|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 36-40
Classification systems of distal radius fractures
Vishal Victor Kujur, Alok Chandra Agrawal, J Rakshit, Harshal Sakale, Bikram Kheshri Kar, Sandeep Yadav
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||28-Jun-2020|
|Date of Decision||15-Jul-2020|
|Date of Acceptance||17-Aug-2020|
|Date of Web Publication||10-Sep-2020|
Alok Chandra Agrawal
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
The fracture of distal radial was first described by Sir Abraham Colles in 1814. In last two centuries, the clinical features, investigative modalities, treatment modalities and complications have been explored extensively. To standardize the treatment, these fractures have been classified in several ways. Here in this article the author has tried to summarise the classifications of distal radius by various authors. It highlights the indications and implications of each classification modality.
Keywords: Distal radial fractures, distal radio ulnar joint, classification, extra-articular, Intra-articular
|How to cite this article:|
Kujur VV, Agrawal AC, Rakshit J, Sakale H, Kar BK, Yadav S. Classification systems of distal radius fractures. J Orthop Dis Traumatol 2020;3:36-40
|How to cite this URL:|
Kujur VV, Agrawal AC, Rakshit J, Sakale H, Kar BK, Yadav S. Classification systems of distal radius fractures. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 31];3:36-40. Available from: https://www.jodt.org/text.asp?2020/3/2/36/294732
| Introduction|| |
Distal radius fractures are one of the most common injuries encountered in orthopedic practice. They make up 8%–15% of all bony injuries in adults. Sir Abraham Colles Distal Radial Fractures Classification is credited with a description of the most common fracture pattern affecting distal end radius in 1814 and is classically named after him. Colles' fracture specifically is defined as metaphyseal injury of the corticocancellous junction (within 2–3 cm of articular surface) of the distal radius with characteristic dorsal tilt, dorsal shift, radial tilt, radial shift, supination, and impaction. Smith, in 1847, classified volarly displaced fractures into three types, based on the anatomical description. Barton, in 1838, described intra-articular fractures with either volar or dorsal displacement of the distal radius. Reverse Barton's occurs with wrist in palmar-flexion and involves the volar lip. Chauffer's fracture was described as originally occurring due to the backfire of the car starter handles in older models. It involves an intra-articular fracture of radial styloid of variable size.
Intra-articular component in the distal radius fractures usually signifies high-energy trauma occurring in young adults. High-energy injuries frequently cause shear and impacted fractures of the articular surface of the distal aspect of the radius, with the displacement of the fracture fragments. The fracture pattern most commonly observed in the geriatric age group is extra-articular, while the high-energy intra-articular type is most frequent in young adult patients.
| Classification System of Distal Radius|| |
The classification systems for distal radius fractures had not been established well. There have been 15 acknowledged classification systems documented in the primary literature for adult distal radius fractures in the past 70 years. The timeline in [Figure 1] shows the 15 acknowledged distal radius classification systems.
|Figure 1: Timeline showing the 15 acknowledged distal radius classification systems|
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The eight classification systems have been frequently used in an attempt to classify adult distal radius fractures for clinical diagnosis and management, as well as attempt to define a useful classification system. They are the Gartland and Werley, Older's, Frykman, Melone, Swiss Association for the Study of Internal Fixation (AO/ASIF), Mayo, Fernandez, and Universal classifications systems.
| Main Classification Systems Used for Distal Radius Fractures|| |
Gartland and Werley created a three-part classification based on metaphyseal comminution, intra-articular extension, and displacement and was first published in 1951. In 1985, Solgaard added a fourth group for completeness. The classification, however, does not include grade and amount of comminution or quantify the extent of fracture displacement, as shown in [Figure 2].
|Figure 2: Gartland and Werley's 1951 classification with Solgaard's added Group (I = Extra-articular displaced; II = Intra-articular, no displacement; III = Intra-articular, displaced; IV = Extra-articular, nondisplaced)|
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Older et al. published a four-part classification system applicable to the extra-articular Colles-type fracture. It was later modified by Solgaard in 1985, as given in [Figure 3]. In Older's classification, several different parameters such as the length of the radial styloid, the dorsal angulation, and the comminution of the dorsal cortex are measured. It was also the first to incorporate shortening of the distal radial fragment in relation to the distal ulna, which was found to be important in predicting functional outcome. Its use is limited as it does not include intra-articular distal radius fractures. However, this classification was of prognostic significance as it could predict the risk of fracture re-displacement.
|Figure 3: Older et al.'s 1965 classification modified by Solgaard (I: dorsal angulation ≤5°, length of radial styloid ≥7 mm; II: Dorsal angulation >5°, length of radial styloid <7 and ≥1 mm; III: Dorsal angulation >5°, length of radial styloid ≤4 mm slight dorsal comminution; IV: Dorsal angulation >5°, length of radial styloid usually negative, comminution, often intra-articular involvement)|
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Frykman was one of the first to recognize the importance of ulna styloid fractures. His classification system identifies the involvement of the radiocarpal and radioulnar joint, as well as the presence or absence of an ulna styloid fracture., It is a simple system with eight main divisions and four main types of injuries (odd numbers), with the addition of an ulna styloid fracture to each injury (even numbers), as shown in [Figure 4]. It does not, however, take into consideration the extent of fracture displacement, degree of comminution, or shortening of the radius, so its ability to guide treatment and predict prognosis is limited.,
|Figure 4: Frykman's 1967 classification (I: Extra-articular; II: As I with fracture of the distal ulna; III: Radiocarpal joint involved; IV: as III with fracture of the distal ulna; V: Distal radioulnar joint involved; VI: As V with fracture of the distal ulna; VII: Radiocarpal and distal radioulnar joints both involved; VIII: As VII with fracture of the distal ulna)|
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Melone classification, initially reported in 1984 and later revised, outlined a classification on intra-articular fracture patterns of the distal radius.,, This system breaks distal radius fractures down into four components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft, as given in [Figure 5]. The two medial fragments (which together create the lunate fossa) are grouped together as the medial complex. The Melone classification attempts to highlight the importance of the lunate facet of the radius and its significance in functional outcome. It has also been useful in defining indications and methods of surgical fixation, but its use is limited to intra-articular fractures.
|Figure 5: The Melone classification (I: Undisplaced, no or minimal comminution; II: “Die punch” fracture with moderate-to-severe displacement (IIa: Reducible; IIb: Irreducible); III Spike fragment present; IV: Wide separation of intra-articular fragments; V: Explosion fracture with severe comminution, transverse split, and rotational displacement)|
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In 1986, the Swiss association for Study of Internal Fixation ASIF proposed a classification for fractures, which was later reviewed by Muller in 1990 and Fernandez in 2001., Initial problems with reproducibility culminated in 1995 when Muller revised the classification into a binary system. Twenty-three distal radius fractures are labeled, and then, there are three main groups based on fracture joint involvement (A – extra-articular, B – partial articular, and C – complete articular) as shown in [Figure 6]. There are further subdivisions into groups and subgroups, making a total of 27 subgroups. Classification is further defined based on the level of comminution and direction of displacement. A qualification (Q) modifier can be added to classify associated ulnar injury.
|Figure 6: Swiss Association for the Study of Internal Fixation (AO/ASIF) classification of 23 distal radius fracture patterns (23-A extra-articular; 23-B partial articular; 23-C complete articular)|
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This classification system serves as a basis for the treatment and retrospective evaluation of results as it is very comprehensive and is heavily used in research. However, such an extensive classification is cumbersome to be used in day-to-day practice, so it remains impractical.
Mayo (1992) Clinic proposed its own classification. It is a four-part classification similar to the Frykman classification in that it focuses on fracture extension into the radiocarpal or radioulnar joint, as in [Figure 7]., In addition, it distinguishes between radioscaphoid and radiolunate joint surface involvement but does not place any emphasis on associated ulna fractures.
|Figure 7: Mayo Clinic classification (I: Extra-articular, undisplaced; II: Intra-articular, displaced, involving significant portion of articular surface; III: Intra-articular, displaced, often presents as “die punch” fracture of lunate fossa; IV: Intra-articular, displaced, involving both radioscaphoid joint surfaces and usually sigmoid fossa of distal radioulnar joint, usually comminuted)|
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Fernandez(1993) proposed simplified system developed in response to AO classification, intended to be based on injury mechanism with more treatment-oriented (treatment suggestions not meant to be used as rigid guidelines but can be used to help decision-making on a case-by-case basis). The classification includes five types of injury, which increase in complexity of the bony lesion and severity of associated soft-tissue injury from type I to type V fractures as in shown [Figure 8]. It also has a separate group for distal radioulnar joint injuries as summarized in [Table 1], which is important since one of the most common causes of disability after healed fractures is posttraumatic derangement of radioulnar articulation. The advantages of this classification are that it is practical, determines stability, includes associate soft-tissue injuries, and provides treatment and recommendations for both adults and pediatric patients.
|Figure 8: Fernández classification (I: Bending of the metaphysis; II: Shearing fractures of the joint surface; III: Compression of the joint surface; IV: avulsion or radiocarpal fracture dislocations; V: Combined fractures with high-velocity injuries)|
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|Table 1: Distal radioulnar joint injuries included in the Fernández classification|
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Universal(1990) classification was proposed by Rayhack and was later refined by Cooney in 1993 [Figure 9]., It attempted to improve on the Frykman classification to make a distinction between displaced and nondisplaced intra-articular fractures. The classification thus simply differentiates extra- and intra-articular fractures and displaced and nondisplaced fractures [Figure 9]. The Universal classification system is not only descriptive but also does not direct treatment.
| Conclusion|| |
There are several classification systems for distal radius fractures, ranging from the description of fracture patterns to complex and detailed articular morphology and fracture mechanisms. Despite the great variety of systems, an adequate fracture classification must be simple and provides adequate intra- and inter-observer reliability, as well as treatment guidelines and prognostic value. Many orthopedic surgeons believe that greater time is invested in memorizing classification systems than in the inherent usefulness it may provide in understanding fracture mechanisms. For all the practical limitations that can be found in determining an ideal classification system, there are many that can be summarized to provide the information needed in each occasion. Gartland and Werley and Older classifications provide ideas on the extent of comminution of a fracture, whereas Lindstrom, Universal, and AO/ASIF classifications provide information on the radiological appearance and degree of displacement of a fracture. For articular joint involvement, Frykman, McMurty and Jupiter, Melone, and Mayo are classifications that differ in the patterns, but all describe the variables of articular fracture morphology. Finally, the Fernandez classification provides an idea on the fracture mechanism and points to its pediatric fracture equivalents. Whatever fracture classification system may be used, its primary objective is the same: to provide the orthopedic surgeon with a reasonable and effective management strategy of distal radius fractures that results in the optimal function and pain-free wrist joint for the patient.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]