Chauffeur’s Fracture

DEFINITION

A chauffeur’s fracture is an avulsion fracture of the distal end of the radial styloid process.

SYNONYMS

• Distal radius fracture

• Radial styloid fracture

Chauffeur's-Fracture

ETIOLOGY

• The fracture typically occurs from a fall on an outstretched hand.

• Falls from higher levels produce worse fractures. Specifics of the fall may account for associated injuries such as fracture of the ulnar styloid, ligament injuries, or carpal fracture or dislocation.

• A strong radiocarpal ligament, particularly the radioscaphocapitate ligament, results in failure at the bone rather than disruption of the ligaments. The relative weakness of the bone results in avulsion of the radial styloid from the metaphysis of the radius.

EPIDEMIOLOGY AND 

DEMOGRAPHICS

• The two peaks of incidence of distal radius fractures are ages 6 to 10 and 60 to 69 years.

 In older adults, there is a 4:1 ratio of fractures in women. In adolescents,there is a 3:1 predominance of males.

 In younger children, the higher incidence can be attributed to bone immaturity and increased likelihood of falls.

• Wrist fractures are more common in women over 65 years of age.There is an increase in incidence in white women between 45 and 60 years of age. The trend then stabilizes.

• Only 15% of wrist fractures occur in men; this incidence does not appear to increase as men age.

• In Europe,the annual incidence of distal forearm fractures in males and females was estimated at 1.7 and 7.3 per 1000 person-years,respectively.

• Distal forearm fractures can be used as an early and sensitive marker of male skeletal fragility.

Chauffeur's-Fracture

MECHANISM OF INJURY

•Fall on an outstretched hand with the wrist ulnar deviated and supinated.

• Radial styloid fractures most commonly occur from tension forces sustained during the ulnar deviation and supination of the wrist.

COMMON SIGNS AND 

SYMPTOMS

• After injury,the patient will report pain in the wrist that may refer proximally into the forearm or distally into the hand.

• Movement may be limited by pain or physical block.

• Deformity in the wrist may be noted.

• Nerve symptoms, especially numbness or weakness in the median nerve distribution, may indicate serious complications.

AGGRAVATING FACTORS

• When seen acutely, wrist fractures will be limited in all motions.Forearm pronation and supination, gripping activities,lifting activities, and functional activities,such as writing and typing, will be limited and painful.

• When seen following immobilization or surgery, the patient will generally be limited in pronation and supination,therefore activities,such as turning doorknobs or typing,will be limited and aggravating.

• Activities, such as gripping, will be aggravating because wrist extension is needed to achieve a full grip.

EASING FACTORS

• Placing the wrist in a cast or splint is generally required to ease wrist symptoms and promote healing.

• Supporting the wrist with the other hand or a sling allows the hand and wrist to be in a resting position and a position of relative elevation.

• Elevation of the hand will help to decrease the amount of dependent edema that can accumulate in the hand after an injury to the wrist.

• Ice is an appropriate modality to slow the production of inflammation and to modulate pain.

• Compression, like elevation, is used to limit the amount of edema that accumulates in the hand and wrist.

• Minimizing wrist and hand use.

24-HOUR SYMPTOM PATTERN

• As with most fractures,initially pain will be experienced most of the day and night. Patients will complain of a deep achiness in the wrist, and this pain will increase during the first 72 hours as the inflammatory phase peaks. Nocturnal achiness is common with fractures.

• As the fracture heals, achiness at night and with weather changes is still common. Morning stiffness that lasts over 30 minutes is not uncommon.

• Increased swelling and edema is normal at the end of the day and depends on use. As edema increases, it is not uncommon for patients to complain of achiness or tightness in the wrist.

PAST HISTORY FOR THE REGION

• In older individuals, history of osteopenia or osteoporosis is common.

• May have history of long-term use of steroids or other bone-weakening medications.

PHYSICAL EXAMINATION

• Pain in the wrist; generally pain and tenderness is located at the radial styloid process. Pain will correlate with the location of the fracture, although the longer the time since injury, the more secondary and remote sites will be hypersensitized by the production of inflammation.

• Inability to move the wrist is experienced partly because of muscle guarding and partly because bony obstructions may prevent normal joint mechanics. Limitations will be especially be noted into ulnar deviation and pronation.

• Edema will be prevalent, especially in the acute phase. Muscle atrophy in the forearm will be noticed after casting. Edema may be present in the wrist even after several weeks of casting, but this edema is present secondary to disuse rather than from tissue injury.

• Bruising will be present acutely after a wrist fracture. Bone structures are highly vascularized, and injury to the tissue will result in damage to vascular structures. The damage to vascularized tissue will result in bruising.

• Numerous ligamentous attachments generally maintain the alignment of the radial styloid in relationship to the carpus, but the styloid may be markedly displaced from the rest of radius.

• The brachioradialis, extrinsic wrist/finger flexors, and wrist/finger extensors will exert a powerful displacing force on the carpus/radial styloid complex.

Chauffeur's-Fracture

• Fractures of the styloid process are frequently accompanied by dislocations of lunate.

IMPORTANT OBJECTIVE TESTS

• Distal radius fracture is usually diagnosed with radiographs. Nondisplaced fractures may sometimes require CT scan.

• The styloid is best visualized radiographically in a partially pronated view.

Chauffeur's-Fracture

DIFFERENTIAL 

DIAGNOSIS

• Although radiographs generally make differential diagnosis straight-forward, other diagnoses to consider would include the following:

 Scaphoid fracture.

 Lunate dislocation or fracture.

 Ligament injury around the carpals.

 Triangular fibrocartilage complex tear.

 Distal radioulnar joint dislocation.

• These pathologies may also occurin conjunction with a distal radius fracture.

TREATMENT

SURGICAL OPTIONS

• Simple,stable fractures that can be reduced manually may require only casting.

• Unstable fractures may require percutaneous pinning or open reduction and hardware fixation.

• The success of surgery depends on the severity of the fracture(displacement, angulation,degree of bone compression,and whether the fracture is intraarticular or extraarticular) and the absence or presence of associated injuries.

Chauffeur's-Fracture

• Surgery may be indicated if there is loss of bone length, unacceptable malalignment, or fracture into the joint, or if the fracture cannot be stabilized with a cast after closed reduction.

REHABILITATION

• The rehabilitation plan will be guided by the examination findings. Pain can be addressed with modalities, gentle manual techniques, and splinting for rest. When hypersensitivity is present, a desensitization program is indicated.Stiffness may benefit from joint and soft tissue mobilization and therapeutic exercise.Weakness will also respond to therapeutic exercise.

• The exercise program should start with gentle active and passive motion of the wrist, forearm, and fingers. Active and passive flexion of the finger MCP joints in the maximum-tolerated range,including while the patient is casted, is important; this can prevent or decrease contractures that will be very difficult to correct once established.

PROGNOSIS

• In younger persons,the primary predisposing factors are lifestyle choices (e.g.,participation in sports such as roller-blading or snowboarding). In older persons, impaired balance and osteopenia create increased risk of wrist fracture.

• Although the severity of the fracture must be considered, most patients will recover most or all of lost function and have little or no pain within 1 year after injury.

SIGNS AND SYMPTOMS 

INDICATING REFERRAL 

TO PHYSICIAN

Any indications of a distal radius fracture requires immediate referral to a physician.If the injury is seen acutely, the patient should be encouraged to remove any rings from the fingers; otherwise, swelling may later necessitate that the rings be cut off.

SUGGESTED READINGS

1- Haentjens P, Johnell O, Kanis JA, et al. Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles’ or spine fracture: Colles’ fracture as an early and sensitive marker of skeletal fragility in white men.J Bone Miner Res. 2004;19:1933–1944.

2- Hanel DP, Jones MD,Trumble TE.Wrist fractures.Orthop Clin North Am. 2002;33(1):35–57,vii.

3- Ismail AA, Pye SR, Cockerill WC, Lunt M,Silman AJ, et al. Incidence of limb fracture across Europe: results from the European Prospective Osteoporosis Study (EPOS).Osteoporos Int. 2002;13:565–571.

4- Owen RA, Melton LJ 3rd, Johnson KA, Ilstrup DM,Riggs BL.Incidence of Colles’fracture in a North American community. Am J Public Health. 1982;72:605–607.