a memoir published posthumously
  • The first widely recognized description of a distal radius fracture in the medical literature is attributed to Abraham Colles in 1814[1]

Epidemiology

  • Overall, most common orthopedic injury representing 15-20% of all adult fractures [2][3]
  • Accounts for 18% of elderly fractures, 25% of pediatric fractures[4]
  • Economic impact
    • There are more than 640,000 cases in the United States alone costing more than $170 million[4]
  • There is a bimodal distribution in young individuals under 18 and older patients over 65
  • Incidence is approximately 200 to 440 per 100,000 person years[5]
  • Fourfold higher incidence in women compared to men

Introduction

Illustration of the typical mechanism of action of a Colle's fracture[6]
Illustration of distal radius fractures[7]
The three-column model of distal radius fracture[8]
Radiographs of a Colles Fracture

General

  • Distal radius fractures (DRF) are commonly encountered traumatic injury to the wrist
  • Defined as a fracture of the distal metaphysis or epiphysis with or without extension into the joint space.
  • Most commonly occurs due to a fall on outstretched hand (FOOSH)
  • Management is fundamentally guided by radiographs

Types of Distal Radius Fractures

  • Barton's Fracture
    • Displaced intra-articular coronal plane fracture-subluxation of dorsal lip of the distal radius
    • The carpal fragment is also displaced
  • Chauffers Fracture
    • Intra-articular fracture of radial styloid of variable size
  • Colles' Fracture
    • By far, the most common DRF
    • Characterized by dorsal tilt of the distal fragment
  • Die-Punch Fracture
  • Radial Styloid Fracture
  • Smith's Fracture
    • Sometimes called a reverse Colles
    • Characterized by palmar tilt of the distal fragment
  • Reverse Barton's
    • Wrist in palmar-flexion and involves the volar lip

Mechanism of Injury

  • Most fractures involve a fall on outstretched hand with the wrist in dorsiflexion
    • For this reason, the dorsally displaced presentation is most common (Colles Fracture)
  • Severity, form and concomitant injuries depend on the position of the wrist when it hits the ground
  • Pronation, supination, abduction determine the force vectors
    • As well as any carpal lesions or ligamentous injuries

Associated Conditions

Articular Involvement

  • Intra-articular component suggests high energy trauma, typically seen in young patients
    • High energy injuries cause shearing and impaction forces, displacement of the distal fragments
  • In geriatric patients, lower energy trauma typically leads to extra-articular lesions

Anatomy of the distal Radius

  • Distal Radioulnar Joint: articulation between the ulnar notch on the radius, head of the ulna
    • Allows for movement in supination, pronation
    • Stabilized by TFCC and other intrinsic ligaments and muscles
  • Radiocarpal Joint: often referred to as the "wrist joint"
    • Distally, articulates with scaphoid, lunate, triquetral of the proximal carpal row
    • An articular disc sits in between the radius and the carpus
    • Stabilized by a series of radiocarpal ligaments

Risk Factors

Demographic Factors

  • Age >60 years (OR 2.86)[9]
  • Female sex (OR 4.44)
  • Bimodal age distribution: peaks in younger individuals (<18 years) and older adults (>65 years)

Bone Health

  • Osteoporosis (OR 2.66)[9]
  • Low bone mineral density at femoral neck, total hip, or lumbar spine
  • Prior fracture history (OR 3.44)

Systemic Conditions

Lifestyle and Behavioral Factors

  • Sedentary lifestyle (OR 1.46)
  • Sports/recreational activities (younger patients)
  • Motor vehicle accidents (younger patients)

Environmental Factors

  • Lower urbanization level

Differential Diagnosis

Differential Diagnosis Wrist Pain

Clinical Features

Clinical appearance of a Colles fracture with corresponding radiographic appearance[11]

History

  • Some form of trauma, typically fall on an outstretched hand
    • Younger patients may have high energy trauma (sports, MVC, etc)
    • Older patients experience low energy ground level falls
  • Pain, swelling of distal radius
  • Important to characterize hand dominance
  • Inquire about neurological symptoms

Physical Exam: Physical Exam Wrist

  • On inspection, tenderness and swelling are often but not universally present
    • Ecchymosis has a 98% specificity[12]
  • On palpation, tenderness of the distal radial metaphysis
    • 96% positive predictive value for a fracture, even when radiographs are negative[13]
  • Range of motion is often deferred secondary to pain
    • Painful dorsiflexion is 96% sensitive for a fracture[12]
    • Forearm pronation and uspination are often painful
  • It is very important to evaluate the median nerve

Evaluation

Distal spiral fracture of radius following MVC
Distal radius fracture-associated distal ulna fracture. The patient was a 67-year-old female with left distal radius and ulna fractures caused by a fall. The distal radius fracture was judged to be AO classification type C1 and the distal ulna fracture as Biyani classification type 2. (B) Preoperative lateral view on plain radiography. Fractures were noted at the distal ends of the radius and ulna. (C) Coronal plane CT. The bone fragment dislocated on the DRUJ surface was noted in the distal ulna fracture, showing DRUJ incongruity[14]

Radiographs

  • Standard Radiographs Wrist
    • Sufficient to make diagnosis
    • Key to diagnosis, classification, treatment and follow up assessment
  • Measured/ considered parameters
    • Radial height
    • Radial inclination
    • Volar tilt
    • Ulnar variance
    • Teardrop angle
    • Intra-articular extension
    • Articular step-off
    • Dorsal comminution
    • Associated injuries (i.e. ulnar fracture)
  • Traction radiographs[15]
    • May improve fracture characterization
    • Increases interobserver reliability
    • Improves detection of intra-articular fragments requiring reduction (from 38.3% to 53.1%)
    • Decreases the perceived need for CT (from 21.7% to 5.1%)

CT Scan

  • Useful to evaluate for:
    • Intra-articular involvement
    • Surgical planning
    • Better characterize fracture pattern
    • Occult fractures
    • Evaluate distal radioulnar joint
  • If possible, obtain after closed reduction and immobilization
  • Compared to radiographs
    • Shows articular fracture characteristics significantly better than radiography
    • CT changes treatment recommendations in approximately 23% of cases[16]
    • Better evaluates sigmoid notch involvement which is missed on standard radiographs in 62% of cases[17]
    • Reveals post-reduction malalignment in up to 53% of cases not seen on radiographs[18]

MRI

  • Evaluate for concurrent soft tissue injuries
  • Can potentially identify[19]
    • Injury to triangular fibrocartilage complex (TFCC)
    • Perforation of interosseous ligaments of proximal carpal row
    • Evaluating occult fractures
    • Post-traumatic or avascular necrosis of carpal bones

Classification

Frykman Classification of Distal Radius Fractures[20]
The AO/OTA classification of distal radial fractures[21]

Melone's Classification of Intra-articular Distal Radius Fractures

  • Type I
    • Four components (radial shaft, radial styloid, dorsal medial and volar medial fragment) are undisplaced or show variable displacement of the medial complex as a unit
    • Such fractures show minimal comminution are are stable after closed reduction
  • Type II
    • There is significant displacement of the medial complex as a unit without a comminution of radial metaphysis and instability (die punch fracture)
  • Type III
    • Displacement and instability similar to type II
    • The spike fragment of the radial shaft component often projecting into the flexor compartment (spike fractures)
  • Type IV
    • There is severe disruption of the radial articular surface and dorsal and volar fragments show wide separation or rotation
    • There are extensive soft tissue damage and nerve injury (split fractures)
  • Type V
    • Fracture results from a severe force comprising both compression and crush that cause extensive comminution
    • Often extending from the articular surface to the diaphysis

Management

Distal radius fractures are typically immobilized in a Sugar Tong Splint following reduction[22]
Proposed treatment algorithm[23]
1. Post operative PA (A) and lateral (B,C) radiographs of a case status post ORIF distal radius fracture with a volar locking plate[24]

Acute Management

  • Closed reduction to as anatomic as possible
    • Consider PO/IV Analgesia, Hematoma Block, Procedural Sedation, Regional Anesthesia
  • Radiographic parameter goals
    • Dorsal tilt ≤ 10°
    • Radial shortening ≤ 2 mm
    • Radial inclination ≥ 15°
    • Articular step off ≤ 2 mm
    • Congruent distal radioulnar joint
    • Absence of carpal malalignment
  • Place patient in Sugar Tong Splint, Shoulder Sling
  • Predictors of fracture instability[25]
    • The presence of 3 or more factors associated with instability and secondary displacement
    • Dorsal tilt > 20°
    • Dorsal comminution
    • Intra-articular radiocarpal fracture
    • Associated ulnar fracture
    • Age older than 60 years
    • Female sex

Nonoperative Management

  • Indications for nonoperative management
    • Extra-articular or stepoff < 2 mm
    • < 5 mm of radial shortening
    • Dorsal angulation < 5° or within 20° of contralateral distal radius
  • Close follow up is important to ensure they maintain acceptable alignment
  • There are no clear guidelines for type immobilization
  • Duration of immobilization
    • 4-8 weeks is most common and usually sufficiency
  • Initiation of rehabilitation
    • Shoulder/finger range of motion exercises should be initiated immediately after immobilization

Operative

  • Radiographic findings indicating instability (pre-reduction radiographs best predictor of stability)[28]
    • Dorsal angulation > 5° or > 20° of contralateral distal radius
    • Volar or dorsal comminution
    • Displaced intra-articular fractures > 2mm
    • Radial shortening > 5mm
    • Associated ulnar fracture (associated ulnar styloid fractures do not require fixation)
    • Severe osteoporosis
    • Articular margin fractures (dorsal and volar Barton fractures)
    • Comminuted and displaced extra-articular fractures (Smith's fractures)
    • Die-punch fractures
    • Progressive loss of volar tilt and loss of radial length following closed reduction and casting
  • Technique
    • Closed reduction with percutaneous pinning
    • External fixation
    • Dorsal bridge plating
    • Open reduction, internal fixatoin

Rehab and Return to Play

Distal radius fracture rehab exercises

Non-Surgical Rehabilitation

  • Active range of motion exercises should be initiated after cast removal
    • One session of physiotherapy providing advice and instructions for a home exercise program[29]
    • However routine physical therapy is not superior to home exercises

Surgical Rehabilitation

  • Accelerated protocol
    • Demonstrate superior early outcomes compared with standard protocols[30]
    • 3-5 Days postoperative: initiate gentle active range of motion
    • 2 weeks postoperative: passive range of motion, strengthening exercises
    • Patients have better mobility, strength, and DASH scores at early postoperative time points (0-8 weeks)
  • Standard protocol
    • Begin passive range of motion and strengthening until 6 weeks postoperatively

Distal Radius Fracture Rehab PDFs

Return to Play/ Work

  • Specific return-to-play timelines depend on:
    • Fracture stability: Stable, well-fixed fractures allow earlier return
    • Sport demands: Contact sports and high-load activities require more conservative timelines
    • Healing progression: Radiographic union and functional recovery milestones
    • Pain-free range of motion and grip strength: Must be adequate for sport-specific demands
  • Timeline
    • Non-contact sports with minimal wrist loading, return may occur as early as 6-8 weeks
    • Contact sports or high-demand activities, return typically occurs at 10-12 weeks

Prognosis and Complications

Post traumatic wrist OA following a lunocapitate fusion[31]

Prognosis

  • General
    • Overall prognosis is generally good
    • Most patients achieve satisfactory functional outcomes, low disability scores at 12 months[32]
    • Patients typically restore 96% pronation, 95% extension, 91% supination, 81% flexion, and 80% grip strength[33]
  • Recovery trajectory[34]
    • Most improvement occurs within the first 6 months, with minimal clinically meaningful changes between 12 and 24 months
    • Over 60 patients experience little disability, low pain, good function, and high quality of life at 24 months regardless of treatment modality
  • Non-surgical
    • DeGeorge et al found that nonsurgical management was associated with a notable decrease in 1-year complications for geriatric patients[35]
  • Radiographic findings and outcomes
    • Dorsal tilt is the radiographic parameter most strongly associated with clinical outcomes[36]
    • Kodama et al: Excessive volar tilt/ ulnar variance predicts worse clinical outcomes[37]

Complications

See Also

Internal

External

References

  1. ↑ Colles, Abraham. "On the fracture of the carpal extremity of the radius." The New England Journal of Medicine, Surgery and Collateral Branches of Science 3.4 (1814): 368-372.
  2. ↑ Meena S, Sharma P, Sambharia AK, Dawar A. Fractures of distal radius: an overview. J Family Med Prim Care. 2014 Oct-Dec;3(4):325-32. doi: 10.4103/2249-4863.148101.
  3. ↑ Nellans, Kate W., Evan Kowalski, and Kevin C. Chung. "The epidemiology of distal radius fractures." Hand clinics 28.2 (2012): 113.
  4. ↑ 4.0 4.1 Kamal, Robin Neil, and Lauren Michelle Shapiro. "AAOS/ASSH Clinical practice guideline summary management of distal radius fractures." The Journal of the American Academy of Orthopaedic Surgeons 30.4 (2022): e480.
  5. ↑ Rundgren, Johanna, et al. "Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an observational study of 23,394 fractures from the national Swedish fracture register." BMC musculoskeletal disorders 21.1 (2020): 88.
  6. ↑ Cautero, Enrico, and Alessandro Mazzola. "Fractures of the Forearm and the Wrist." Textbook of Musculoskeletal Disorders. Cham: Springer International Publishing, 2023. 667-672.
  7. ↑ Image courtesy of AAOS
  8. ↑ Zhou, Jinhua, et al. "Morphological characteristics of different types of distal radius die-punch fractures based on three-column theory." Journal of Orthopaedic Surgery and Research 14 (2019): 1-10.
  9. ↑ 9.0 9.1 Liu, Yong, et al. "A study of factors influencing distal radius fractures and predictive modeling in emergency department patients." Medicine 105.5 (2026): e46878.
  10. ↑ Shariatzadeh, Hooman, Ahmad Dashtbozorg, and Neda Gorjizadeh. "Association of distal radial fracture with comorbidities: model development and validation." Injury 55.7 (2024): 111607.
  11. ↑ Image courtesy of litfl.com
  12. ↑ 12.0 12.1 Patel, Deepak S., Siobhan M. Statuta, and Natasha Ahmed. "Common fractures of the radius and ulna." American family physician 103.6 (2021): 345-354.
  13. ↑ Glickel, Steven Z., et al. "Predictive power of distal radial metaphyseal tenderness for diagnosing occult fracture." The Journal of Hand Surgery 42.10 (2017): 835-e1.
  14. ↑ Naito, Kiyohito, et al. "Screw fixation and autogenous bone graft for an irreducible distal ulna fracture associated with distal radius fracture." The Journal of Hand Surgery (Asian-Pacific Volume) 22.02 (2017): 236-239.
  15. ↑ Goldwyn, Elan, et al. "Do traction radiographs of distal radial fractures influence fracture characterization and treatment?." JBJS 94.22 (2012): 2055-2062.
  16. ↑ Arora, Sumit, et al. "Comparative evaluation of postreduction intra-articular distal radial fractures by radiographs and multidetector computed tomography." JBJS 92.15 (2010): 2523-2532.
  17. ↑ Hruby, Laura A., et al. "Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study." Archives of Orthopaedic and Trauma Surgery 142.6 (2022): 1075-1082.
  18. ↑ Dankelman, Lente HM, et al. "Traditional radiography versus computed tomography to assess reduced distal radius fractures." European Journal of Trauma and Emergency Surgery 50.5 (2024): 2313-2321.
  19. ↑ Golimbu, C. N., et al. "Tears of the triangular fibrocartilage of the wrist: MR imaging." Radiology 173.3 (1989): 731-733.
  20. ↑ Image courtesy of faculty.washington.edu
  21. ↑ Bergvall, Malena, et al. "Validity of classification of distal radial fractures in the Swedish fracture register." BMC musculoskeletal disorders 22.1 (2021): 587.
  22. ↑ Boyd, Anne S., Holly J. Benjamin, and Chad A. Asplund. "Splints and casts: indications and methods." American family physician 80.5 (2009): 491-499.
  23. ↑ Abramo, Antonio, Philippe Kopylov, and Magnus Tägil. "Evaluation of a treatment protocol in distal radius fractures." Acta orthopaedica 79.3 (2008): 376-385.
  24. ↑ Salehi, Lily, Phong Tran, and Adrian J. Talia. "The utility of post-operative X-rays in distal radius fracture fixation: A literature review." Journal of Orthopaedic Reports 4.4 (2025): 100496.
  25. ↑ Lafontaine, Murielle, Dominique Hardy, and P. H. Delince. "Stability assessment of distal radius fractures." Injury 20.4 (1989): 208-210.
  26. ↑ Bong, Matthew R., et al. "A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal radius: a prospective randomized study of long-arm versus short-arm splinting." The Journal of hand surgery 31.5 (2006): 766-770.
  27. ↑ Park, M. J., et al. "Is a short arm cast appropriate for stable distal radius fractures in patients older than 55 years? A randomized prospective multicentre study." Journal of Hand Surgery (European Volume) 42.5 (2017): 487-492.
  28. ↑ https://www.orthobullets.com/trauma/1027/distal-radius-fractures
  29. ↑ Handoll, Helen HG, and Joanne Elliott. "Rehabilitation for distal radial fractures in adults." Cochrane Database of Systematic Reviews 9 (2015).
  30. ↑ Brehmer, Jess L., and Jeffrey B. Husband. "Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study." JBJS 96.19 (2014): 1621-1630.
  31. ↑ Yao, Yu-Cheng, et al. "Lunocapitate fusion with scaphoid excision for the treatment of scaphoid nonunion advanced collapse or scapho-lunate advanced collapse wrist." Journal of the Chinese Medical Association 80.2 (2017): 117-120.
  32. ↑ Quax, M. L. J., et al. "Managing patient expectations about recovery after a distal radius fracture based on patient reported outcomes." Journal of Hand Therapy 36.4 (2023): 903-912.
  33. ↑ Johnston, Geoffrey, Samuel A. Stewart, and Laura A. Sims. "Serial range of motion and grip strength measurements, patient-reported outcomes, and radiographic thresholds associated with less satisfactory outcomes after low-energy distal radius fracture in women aged 50 years and older." The Journal of Hand Surgery 49.9 (2024): 827-845.
  34. ↑ Chung, Kevin C., et al. "Comparison of 24-month outcomes after treatment for distal radius fracture: the WRIST randomized clinical trial." JAMA Network Open 4.6 (2021): e2112710.
  35. ↑ DeGeorge Jr, Brent R., et al. "Outcomes and complications in the management of distal radial fractures in the elderly." JBJS 102.1 (2020): 37-44.
  36. ↑ Schmidt, Viktor, et al. "Association between radiographic and clinical outcomes following distal radial fractures: a prospective cohort study with 1-year follow-up in 366 patients." JBJS 105.15 (2023): 1156-1167.
  37. ↑ Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y: Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients. J Orthop Sci 2014;19:292-297.
Created by:
John Kiel on 11 June 2019 14:17:58
Authors:
Last edited:
12 March 2026 16:57:25
Categories:
Trauma | Osteology | Wrist | Forearm | Upper Extremity | Fractures | Acute | Featured
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