EWJ June 61 2025 web - Flipbook - Page 38
types in total). It is rarely used in isolation in modern
practice due to poor correlation with outcome but is
often quoted by trainees for the exams as it’s easier to
remember and articulate.
weaker at resisting transverse forces (e.g. direct blows)
or torsional forces (twisting mechanisms). The metaphysis is better at resisting transverse and torsional
forces, but it has less thick cortical bone, so is susceptible to fractures at this junctional area.
AO (Arbeitsgemeinschaft für Osteosynthesefragen) /
OTA classification is the most detailed:
• Type A: Extra-articular
• Type B: Partial articular
• Type C: Complete articular
o With further subgroups describing
complexity and comminution.
Other common medical words are proximal and
distal; and volar and dorsal. Proximal means closer to
the centre of the body or origin, and distal means further away from the centre of the body or origin. For
example a distal radius fracture is further away from
the body, so is closer to the wrist than the elbow. A
proximal radius fracture would be closer to the elbow.
Volar means the palm side of the hand/forearm and
dorsal refers to the upper side or back (e.g. back of the
hand/forearm).
While comprehensive, its complexity limits use in routine medicolegal reporting unless fracture details are
specifically documented.
Finally we talk about fractures in terms of their mode
of displacement. Fractures can be described as:
1. Shortening or lengthening (i.e. distraction)
2. Angulation
3. Rotation
4. Transverse displacement
Fernandez classification is based on the mechanism of
injury and assesses the fracture stability and associated
soft tissue injury. It can be applied to both adults and
children. It is credited as more practical to apply but
it is more complex and time-consuming, and studies
suggest it performs similarly to other existing systems.
So for a simple Colles type fracture (see below), this
refers to a distal radius fracture that is likely to have
some shortening with dorsal angulation and possibly
some dorsal translation. Usually there isn’t a rotation
component, unless it is significantly displaced and the
volar periosteum is disrupted (periosteum is the thick
fibrous / tough layer on the bone that you encounter
when eating barbeque ribs for example).
Melone divides the radius into four fragments; shaft,
radial styloid, dorsal lunate fossa, volar lunate fossa.
This is easy to apply and practically useful as it allows
the surgeon to identify the fracture fragments that require capturing as part of the fixation to enable the
fracture to be stabilised. Its use is however limited to
intra-articular fractures only.
The simplest method for classification therefore
classifies fractures based on:
• Anatomical location (proximal / mid-shaft / distal radius)
Three Column Theory (radial/scaphoid column,
intermediate/lunate column, ulna column) classifies
fractures based on their involvement of the respective
columns and aides in the selection of the appropriate
treatment strategy.
• Fracture pattern i.e. involving the joint or not
(intra-articular / extra-articular)
There are more classification systems and all have
their strengths and weaknesses.
• Displacement (angulation, shortening, rotation)
Importance of Classification in Medicolegal
Reports
In the medicolegal setting, classification systems
provide useful information about:
• Severity of injury
• Likely treatment (operative vs non-operative)
• Prognostic implications
This approach is often adequate for clinical and
medicolegal reporting.
Eponymous Fractures
Some fracture types are referred to by eponymous
names:
Fracture Name
Colles’ fracture
Description
Fracture of the distal radius
with dorsal angulation
Smith’s fracture
Fracture of the distal radius
with volar angulation
Barton’s fracture
Intra-articular fracture with
an intact volar/dorsal cortex
Chauffeur’s fracture
Fracture of radial styloid
process
However, the specific classification used is less
important than a clear, accurate description of the
fracture morphology and displacement, and the
rationale for the selected treatment strategy.
The Role of Surgery in Wrist Fractures
Surgical fixation of wrist fractures has become
increasingly common, particularly with the advent of
volar locking plates which allow stable fixation even in
osteoporotic bone. However, the decision to operate
is nuanced and must balance the benefits of anatomical reduction against surgical risks.
These terms remain common in clinical practice but
have limited prognostic value.
In medicolegal cases, scrutiny often focuses on
whether surgical intervention was appropriate or
whether non-operative treatment would have sufficed.
Conversely, delays in surgery or missed indications can
be grounds for criticism.
Classification Systems
There are many classifications systems including:
Frykman categorises distal radius fractures based on
involvement of the radiocarpal and distal radioulnar
joints, and the presence of an ulnar styloid fracture (8
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