Distal radius fractures

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

The distal radius is one of the most commonly fractured bones in adults, usually after a fall onto an outstretched hand (FOOSH). In older people with osteoporosis a simple trip is enough; in young adults it takes higher energy, and the fracture is more likely to involve the joint. The film has three jobs: name the pattern (Colles, Smith, Barton and so on), measure the displacement against the normal wrist, and check the carpus and the distal radioulnar joint for injuries that change management.

1. Views and how to look

A standard wrist series is a PA and a true lateral. On a true lateral the pisiform projects over the distal pole of the scaphoid, and the radius and ulna overlap. Work through the film in a fixed order:

1. Distal radius: trace the cortex all the way round, on both views. Look for a cortical break, buckle, step or sclerotic band (impaction).
2. Ulnar styloid and distal ulna: an ulnar styloid fracture often accompanies a distal radius fracture.
3. Distal radioulnar joint (DRUJ): widened on the PA, or the ulna displaced on the lateral?
4. Carpus: the three Gilula arcs on the PA, the scaphoid, and on the lateral the lunate sitting in the radius with the capitate in the lunate. See scaphoid fracture.
5. Soft tissues: the pronator quadratus fat line on the lateral, which can be bowed or lost over a subtle fracture.

2. Normal measurements

These describe the shape of the normal distal radius. You need them both to recognise subtle impaction and to describe how far a fracture has moved.

The key concept is that the normal radial articular surface tilts towards the palm on the lateral. A fracture that leaves the surface flat (0°) or tilted backwards (dorsal tilt) has lost the normal volar tilt, and this is the most common deformity you will measure.

3. The named patterns

Name	Description	Typical mechanism
Colles	Extra-articular fracture within about 2.5 cm of the wrist, with dorsal angulation and displacement of the distal fragment. Often with an ulnar styloid fracture. Clinically the "dinner-fork" deformity.	FOOSH with the wrist extended; older adults
Smith ("reverse Colles")	Distal radius fracture with volar (palmar) angulation or displacement of the distal fragment	Fall onto a flexed wrist
Barton	Intra-articular fracture of the dorsal or volar rim of the radius, with the carpus subluxing with the fragment. The volar type is more common.	Shearing force; often unstable
Chauffeur's (Hutchinson)	Intra-articular fracture of the radial styloid	Force transmitted through the scaphoid. Look for scapholunate injury.
Die-punch	Depressed fracture of the lunate fossa of the radius	Axial load through the lunate

Eponyms are useful shorthand, but they are used loosely in practice. A description of what you see is always safer than an eponym alone. Formal systems such as the AO/OTA classification (extra-articular, partial articular, complete articular) are used in orthopaedic practice.

In children, the commonest distal radius injury is the buckle (torus) fracture, a bulge of the cortex with no break in the opposite side, and physeal fractures are common in adolescents. See buckle and greenstick fractures and Salter-Harris fractures.

4. Describing the fracture

Use the standard language from how to describe a fracture, and add the wrist-specific features:

• Intra-articular or extra-articular? Does the line reach the radiocarpal joint or the DRUJ? Is there a step in the articular surface?
• Dorsal or volar angulation of the distal fragment, measured as the tilt of the articular surface on the lateral. Say which convention you are using: "dorsal tilt of the distal fragment" means the same as "apex-volar angulation".
• Loss of radial height (shortening) and loss of radial inclination on the PA.
• Comminution, particularly of the dorsal cortex, which predicts instability.
• Ulnar styloid fracture and the state of the DRUJ.

When is it "acceptable"?

Whether a position is acceptable is an orthopaedic decision that takes account of age, function and bone quality. Commonly cited targets include dorsal tilt under about 10° (some sources use 5–15°), radial shortening under about 3 mm and an intra-articular step under about 2 mm. These thresholds vary between guidelines, including the British Orthopaedic Association standard (BOAST) and US guidance, so use them as context for your description rather than as a decision rule.

5. Associated injuries

• Scaphoid fracture: the same FOOSH mechanism. Look at the scaphoid on every wrist film.
• Scapholunate ligament injury: especially with a radial styloid fracture. A widened scapholunate gap (often quoted as more than about 3–4 mm; sources vary) suggests dissociation.
• Perilunate or lunate dislocation: on the lateral, check that the radius, lunate and capitate line up. These are easily missed and are surgical emergencies.
• DRUJ disruption and, with a more proximal radial shaft fracture, the Galeazzi injury.
• Median nerve: acute carpal tunnel syndrome can follow a displaced fracture. This is a clinical finding.

A low-energy distal radius fracture in an older adult is a fragility fracture. It should prompt consideration of bone health assessment, in line with local fracture liaison pathways.

6. Pitfalls

• Subtle impaction: the only signs may be a sclerotic band across the metaphysis, a slight loss of volar tilt or a buckle of the dorsal cortex. Measure the tilt.
• Calling a Smith fracture a Colles because of a poor lateral. The direction of displacement is only judged on a true lateral.
• Missing the carpus after spotting the radius fracture (satisfaction of search).
• Normal growth plates and the pronator quadratus line in children and adolescents can mislead. Compare with the other side if unsure.
• Post-reduction films must be reassessed with the same measurements; the position can slip in the first week or two.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Colles vs Smith vs Barton, the "dinner fork", and the normal volar tilt.
Nurse / ENP	Recognise the common patterns and buckle fractures in children. Check median nerve function and the skin.
Junior doctor	Measure tilt, height and inclination before and after reduction. Always check the carpus and the DRUJ.
Radiographer	True lateral wrist positioning (pisiform over the distal scaphoid). Consider scaphoid views when the clinical request or findings suggest it.
Advanced / FRCR	Articular step, die-punch fragments, DRUJ and carpal ligament injury.

Practise on real upper limb X-rays →

References

1. Radiopaedia. Distal radius fracture. radiopaedia.org
2. British Orthopaedic Association. BOAST guidelines. boa.ac.uk
3. NICE NG38. Fractures (non-complex): assessment and management. nice.org.uk
4. LITFL. Gilula carpal arcs. litfl.com
5. AO Foundation. AO/OTA fracture classification. aofoundation.org

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.