Commentary & Perspective on
"Sonography for Monitoring Closed Reduction of Displaced Extra-Articular Distal Radial Fractures"
By Tai-Chang Chern, MD et al.

Commentary & Perspective by
Jesse B. Jupiter, MD*,
Orthopaedic Hand Service, Massachusetts General Hospital, Boston, MA

The development of x-ray in the latter part of the nineteenth century had an immediate and dramatic impact on the diagnosis and management of musculoskeletal disorders, not the least of which were fractures of the distal end of the radius. Treating physicians now had the ability to visualize (albeit in two dimensions) the results of manipulation and immobilization of displaced fractures.

Recent technological advances in three-dimensional imaging, such as 3-D computed tomography and magnetic resonance imaging, portray a more precise picture of these patterns of traumatic disruption. It is now increasingly apparent that the stability of a reduced Colles or extra-articular distal radial fracture depends upon the realignment of the cortical margins of the metaphyseal end of the radius, including the radial, palmar, ulnar, and dorsal cortices. Yet the acceptability of the fracture reduction is most commonly decided on the basis of two-dimensional radiographic projections, which are rarely able to definitely portray all four cortical margins. Furthermore, with use of plain radiographs the accepted parameters of radial inclination, radial height, and ulnar variance are, in reality, proxy measurements, remote from the actual fracture lines.

It would appear, therefore, that there would be a distinct benefit to the use of ultrasound as a reliable and easily applied technology that would enable identification of cortical realignment in three dimensions. Yet this particular imaging modality may have enough inherent limitations, as identified by the authors, to temper enthusiasm for its use on a routine basis.

Ultrasonic imaging is not applicable to many types of distal radial fracture that include compression or shear fractures of the radiocarpal articulation or those that extend into the sigmoid notch. Once a splint or cast has been applied, the realignment must be assessed with use of standard radiographs rather than ultrasound images. Finally, knowledge of ultrasound technology and image interpretation are not currently part of the vast majority of orthopaedic practices.

Despite these pitfalls, the current study offers additional evidence of the need to view these injuries as three-dimensional problems. Greater accuracy in aligning all of the cortical margins will result in improved stability and improved results.

*The author did not receive grants or outside funding in support of this research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.