Outline:  
Fracture of the distal end of radium is the fracture in the section between the distal end and 3 cm to the end of radius, often seen in old persons. It is mostly caused by indirect violence. It mainly includes extension (Colles’ fracture) and flexion (Smith’s fracture) types. Extension fracture is usually caused by a fall with the palm touching the ground. The distal end of fractured bone is displaced toward radial and dorsal side, the broken end makes an angle to the palmar aspect.

And it is often accompanied by avulsion fracture of ulnar styloid process or separation of the lower radioulnar joint. When the distal end presents a comminuted fracture, the fracture line may insert into the articular surface. Flexion fracture is commonly caused by fall with the dorsum of hand touching the ground, the distal end of fracture is displaced toward radial and palmar side. Clinically, the commonly encountered fracture is extension type, accounting for more than 90%. In the youngsters, it often presents in the form of fracture with epiphysis separation.
 
Major points for diagnosis  
1. The patient has a traumatic history of fall with wrist touching the ground.

2. There are swelling and pain in the wrist, with intolerance of motion.

3. There is obvious tenderness in the distal end of radius with impaired movement of the wrist joint and rotation of the forearm. There may appear "dinner-fork" deformity in extension fracture with the distal end of fracture displaced toward dorsal side, "slice-shaped" deformity in flexion fracture with the distal end of fracture displaced toward palmar side, and "bayonet-shaped" deformity in the cases of the distal end of fracture displaced toward radial side. A bony crepitus may be felt.
 
4. Roentgenogram can confirm the type of fracture.

Treatment:  
For fractures with no displacement, 3-week splintage may be applied directly, and for those with displacement, reduction and fixation must be used.

Reduction:
No anesthesia is needed for fresh displaced fracture. For the reduction of extension type, the patient takes a sitting position. One assistant holds the upper part of the elbow. The operator holds the distal end of the wrist with two hands, presses the dorsal aspect of the distal end of fracture with two thumbs and pulls the main and minor thenar eminence on the palm with the rest fingers. He works in cooperation with the assistant to apply a slow counter-traction for 3 to 4 minutes. After that, the assistant is asked to hold the elbow steadily, while the operator slowly enlarges the degree of the angle along the original direction of angulation, the severer the displacement is the greater the angulation should get.

When the operator feels that dorsal cortical bones of the two ends of fracture have gone against each other, he should make the wrist do a sudden arc movement to dorsal aspect of the radius, thus the reposition of fracture may be achieved. Then the operator holds the patient's hand to work in cooperation with the assistant to keep the sick wrist in a position of moderate dorsoflexion and ulnar deviation, the operator corrects the residual displacement. A spontaneous reduction can be obtained during the manipulation mentioned above in the case of fracture of styloid process of ulna or separation of the lower radioulnar joint. For the reduction of flexion fracture, the patient takes a sitting or lying position.

Two assistants hold respectively the sick elbow and hand to apply counter-traction, while the operator puts his two palms respectively on the radial aspect of distal end and ulnar aspect of proximal end of fracture to apply opposite squeezing and pressing manipulations, correcting displacement of radial deviation. Then he uses his two thumbs to push and squeeze the distal end of fracture from the palmar side to the dorsal side, at the same time, uses his second, third and fourth fingers to press the proximal end to palmar side. After that, he pinches the fractured part and the assistant holding the hand slowly extends patient's wrist dorsally to get the effect of tension of the flexors, thus avoiding redisplacement.

Fixation:  
After a cotton pad is put on the sick wrist and forearm, for extension fracture, four flat pads are put respectively on the dorsal and radial aspects of the distal end, and the palmar and ulnar aspects of the proximal end. Then the palmar, dorsal, radial and ulnar splints are successively put. The upper borders of the splints should reach the level of the middle-upper part of the forearm. The lower ends of the radial and dorsal splints should overtake the radiocarpal joint. The distal end of the palmar splint should reach the transverse pal-mocarpal crease. And the distal end of ulnar splint should reach the head of ulna.  For flexion fracture, four flat pads are respectively put on the palmar and radial sides of the distal end, and the dorsal and ulnar sides of the proximal end. The distal ends of palmar and radial splints should overtake the radiocarpal joint, the others are the same as for extension fracture. Mter being rightly put, the splints are tied with three or four pieces of string for fixation. Finally, the diseased arm is suspended before the chest with supporting board. The duration of fixation is 4 to 5 weeks for adults and 2 to 3 weeks for children.
    
Functional exercise:    
In the early stage, the patient is encouraged to practice extending and flexing joints of fingers in the position of fixation of wrist joint. When swelling and pain subside, the patient is asked to practice clenching his fist and exercising his elbow and shoulder joints. After removal of the fixation, the patient is advised to exercise mobile training of the wrist joint and rotation of the forearm.
    
Herbal therapy:  
Internal treatment based on syndrome differentiation

1. In the early stage
Main symptoms and signs:
Swelling and pain in the sick wrist, intolerance of motion.

Therapeutic methods:
Promoting blood flow to remove the stasis, resolving the swelling to relieve pain.

Recipe and herbs:
Modified Huoxue Zhitong Decoction. The herbs see the treatment of fracture of shafts of radius and ulna in the early stage.

 
2. In the middle stage
Main symptoms and signs:
Subsided swelling and pain, impaired movement of fingers.

Therapeutic methods:
Promoting blood flow and reuniting the bone.

Recipe and herbs:
Modified Xugu Huoxue Decoction. The herbs see the treatment of clavicular fracture in the middle stage.
 
3. In the late stage
Main symptoms and signs:
Rigidity of the wrist, or pain, muscular atrophy, weakness of the limbs.

Therapeutic methods:
Promoting blood flow, relaxing tendons, and freeing joint movement.
 
Recipe and herbs:
Modified Huoxue Shujin Decoction. The herbs see the treatment of clavicular fracture in the late stage.
 
External therapy:
In the early and middle stages, Sanse Application may be externally used. In the late stage, for the cases of marked impaired movement of joint, fumigation and bathing should be applied with Haitongpi Decoction. Specifically, Haitongpi (Cortex Erythrinae)6 g, Tougucao (Herba Speranskiae seu Impatientis)6 g, Ruxiang (Gummi Olibanum)6 g, Moyao ( Myrrha )6 g, Chuanjiao (Pericarpium Zanthoxyti Bungeani )10 g, Danggui (Radix Angelicae Sinensis)5 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)3 g, Honghua (F los Carthmi)3 g, Weilingxian (Radix Clematidis)3 g, Gancao (Radix Glycyrrhizae)3 g, Fangfeng ( Radix LedebourieUae Divaricatae)3 g and Baizhi ( Radix Angelicae Dahuricae )3 g. All the herbs are decocted in water, using the hot decoction for fumigating and bathing the diseased part, 3 to 4 times daily.