Mechanism of injury & Classification

23

Mechanism of injury

Most commonly, injuries occur after a simple fall from standing
height. Rarely do clinicians take any more detailed history. Yet much
information can be gained from asking patients to describe their fall.
[46]
It is natural to pronate the forearm as you fall forwards, and supinate it
as you fall backwards. Impact on the pronated forearm is likely to be on the
radial side of the wrist, whilst that on the supinated forearm is likely to be on
the ulnar side of the wrist. This information stimulates thought as to which
other associated structures could be injured during the fall. A fall forwards
will focus the examination on the radial structures in the wrist; a fall
backwards will draw attention to the ulnar structures.
[46]

Almost all distal radius fractures (apart from dorsal rim avulsion
fractures) can be produced by hyperextension of the wrist.
[47]
Bending forces
tend to occur in low-energy falls and typically produce dorsal displacement.
Shearing forces disrupt the ligamentous connections of the wrist and
produce unstable fracture-dislocations, whilst axial loading, high-energy
injuries compress the articular surface and cause fragments of joint surface
to be impacted.
[46]
Important work, published by Rikli and Regazzoni
[15]
, on load transfer
across the wrist described the existence of three separate structural
columns within the wrist. This 3 column concept highlights not only how
the intact wrist functions, but also provides clear mechanical guidance on
how best to reconstruct fractures in this area. The radius has both a radial
and intermediate column, and the ulna represents the third column (Fig.
12).
[15]
The understanding of this concept allows the surgeon to think about
Mechanism of injury & Classification

24

rebuilding the fragmented wrist in a logical and natural manner and also
emphasizes the importance of distal ulnar injuries. Indeed, this concept has
also been pivotal in the design of anatomic implants for both the distal radius
and ulna.
[48]
The intermediate column is the major load-bearing column of the
wrist, confirmed by the dense subchondral bone seen in X-rays of the intact
radius. This also explains its involvement in dye-punch articular
depression injuries. In addition to being a central structural column, the
intermediate column also provides the radial component of the distal
radioulnar joint (DRUJ) with the sigmoid notch. The bone quality in this
distal ulnar corner of the radius is universally good (as a result of its
function) and, by virtue of its involvement in both flexion/extension and
forearm rotation movements, forms the key area when planning surgical
fracture reconstruction. Consequently, surgical reconstruction of the
fractured distal radius will concentrate on restoring the integrity and shape of
the intermediate column (together with the orientation of the two associated
joint surfaces) before restoring the buttressing function of the radial column,
and the pivotal function of the distal ulna.
[46]



Mechanism of injury & Classification

25



(Fig. 12)The three column concept of Rickli & Regazzoni.
[15]


Classification
Various classification systems have been proposed to describe the
injury and help formulate a treatment plan. Broadly they tend to be
anatomical classifications that group fracture patterns, biomechanical that
describe the mechanism of injury and fracture stability or a combination of
both.
[46]
The eponymous descriptions associated with distal radius fractures
have traditionally been good indicators of the type of injury and treatment.
Colles fracture: It is an extra-articular distal radius fracture with dorsal
comminution, dorsal angulation, dorsal displacement, and radial
shortening.
[49]

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26



(Fig. 13): Colles' fracture, Diagrammatic representation of displacement, Top, Characteristic dorsal
angulation and impaction with shortening (lateral view). Below, loss of radial angulation, Radial shortening
with impaction and radial displacement (postero-anterior view)
[50]

Smiths fracture: It is a fracture of the distal radius with volar
displacement.
[51]



(Fig. 14): Smith's fracture. Modified Thomas classification. Palmar angulated fracture. Type 1, extra-
articular transverse, Type 2,extra-articular oblique with palmar carpal displacement and Type 3,intra-
articular palmar displacement of the carpus entering the radiocarpal joint. Type 3, is equivalent to a palmar
Barton fracture-dislocation
[50]

Mechanism of injury & Classification

27

Bartons fracture: It is is a displaced, unstablearticular fracture-subluxation
of the distal radius with displacementof the carpus along with the articular
fracture fragment.These may be either dorsal or volar.
[52]

(Fig. 15): Palmar Barton's fracture, palmar displacement of the carpus with intra-articular component
(identical to Smith type 3). Dorsal Barton's fracture, dorsal displacement of the carpus, presenting as
complex fracture of the distal radius or as fracture-disloaction of the wrist.
[50]


Chauffeurs fracture: It is a fracture of the radial styloid. It may be
associated with displacement of the carpus and may be the only bony
component of perilunate injury.
[53]

Die-punch fracture: It is an intra-articular fracture with depression of the
dorsal aspect of the lunate fossa.
[54]

FRYKMAN'S CLASSIFICATION:

In 1967, Frykman published a classification system that was important
in being the first to recognize the involvement (and relevance) of injuries to
the distal ulna.
[55]
Mechanism of injury & Classification

28


Type I: Is an extra-articular radial fracture.
Type II: Is an extra-articular radial fracture with an ulnar styloid
fracture.
Type III: Is an intra-arlicular fracture of the radiocarpal joint.
Type IV: Is an intra-articular fracture of the radiocarpal joint with an
ulnar styloid fracture.
Type V: Is an intra-articular fracture of the radioulnar joint.
Type VI: Is an intra-articular fracture of the radioulnar joint with
fracture of the ulnar styloid.
Type VII: Is an intra-articular fracture involving both radio-carpal and
radioulnar joints.
Type VIII: Is an intra-articular fracture involving both radiocarpal and
radioulnar joints with an ulnar styloid fracture.




(Fig. 16): Frykman classification. Six types of intra-articular fractures: 3/4, radiocarpal joint alone+/- ulnar
styloid; 5/6, radioulnar joint alone +/- ulnar styloid; and 7/8, both radiocarpal and radioulnar joints.
[50]
Mechanism of injury & Classification

29

MELONE'S CLASSIFICATION OF INTRA-ARTICULAR
FRACTURES:

The Melone system (1993) identified the importance of fragmentation
patterns and articular involvement. This classification was developed from
the observation that components of articular fractures consistently fall into
four basic parts despite frequent comminution; they are:
[56]

1. The radial shaft.
2. The radial styloid.
3. The dorsal medial fragment.
4. The palmar medial fragment.

Type I: Undisplaced or displaced but stable after closed reduction
Type II: The medial complex is displaced as a unite with
comminution and instability which may affect dorsal
fragment (Die-punch fragment) or less often the palmar
fragment (volar Barton's fracture)
Type III: It equals to type II with displacement of a spike fragment
which may injure the median nerve or flexor tendons
Type IV: Fractures demonstrate wide separation or rotation of the
dorsal or palmar medial fragments with profound disruption
of the distal radial articulations, usually associated with
severe damage to adjacent soft tissues.

Mechanism of injury & Classification

30

(Fig. 17): Melon classification. A, classification of articular fractures on the basis of consistent patterns
results from the characteristic die punch mechanism of injury. Four articular fractures: 1, Radial shaft; 2,
Radial styloid; 3, Lunate fossa, dorsal medial ; and 4, Lunate fossa , palmar medial.
[50]

UNIVERSAL CLASSIFICATION:


A fracture may be defined as either extra-articular or intra-articular.
[57]
Type I: Extra-articular non displaced
Type II: Extra-articular displaced
Type III: Intra-articular non-displaced
Type IV: Intra-articular displaced
Further, displaced articular or nonarticular fractures may be:
a) Reducible, Stable.
b) Reducible, Unstable.
c) Complex, Irreducible.
Indicators of instability are:
i. Shortening of greater than 5 mm.
ii. Dorsal angulation greater than 20.
iii. Marked dorsal comminution.
iv. Displacement in a plaster of Paris cast.
Mechanism of injury & Classification

31



(Fig. 18): Universal classification. Type I, Nonarticular (extra-articular), undisplaced, and stable. Type II,
Nonarticular (extra-articular), displaced, and unstable. Type III, Intra-articular, undisplaced, and
stable.Type IV, Intra-articular and displaced.A, Reducible and stable after the reduction.B, Reducible but
unstable.C, Irreducible and unstable. D, Complex (comminuted, unstable, and irreducible) (not shown)
[50]

MODIFIED "MAYO CLINIC" CLASSIFICATION:

For more clear distinguishing of different articular fractures that
individually can be involved with DRFs, this classification has been
proposed as a second sub-classification in which the scaphoid, lunate, and
sigmoid notch of the distal radius are considered as separate articulations.
[58]

This classification has four types:-
Type I: Fractures are intra-articular but un-displaced.
Type II: Fractures are displaced and involve the radio-scaphoid joint.
Type III: Fractures are displaced and involve the radio-lunate joint.
Type IV: Fractures are displaced and involve both the radio-scapho-lunate
joints and the sigmoid fossa of the distal radius.


Mechanism of injury & Classification

32




(Fig. 19): Modified Mayos classification of DRFs. Intra-articular fractures involve one or more
articular fossae of the distal radius. Type I, Intra-articular but undisplaced involving the radio-lunate
joint. Type II, Radioscaphoid (RS) fossa fracture, displaced. Type III, Radiolunate fossa fracture with
die punch fracture (thin arrows) components. Direction of fracture displacement (thick arrows). Type
IV, Radio-scapho-lunate fossa involvement with extension into the distal radioulnar joint. The fracture
surface involvement extends into all three joints with articular step-off and displacement. D, dorsal; L,
lunate; S, scaphoid; V, volar.
[50]




Mechanism of injury & Classification

33

A.O. CLASSIFICATION:

This classification is proposed by Mller et al., (1988). They
differentiated between simple and multi-fragmentary fractures and between
extra and intra-articular fractures with further recognition of different
degrees of articular surface involvement.
[59]

Group A: Extra-articular fractures:-
Al: Extra-articular fracture, of ulna, radius intact.
1. Styloid process
2. Metaphyseal simple
3. Metaphyseal multi-fragmentary
A2 Extra-articular fracture, of radius, simple and impacted
1. Without any tilt
2. With dorsal tilt (Pouteau-Colles')
3. With volar tilt (Goyrand-Smith)
A3 Extra-articular fracture, of radius, multi-fragmentary
1. Impacted with axial shortening
2. With a wedge
3. Complex



Mechanism of injury & Classification

34

Group B: Partial articular fractures:-
B1: Partial articular fracture of radius, sagittal
1. Lateral simple
2. Lateral multi-fragmentary
3. Medial
B2 Partial articular fracture of radius, dorsal rim
1. Simple
2. With lateral sagittal fracture
3. With dorsal dislocation of the carpus
B3 Partial articular fracture of radius, volar rim
1. Simple, with a small fragment
2. Simple, with a large fragment
3. Multi-fragmentary

Group C: Complete articular fractures:-
C1: Complete articular fracture, of radius, articular simple metaphyseal
simple
1. Posteromedial articular fragment
2. Sagittal articular fracture line
3. Frontal articular fracture line

Mechanism of injury & Classification

35

C2: Complete articular fracture, of radius, articular simple, metaphyseal
multi-fragmentary
1. Sagittal articular fracture line
2. Frontal articular fracture line
3. Extending into diaphysis
C3: Complete articular fracture, of radius, multi-fragmentary
1. Metaphyseal simple
2. Metaphyseal multi-fragmentary
3. Extending into diaphysis


(Fig. 20) AO Classification of DRFs.
[60]