778 ORTHOPEDICS | Healio.com/Orthopedics n trauma update Section Editors: David J. Hak, MD, MBA & Philip F. Stahel, MD Current Concepts in the Treatment of Distal Radial Fractures Kyros Ipaktchi, MD; Meryl Livermore, MD; Christopher Lyons, MD; Rodrigo Banegas, MD F ractures of the distal end of the radius account for the majority of upper extremity fractures and for up to 15% of all extremity fractures seen in emergency departments. 1 Apart from pediatric fractures, one must differentiate high-energy injuries in younger patients from fragility fractures seen in elderly patients. 2 Given the topographic vicinity, high-energy fractures of the distal radius can be as- sociated with concomitant in- juries to adjacent bones, joints, and ligaments (ie, carpal bones and ligaments, distal radioulnar joint, interosseous membrane), as well as neurovascular injury (Figures 1, 2). Patient treatment targets functional reconstruction of the distal forearm, restoring anatomy and articular congru- ity. Although earlier recommen- dations suggested that outcomes are determined by residual joint incongruities, 3 current evidence suggests a multifactorial in- fluence on outcomes, and the literature lacks higher-level evidence. 4 In contrast with the pathophysiology of fractures in younger patients, fractures seen in elderly patients are largely based on skeletal fragility and reduced proprioceptive feed- back. Treatment must respect skeletal insufficiency and al- tered daily activity levels (Fig- ure 3). Surgical treatment for dis- tal radial fractures has seen a significant evolution over the past decade with the advent of locking plate technologies and anatomic and low-profile plate contouring, as well as the use of novel materials. These in- novations have challenged and advanced traditional treatment concepts, including the choice of surgical approach, the use of structural bone grafting, and re- habilitation. Although techno- logical advances offer current surgeons more refined treat- ment choices, there is a lack of evidence-supported guidance for conservative and surgical treatment of this commonly seen upper extremity fracture. 5,6 SURGICAL ANATOMY AND PATHOPHYSIOLOGY The carpal surface of the distal radius shows 2 distinct impressions: the scaphoid and lunate facets, which articulate with the correspondingly named carpal bones. Medially, the sig- moid notch (a shallow groove accommodating the ulnar head) forms part of the distal radioul- nar joint. This joint allows rota- tional and translational motion of the forearm during pronosu- pination. It is stabilized by the dorsal and volar radioulnar liga- ments, the joint capsule, the ex- tensor carpi ulnaris, and the tri- angular fibrocartilage complex, which features a meniscoid disk suspended between the sigmoid notch and the ulnar fovea. 7 Disruption of the distal radio- ulnar joint commonly leads to unrestrained dorsal translation of the ulnar head in pronation and ulnar-sided pain. Although coronal displacement of distal The authors are from the Department of Orthopaedic Surgery (KI, ML, RB), Denver Health Medical Center, Denver; and the University of Colorado School of Medicine (CL), Aurora, Colorado. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Kyros Ipaktchi, MD, Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock St, Den- ver, CO 80204 (kyros.ipaktchi@dhha.org). doi: 10.3928/01477447-20130920-07 Abstract: Distal radial fractures are among the most commonly encountered traumatic fractures of the upper extremity. Initial trauma mechanism, fracture pattern, associated injuries, and patient age influence treatment and outcome. Although stable fractures are commonly treated conservatively, the past decade has seen changes in surgical practice and techniques. Indica- tions for surgery have been extended and refined based on new insight into the pathophysiology of the distal end of the forearm and technological advances in implant design. Despite the fre- quency of this fracture, only limited higher-level evidence exists to guide practitioners in decision making for this injury. This article highlights key concepts in the treatment of distal radial fractures and summarizes current evidence.