Distal radius fracture pathophysiology: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
*The fracture pattern and severity of [[comminution]] depends on multiple factors: | *The fracture pattern and severity of [[comminution]] depends on multiple factors including: | ||
**Nature of the fall | **Nature of the fall | ||
**[[Bone]] quality | **[[Bone]] quality | ||
| Line 16: | Line 16: | ||
===Mechanism of Fracture=== | ===Mechanism of Fracture=== | ||
* | * Mechanism of fracture may be described as follows:<ref>{{cite book | last = Brown | first = Charles | title = Rockwood and Green's fractures in adults | publisher = Lippincott Williams & Wilkins/Wolters Kluwer Health | location = Philadelphia | year = 2015 | isbn = 9781451175318. }}</ref><ref>{{cite book | last = Elstrom | first = John | title = Handbook of fractures | publisher = McGraw-Hill, Medical Pub. Division | location = New York | year = 2006 | isbn = 9780071443777 }}</ref><ref>{{cite book | last = Azar | first = Frederick | title = Campbell's operative orthopaedics | publisher = Elsevier | location = Philadelphia, PA | year = 2017 | isbn = 9780323433808 }}</ref><ref>{{cite book | last = Fernandez | first = Diego | title = Fractures of the Distal Radius : a Practical Approach to Management | publisher = Springer New York | location = New York, NY | year = 2002 | isbn = 9781461300335 }}</ref><ref name="pmid1983626">{{cite journal| author=Havemann D, Busse FW| title=[Accident mechanisms and classification in distal radius fracture]. | journal=Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir | year= 1990 | volume= | issue= | pages= 639-42 | pmid=1983626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1983626 }} </ref><ref name="pmid25657938">{{cite journal| author=Meena S, Sharma P, Sambharia AK, Dawar A| title=Fractures of distal radius: an overview. | journal=J Family Med Prim Care | year= 2014 | volume= 3 | issue= 4 | pages= 325-32 | pmid=25657938 | doi=10.4103/2249-4863.148101 | pmc=4311337 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25657938 }} </ref><ref name="pmid12895353">{{cite journal| author=Gong XY, Rong GW, An GS, Wang Y, Zhang GZ| title=[Selection of dorsal or volar internal fixation for unstable distal radius fractures]. | journal=Zhonghua Wai Ke Za Zhi | year= 2003 | volume= 41 | issue= 6 | pages= 436-40 | pmid=12895353 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12895353 }} </ref><ref name="pmid24612524">{{cite journal| author=Couzens GB, Peters SE, Cutbush K, Hope B, Taylor F, James CD et al.| title=Stainless steel versus titanium volar multi-axial locking plates for fixation of distal radius fractures: a randomised clinical trial. | journal=BMC Musculoskelet Disord | year= 2014 | volume= 15 | issue= | pages= 74 | pmid=24612524 | doi=10.1186/1471-2474-15-74 | pmc=3984716 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24612524 }} </ref> | ||
*The form and severity of [[Bone fracture|fracture]] of [[distal radius]] as well as the concomitant injury of disco-ligamentary structures of the wrist | **The majority of the [[Distal radius fracture|distal radius fractures]] are caused by a fall on the outstretched hand with the [[wrist]] in [[dorsiflexion]]. | ||
*The width of the angle influences the localization of the [[Bone fracture|fracture]]. | **The form and severity of [[Bone fracture|fracture]] of [[distal radius]] as well as the concomitant injury of disco-ligamentary structures of the wrist depends on the position of the [[wrist]] at the moment of hitting the ground. | ||
*[[Pronation]], [[supination]] and [[abduction]] determine the direction of the force and the compression of carpus and different appearances of [[ligamentary]] injuries. | **The width of the angle influences the localization of the [[Bone fracture|fracture]]. | ||
*The [[radius]] initially fails in tension on the [[volar]] aspect, with the [[Bone fracture|fracture]] progressing dorsally where bending forces induce compressive stresses, resulting in [[dorsal]] [[comminution]]. | **[[Pronation]], [[supination]], and [[abduction]] determine the direction of the force and the compression of [[carpus]] and different appearances of [[Ligament|ligamentary]] injuries. | ||
*As the deformation of the [[wrist]] continues, the [[Ulnar styloid process|ulnar styloid]] may also fracture due to the attachment of the [[triangular fibrocartilage complex]] to its base and the [[distal radius]]. | **The [[radius]] initially fails in tension on the [[volar]] aspect, with the [[Bone fracture|fracture]] progressing dorsally where bending forces induce compressive stresses, resulting in [[dorsal]] [[comminution]]. | ||
*In elderly [[Osteoporosis|osteoporotic]] patients the distal [[ulna]] may [[Bone fracture|fracture]] through the [[metaphysis]]. | **As the deformation of the [[wrist]] continues, the [[Ulnar styloid process|ulnar styloid]] may also fracture due to the attachment of the [[triangular fibrocartilage complex]] to its base and the [[distal radius]]. | ||
*[[Cancellous bone|Cancellous]] impaction of the [[metaphysis]] further compromises dorsal stability. | **In elderly [[Osteoporosis|osteoporotic]] patients, the distal [[ulna]] may [[Bone fracture|fracture]] through the [[metaphysis]]. | ||
*Additional shearing forces influence the injury pattern, resulting in articular surface involvement. | **[[Cancellous bone|Cancellous]] impaction of the [[metaphysis]] further compromises dorsal stability. | ||
*[[Distal radius fracture|Distal radius fractures]] typically occur with the [[wrist]] bent back from 60 to 90 degrees. | **Additional shearing forces influence the injury pattern, resulting in articular surface involvement. | ||
*[[Radial styloid process|Radial styloid]] [[Bone fracture|fracture]] would occur if the [[wrist]] is [[ulnar]] deviated and vice versa. | **[[Distal radius fracture|Distal radius fractures]] typically occur with the [[wrist]] bent back from 60 to 90 degrees. | ||
*If the [[wrist]] is | **[[Radial styloid process|Radial styloid]] [[Bone fracture|fracture]] would occur if the [[wrist]] is [[ulnar]] deviated and vice versa. | ||
**If the [[wrist]] is less dorsifelxed, then [[proximal]] [[forearm]] [[Bone fracture|fracture]] would occur, but if the dorsiflexion is more, then the [[carpal bones]] would [[Bone fracture|fracture]]. | |||
===Anatomy of Articular Interface of Distal Radius=== | ===Anatomy of Articular Interface of Distal Radius=== | ||
Revision as of 19:25, 14 December 2018
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Distal radius fracture Microchapters |
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Distal radius fracture pathophysiology On the Web |
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Risk calculators and risk factors for Distal radius fracture pathophysiology |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]
Overview
The pattern of fracture and degree of comminution are the resultant of several factors or variables such as the nature of the fall, the bone quality, the age and weight of the patient, the energy involved, and the position of the hand and wrist at the time of impact. Various combinations of these variables lead to a variety of different fracture patterns.
Pathophysiology
- The fracture pattern and severity of comminution depends on multiple factors including:
Mechanism of Fracture
- Mechanism of fracture may be described as follows:[1][2][3][4][5][6][7][8]
- The majority of the distal radius fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion.
- The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist depends on the position of the wrist at the moment of hitting the ground.
- The width of the angle influences the localization of the fracture.
- Pronation, supination, and abduction determine the direction of the force and the compression of carpus and different appearances of ligamentary injuries.
- The radius initially fails in tension on the volar aspect, with the fracture progressing dorsally where bending forces induce compressive stresses, resulting in dorsal comminution.
- As the deformation of the wrist continues, the ulnar styloid may also fracture due to the attachment of the triangular fibrocartilage complex to its base and the distal radius.
- In elderly osteoporotic patients, the distal ulna may fracture through the metaphysis.
- Cancellous impaction of the metaphysis further compromises dorsal stability.
- Additional shearing forces influence the injury pattern, resulting in articular surface involvement.
- Distal radius fractures typically occur with the wrist bent back from 60 to 90 degrees.
- Radial styloid fracture would occur if the wrist is ulnar deviated and vice versa.
- If the wrist is less dorsifelxed, then proximal forearm fracture would occur, but if the dorsiflexion is more, then the carpal bones would fracture.
Anatomy of Articular Interface of Distal Radius
- The articular surface of the distal aspect of the radius tilts 21 degrees in the antero-posterior plane and 5 to 11 degrees in the lateral plane.
- The dorsal cortical surface of radius thickens to form the Lister tubercle as well as osseous prominences that support the extensors of the wrist in second dorsal compartment.
- A central ridge divides the articular surface of the radius into a scaphoid facet and a lunate facet.
- The triangular fibrocartilage extends from the rim of the sigmoid notch of the radius to the ulnar styloid process.
- Only the brachioradialis tendon inserts onto the distal aspect of the radius; the other tendons of the wrist pass across the distal aspect of the radius to insert onto the carpal bones or the bases of the metacarpals.
- In addition to the extrinsic ligaments of the wrist, the scapholunate interosseous and lunotriquetral interosseous ligaments maintain the scaphoid, lunate and triquetrum in a smooth articular unit that comes into contact with the distal aspect of the radius and the triangular fibrocartilage complex.
- Because of the different areas of bone thickness and density, the fracture patterns tend to propagate between the scaphoid and lunate facets of the distal aspect of the radius.
- The degree, direction and extent of the applied load may cause coronal or sagittal splits within the lunate or scaphoid facet.
Associated Conditions
Conditions associated with poor bone quality leading to distal radius fracture include:
- Osteoporosis
- Osteopenia
- chronic stroke
- Diabetes
- Rheumatoid arthritis
- Chronic kidney disease
- Hyperparathyroidism
- Hypophosphatemic rickets
- Immobility
- Menopause
- Multiple myeloma
- Mixed connective tissue disease
- Paget's disease of bone
- Primary hypoparathyroidism
- Short stature
- Chronic corticosteroid use
Gross Pathology
On gross pathology, decreased bone density and small pores in diaphysis of bones are characteristic findings of osteoporosis, leading to distal radius fracture.
 |
Microscopic Pathology
- Bone with osteoporosis shows increased number of osteoclasts and decreased number of osteoblasts under the microscope.[9]
- Autophagy is the mechanism through which osteocytes evade oxidative stress.
- The capability of autophagy in cells decreases as they age, a major factor of aging.
- As osteocytes grow, viability of cells decrease thereby decreasing the bone mass density.
References
- ↑ Brown, Charles (2015). Rockwood and Green's fractures in adults. Philadelphia: Lippincott Williams & Wilkins/Wolters Kluwer Health. ISBN 9781451175318. Check
|isbn=value: invalid character (help). - ↑ Elstrom, John (2006). Handbook of fractures. New York: McGraw-Hill, Medical Pub. Division. ISBN 9780071443777.
- ↑ Azar, Frederick (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. ISBN 9780323433808.
- ↑ Fernandez, Diego (2002). Fractures of the Distal Radius : a Practical Approach to Management. New York, NY: Springer New York. ISBN 9781461300335.
- ↑ Havemann D, Busse FW (1990). "[Accident mechanisms and classification in distal radius fracture]". Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir: 639–42. PMID 1983626.
- ↑ Meena S, Sharma P, Sambharia AK, Dawar A (2014). "Fractures of distal radius: an overview". J Family Med Prim Care. 3 (4): 325–32. doi:10.4103/2249-4863.148101. PMC 4311337. PMID 25657938.
- ↑ Gong XY, Rong GW, An GS, Wang Y, Zhang GZ (2003). "[Selection of dorsal or volar internal fixation for unstable distal radius fractures]". Zhonghua Wai Ke Za Zhi. 41 (6): 436–40. PMID 12895353.
- ↑ Couzens GB, Peters SE, Cutbush K, Hope B, Taylor F, James CD; et al. (2014). "Stainless steel versus titanium volar multi-axial locking plates for fixation of distal radius fractures: a randomised clinical trial". BMC Musculoskelet Disord. 15: 74. doi:10.1186/1471-2474-15-74. PMC 3984716. PMID 24612524.
- ↑ Onal M, Piemontese M, Xiong J, Wang Y, Han L, Ye S; et al. (2013). "Suppression of autophagy in osteocytes mimics skeletal aging". J Biol Chem. 288 (24): 17432–40. doi:10.1074/jbc.M112.444190. PMC 3682543. PMID 23645674.