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CURRENT MANAGEMENT OF CURRENT MANAGEMENT OF FRACTURES OF THE DISTAL FRACTURES OF THE DISTAL
RADIUSRADIUS
• Presenter : Dr. Sreenivas Presenter : Dr. Sreenivas .T.T
• Moderators : Dr. Vikas Moderators : Dr. Vikas GuptaGupta
: Dr. Shamshery : Dr. Shamshery
CONTENTSCONTENTS
• IntroductionIntroduction
• AnatomyAnatomy
• DiagnosisDiagnosis
• ClassificationClassification
• Treatment Goals and Considerations Treatment Goals and Considerations
• ComplicationsComplications
• Associated injuriesAssociated injuries
• Current managementCurrent management
INTRODUCTIONINTRODUCTION
• -Fractures of the distal radius -1/6 of all fractures-Fractures of the distal radius -1/6 of all fractures• -Bimodal age distribution- one peak in early -Bimodal age distribution- one peak in early
adolescence, second in the older ageadolescence, second in the older age• -Controversy and confusion exists in medical -Controversy and confusion exists in medical
literature literature • -Fundamental principle -restoration of anatomy -Fundamental principle -restoration of anatomy
with the hope of producing full ,painless motion of with the hope of producing full ,painless motion of wrist.wrist.
• -Employment of a single technique -prone to -Employment of a single technique -prone to variable and often disappointing resultsvariable and often disappointing results
ANATOMYANATOMY
• Distal radius Distal radius articulates with ulnar articulates with ulnar head and carpus.head and carpus.
• This articulation This articulation enable the radius to enable the radius to guide forearm guide forearm rotation and wrist rotation and wrist movements.movements.
• The cortical bone in The cortical bone in the area of distal the area of distal radial metaphysis is radial metaphysis is thin.thin.
Contd…Contd…
• Normal palmar angulation Normal palmar angulation -11º in the lateral plane.-11º in the lateral plane.
• Normal radial angulation- Normal radial angulation- 23º in the AP plane23º in the AP plane
• Average radial length is Average radial length is around 12mm with around 12mm with negative ulnar variancenegative ulnar variance..
DIAGNOSISDIAGNOSIS
• HistoryHistoryAge of the patientAge of the patient
Mechanism of Mechanism of injuryinjury
-FOOSH-FOOSH
-wrist 40-60-wrist 40-60ºº dorsiflexiondorsiflexion
Clinical examinationClinical examination
--ExaminationExamination of joints above and of joints above and below the wristbelow the wrist
-Deformity ;dinner fork-Deformity ;dinner fork
-Swelling ,degree of radial and -Swelling ,degree of radial and ulnar tilt ,DRUJulnar tilt ,DRUJ
-Associated scaphoid fracture-Associated scaphoid fracture
-Neurovascular assessment - -Neurovascular assessment - Median nerve compressionMedian nerve compression
Radiological evaluationRadiological evaluation
•X-rayX-ray• PA/Lateral PA/Lateral
Check forCheck for• Loss of radial height (>5mm) Loss of radial height (>5mm)
• Loss of radial inclination (Normal 20-Loss of radial inclination (Normal 20-25º) 25º)
• Dorsal tilt (Normal 10º volar) Dorsal tilt (Normal 10º volar)
• Comminution Comminution
• Ulnar fractureUlnar fracture
• Axial or rotational malalignment can Axial or rotational malalignment can produce DRUJ problemsproduce DRUJ problems
CTCT
• For intra-articular For intra-articular fracturesfractures
Wrist arthroscopyWrist arthroscopyAs a diagnostic aid- eg-to R/O associated TFCC tearsAs a diagnostic aid- eg-to R/O associated TFCC tears
CLASSIFICATIONSCLASSIFICATIONS
Fracture Classification
-SHOULD be practical and useful in treatment decision -SHOULD NOT BE cumbersome and impractical -Recognizing that the major forces resulting in fracture propagation-Some basic principles can be developed to separate out potentially unstable from stable fractures
•15 different Classification systems exist!
1.1. Frykman Frykman (1967)(1967)
• Descriptive only and does not include Descriptive only and does not include variables, such as direction and degree of variables, such as direction and degree of displacement or Comminutiondisplacement or Comminution
2 .McMurtry and Jupiter2 .McMurtry and Jupiter
• 2 parts: Barton #, 2 parts: Barton #, Chauffeur #,Die-Chauffeur #,Die-punch #punch #
• 3 parts: lunate and 3 parts: lunate and scaphoid fossae scaphoid fossae separate from distal separate from distal radiusradius
• 4 parts :lunate fossa 4 parts :lunate fossa fractured into dorsal fractured into dorsal and volar fragmentsand volar fragments
• 5 parts or more5 parts or more
3 3 MeloneMelone Classification(1984)Classification(1984)• Sub-types of 4-part intra-articular fractures Sub-types of 4-part intra-articular fractures • Gives indication to treatmentGives indication to treatment
Types Types
1 Minimal 1 Minimal
comminution – stablecomminution – stable 2 Comminuted – 2 Comminuted –
stablestable 3 Displacement of 3 Displacement of
medial complex as a medial complex as a unit + anterior spikeunit + anterior spike
4 Wide separation or 4 Wide separation or rotation of the dorsal rotation of the dorsal fragment + palmar fragment + palmar fragment rotationfragment rotation
4 .Universal 4 .Universal ClassificationClassification• Based on the Based on the
concept and concept and principle of EA vs principle of EA vs IA fractures and IA fractures and stable vs unstable stable vs unstable
5.AO Classification5.AO Classification
• Comprehensive Comprehensive but has poor inter but has poor inter and intra observer and intra observer agreementagreement
TREATMENT GOALS AND TREATMENT GOALS AND CONSIDERATIONSCONSIDERATIONS
PrinciplesPrinciples1.1. restoration of articular congruity and axial restoration of articular congruity and axial
alignment alignment 2.2. maintenance of reduction maintenance of reduction 3.3. achievement of bony union achievement of bony union 4.4. restoration of hand and wrist functionrestoration of hand and wrist function
Principles needs to be tailored to the needs of Principles needs to be tailored to the needs of the patientthe patient
CONTD…CONTD…
Other factorsOther factors • Low functional demand Low functional demand • Significant medical illness Significant medical illness • Inability to comply with postoperative instructions Inability to comply with postoperative instructions • Previous fracture and deformityPrevious fracture and deformity -These may justify acceptance of less than -These may justify acceptance of less than
anatomic results. anatomic results. -Chronological age does not correlate with -Chronological age does not correlate with
functional age and many of these fractures, even in functional age and many of these fractures, even in older patients, will benefit from aggressive older patients, will benefit from aggressive treatmenttreatment
Anatomical aimsAnatomical aimsTo restore radial length, inclination To restore radial length, inclination
and tiltand tiltAcceptance criteriaAcceptance criteria
1.1. 10º loss of normal volar angulation 10º loss of normal volar angulation (i.e. No more than 0º or 20º volar (i.e. No more than 0º or 20º volar angulation) angulation)
2.2. < 5º loss of radial inclination < 5º loss of radial inclination 3.3. < 2mm shortening < 2mm shortening 4.4. Accurate restoration of the articular Accurate restoration of the articular
surface < 2mm step surface < 2mm step
Characteristics of Characteristics of instabilityinstability
• Dorsal +/or volar cortical comminution Dorsal +/or volar cortical comminution • Fragmentary displacement >5 mm Fragmentary displacement >5 mm • Angulation >10 Angulation >10 • Shortening (impaction) > 5 mm Shortening (impaction) > 5 mm • Articular comminution Articular comminution • Diastasis DRUJ Diastasis DRUJ • Fracture ulnar head/neck Fracture ulnar head/neck • Concomitant scaphoid fracture or Concomitant scaphoid fracture or
scapholunate dissociation scapholunate dissociation • These principles -basis for practical These principles -basis for practical
classification system which guide treatment classification system which guide treatment
Displaced + stableDisplaced + stable
• Closed reduction + Cast immobilizationClosed reduction + Cast immobilization
Plaster/bracePlaster/brace
AdvantagesAdvantagesEasy to applyEasy to apply Operation not requiredOperation not required
DisadvantagesDisadvantages
Movement of the hand may result in loss of Movement of the hand may result in loss of position of the fracture especially as swelling position of the fracture especially as swelling goes downgoes down Plaster needs to be kept on for six weeks and so Plaster needs to be kept on for six weeks and so wrist and hand stiffness may resultwrist and hand stiffness may resultPlaster cannot control dorsal comminutionPlaster cannot control dorsal comminution
Displaced Intraarticular Displaced Intraarticular FracturesFractures
• Specific subset of distal radius fractures Specific subset of distal radius fractures • High energy injury resulting in comminuted High energy injury resulting in comminuted
fracture pattern fracture pattern • Usually occurs in younger age population Usually occurs in younger age population • Inherent tendency for shortening and Inherent tendency for shortening and
collapse collapse • Associated with carpal and distal radioulnar Associated with carpal and distal radioulnar
instability instability • Less amenable to closed manipulation and Less amenable to closed manipulation and
casting casting
ASSOCIATED INJURIESASSOCIATED INJURIES
Distal Radioulnar JointDistal Radioulnar Joint - Ulnar styloid fracture - - Ulnar styloid fracture - frequent - rarely frequent - rarely
unstableunstable - partial TFCC tear - partial TFCC tear - rarely - rarely needs treatment (50%)needs treatment (50%) – DisruptionDisruption
• Diastasis - Complete TFCC tearDiastasis - Complete TFCC tear• Bony constraints cannot control Bony constraints cannot control • Requires soft tissue stabilization Requires soft tissue stabilization • Repair with sutures/suture anchors Repair with sutures/suture anchors • ORIF larger fragments ORIF larger fragments
– Ulnar Head/Neck FractureUlnar Head/Neck Fracture - Comminuted - - Comminuted - very unstable very unstable • Difficult to securely fix Difficult to securely fix • Treat with excision/soft tissue reconstruction Treat with excision/soft tissue reconstruction • Bone can be used for grafting radiusBone can be used for grafting radius
Median Nerve Injury (13-Median Nerve Injury (13-23%)23%)
• Contusion Contusion • Hematoma/Compression Hematoma/Compression • Traction / Neuropraxia Traction / Neuropraxia • Reduction frequently increases Reduction frequently increases
intracompartmental pressure in carpal canal intracompartmental pressure in carpal canal • Early surgical decompression - if significant Early surgical decompression - if significant
symptoms symptoms • Late decompression - less successful Late decompression - less successful
Intercarpal Ligament Intercarpal Ligament Injury Injury
Total/PartialTotal/Partial• Scapholunate (30%) Scapholunate (30%)
• Lunotriquetral(15%)Lunotriquetral(15%)
• Can see diastasis in Can see diastasis in traction x-ray traction x-ray
• Treated early with Treated early with percutaneous pin percutaneous pin fixation - usually fixation - usually adequate adequate
Scaphoid FractureScaphoid Fracture
• If nondisplaced - percutaneous pin If nondisplaced - percutaneous pin fixation fixation
• If displaced - ORIF If displaced - ORIF
COMPLICATIONSCOMPLICATIONS Early Early
– Difficult reduction, loss of reduction, Difficult reduction, loss of reduction, unstable reductionunstable reduction
– Associated carpal injury: fracture or Associated carpal injury: fracture or ligamentous tear ligamentous tear
– TFCC tear - 50% TFCC tear - 50% – DRUJ subluxation or dislocationDRUJ subluxation or dislocation– Acute Carpal Tunnel SyndromeAcute Carpal Tunnel Syndrome – Acute post reduction swelling / Acute post reduction swelling /
Compartment syndrome Compartment syndrome – Nerve - median most common - 13-23% Nerve - median most common - 13-23% – Vessel - rare - radial artery commonest Vessel - rare - radial artery commonest – Tendon - rare Tendon - rare
Contd..Contd..
Intermediate and LateIntermediate and Late• Loss of reduction and 2° deformity Loss of reduction and 2° deformity • Malunion, Malunion, • Non-union - rare Non-union - rare • Symptomatic Radiocarpal OA - 7% ( Stiff Hand)Symptomatic Radiocarpal OA - 7% ( Stiff Hand)• Median Nerve compression (23%), carpal tunnel Median Nerve compression (23%), carpal tunnel
syndrome, ulnar or radial nerve compression syndrome, ulnar or radial nerve compression • EPL rupture in 1.5% (Treatment EPL rupture in 1.5% (Treatment
EIP to EPL transferEIP to EPL transfer) ) • RSD 25% RSD 25% • DRUJ OA (Treatment = Darrach's / Suave-DRUJ OA (Treatment = Darrach's / Suave-
Kapandji procedure) Kapandji procedure)
ADVANCES IN DISTAL ADVANCES IN DISTAL RADIUS FRACTURE RADIUS FRACTURE MANAGEMENTMANAGEMENT • Pearls and Pitfalls of External FixationPearls and Pitfalls of External FixationWilliam H. William H.
Seitz, Jr, MD, Cleveland, OH Seitz, Jr, MD, Cleveland, OH • Internal Fixation and Early MotionInternal Fixation and Early Motion
Jesse B. Jupiter, MD, Boston, MA Jesse B. Jupiter, MD, Boston, MA • The Role of Arthroscopic-Assisted FixationThe Role of Arthroscopic-Assisted Fixation
William Geissler, MD, Jackson, MS William Geissler, MD, Jackson, MS • The Roles of the DRUJ and Rehabilitation in The Roles of the DRUJ and Rehabilitation in
Outcome of Distal Radius FracturesOutcome of Distal Radius FracturesMatthew D. Putnam, MD, Minneapolis, MN Matthew D. Putnam, MD, Minneapolis, MN
• Augmentation of Fracture Fixation: Bone Augmentation of Fracture Fixation: Bone Graft and AlternativesGraft and AlternativesScott W. Wolfe, MD, New Haven, CTScott W. Wolfe, MD, New Haven, CT
1.External Fixation1.External Fixation
• NOT applicable to all fractures NOT applicable to all fractures
• DOES provide a useful tool for many fractures DOES provide a useful tool for many fractures
• Provides LIMITED, GROSS CONTROL of major Provides LIMITED, GROSS CONTROL of major fragments fragments
• It does so by controlling length, alignment and It does so by controlling length, alignment and rotational orientation of the hand on the rotational orientation of the hand on the forearm forearm
• DOES NOT provide precise fragment DOES NOT provide precise fragment realignment nor restoration of articular realignment nor restoration of articular congruence congruence
BIOMECHANICAL PRINCIPLES FOR BIOMECHANICAL PRINCIPLES FOR APPLICATIONAPPLICATION
• LIGAMENTOTAXISLIGAMENTOTAXIS
– Tension across Tension across intact soft tissue intact soft tissue structures structures
– Spanning a joint Spanning a joint will help to mold will help to mold major fragments major fragments back into back into alignment & hold alignment & hold these there using these there using physiological physiological tension tension
PEARLSPEARLS
Physiologic tension - maintains Physiologic tension - maintains "healthy" capsular stretch"healthy" capsular stretch– R-C joint 1 mm > mid carpal joint R-C joint 1 mm > mid carpal joint – Avoid over distraction (back off) Avoid over distraction (back off) – Watch for scapholunate displacement Watch for scapholunate displacement
(pin/suture) (pin/suture) – Watch for scaphoid fracture displacement Watch for scaphoid fracture displacement – Don't try to gain full alignment Don't try to gain full alignment
restoration by over distraction restoration by over distraction
PITFALLSPITFALLS
– Over distraction -Over distraction -disasterdisaster
– Median neuropraxia Median neuropraxia – RSDRSD– Finger stiffnessFinger stiffness
FIXATOR APPLICATION/FRACTURE FIXATOR APPLICATION/FRACTURE REDUCTIONREDUCTION
– With pins in place - assemble and apply fixator to pins With pins in place - assemble and apply fixator to pins with fixation in unassembled mode with fixation in unassembled mode
– Apply gentle - but firm - traction to hand and gently Apply gentle - but firm - traction to hand and gently manually compress fracture fragments into alignment manually compress fracture fragments into alignment between thumb and palm between thumb and palm
– Secure fastener lock-ups and check overall alignment Secure fastener lock-ups and check overall alignment for length, angle and rotation of fragments by image for length, angle and rotation of fragments by image intensifier intensifier
– Adjust traction as needed Adjust traction as needed – Re-adjust/re-reduce if needed Re-adjust/re-reduce if needed – Proceed with fine fragment reduction/augmentation Proceed with fine fragment reduction/augmentation – Ensure Ensure NONO over distraction over distraction – Following internal fixation - return to neutral position Following internal fixation - return to neutral position
AugmentationAugmentation – Limited internal Limited internal
fixation with fixation with percutaneous K-percutaneous K-wires provides-wires provides-Interfragmentary Interfragmentary realignment & realignment & precise articular precise articular restorationrestoration
– In complex In complex irreducible irreducible fractures (usually fractures (usually high energy)-high energy)-ORIF+External ORIF+External fixationfixation
Percutaneous K-wiresPercutaneous K-wires
Extra focal -Classical styloid + Lister's tubercle wire placement -Trans-ulnar pin placement Intra-focal - Kapandji technique (Kapandji A. Ann. Chir. Main. Memb. Super. 6:57-63. 1987)
Contd…Contd…
Arum pinningArum pinning
Contd…Contd…
Subchondral SupportSubchondral Support– When there is > 5 mm shortening When there is > 5 mm shortening – i.e. impaction with very osteopenic i.e. impaction with very osteopenic
bone - or after reduction a large bone - or after reduction a large void is noted radiographically void is noted radiographically
– Metaphyseal bone replacement Metaphyseal bone replacement prevent late collapse and affords prevent late collapse and affords relatively early fixator removal relatively early fixator removal
Postoperative CarePostoperative Care
Bulky soft dressing - Compress Bulky soft dressing - Compress gently - controls edema - fingers gently - controls edema - fingers free - allows hand use free - allows hand use 4 days 4 days onlyonlyREHABILITATION REHABILITATION • Begins Pre-operatively Begins Pre-operatively
• Patient instructed in what to expect Patient instructed in what to expect and what his/her responsibility will be and what his/her responsibility will be
– HypothesisHypothesis - - Anatomy does correlate with Anatomy does correlate with function! function!
– Distal radius. Foundation of two joints. Distal radius. Foundation of two joints. Radiocarpal- radial alignment.Radiocarpal- radial alignment.
Important for normal carpal kinematics. Important for normal carpal kinematics.
– Critical capsular ligaments originate from radius Critical capsular ligaments originate from radius – Intercarpal ligament injuries shown to be Intercarpal ligament injuries shown to be
commonplace commonplace – Axial scaphoid shift sign - scaphoid more distal Axial scaphoid shift sign - scaphoid more distal
than lunate with traction suggests S-L ligament than lunate with traction suggests S-L ligament injury. injury.
– Carpal instability post-fracture more Carpal instability post-fracture more commonplace than previously thought commonplace than previously thought
2.Internal Fixation and Early 2.Internal Fixation and Early MotionMotion
ANATOMIC ISSUESANATOMIC ISSUES
Dorsal FixationDorsal Fixation• Great obstacle to stable internal fixation -Great obstacle to stable internal fixation -
soft tissue problems by application of large soft tissue problems by application of large metallic implants on the dorsummetallic implants on the dorsum
• Complications -pain, tendon irritation, and Complications -pain, tendon irritation, and tendon rupturetendon rupture
• Dorsal fixation devices can be applied free Dorsal fixation devices can be applied free from extensor tendon irritation only if they from extensor tendon irritation only if they lie within narrow space along the dorsal lie within narrow space along the dorsal ridge and between the wrist extensor and ridge and between the wrist extensor and the digital extensor tendonsthe digital extensor tendons
Volar FixationVolar Fixation
• Not associated with tendon problems as there Not associated with tendon problems as there is much more space on the volar aspect is much more space on the volar aspect
• The volar radius is concave in the sagittal The volar radius is concave in the sagittal plane and the flexor tendons lie well above plane and the flexor tendons lie well above the floor of the concavity; the pronator the floor of the concavity; the pronator quadratus fills this space quadratus fills this space
• Volar implants can be much larger than Volar implants can be much larger than dorsal and can therefore withstand the loads dorsal and can therefore withstand the loads imposed by functional use of the hand. imposed by functional use of the hand.
FIXATION ISSUESFIXATION ISSUES
• To provide stable internal fixation - To provide stable internal fixation - conventional screws were unable to gain conventional screws were unable to gain purchase in the distal fragment, except in purchase in the distal fragment, except in favorable circumstances.favorable circumstances.
• Fixation plates used in the pure buttress Fixation plates used in the pure buttress mode, when there was no cortical mode, when there was no cortical comminution of the opposite cortex.comminution of the opposite cortex.
• Introduction of fixed angle fixation solved Introduction of fixed angle fixation solved the distal fixation problem and had been the distal fixation problem and had been utilized in orthopedics for many decades; utilized in orthopedics for many decades; (Matthew D. Putnam, MD, and then further developed by (Matthew D. Putnam, MD, and then further developed by Jesse Jupiter, MD, and Robert J. Medoff, MD).Jesse Jupiter, MD, and Robert J. Medoff, MD).
Contd…Contd…
• A fixed angle device provides distal fixation A fixed angle device provides distal fixation by functioning as a nail plate; by functioning as a nail plate;
• It supports the distal fragment by It supports the distal fragment by interference effect created by rigid interference effect created by rigid extensions referred to as extensions referred to as tines, pegs, or tines, pegs, or locking screws.locking screws.– Fixed angle fixation works best if the pegs are Fixed angle fixation works best if the pegs are
placed immediately underneath the subchondral placed immediately underneath the subchondral bone, as this frequently is the only substantial bone, as this frequently is the only substantial bone left in the distal fragment of osteoporotic bone left in the distal fragment of osteoporotic patients. patients.
– Pegs must support primarily the dorsal aspect of Pegs must support primarily the dorsal aspect of the joint surface, as majority of these fractures the joint surface, as majority of these fractures are unstable in a dorsal directionare unstable in a dorsal direction
VOLAR APPROACH TO DORSAL VOLAR APPROACH TO DORSAL FRACTURESFRACTURES
• Introduction of volar fixed angle implants Introduction of volar fixed angle implants for dorsally unstable fractures challenged for dorsally unstable fractures challenged old surgical paradigms old surgical paradigms
• Benefits of volar fixed angle fixation- Benefits of volar fixed angle fixation- mainly less soft tissue disturbance and mainly less soft tissue disturbance and hence faster recovery, soon convinced hence faster recovery, soon convinced many and this has now become an many and this has now become an accepted treatment method. accepted treatment method.
AdvantagesAdvantages
• Minimizes dissection and surgical insult to the Minimizes dissection and surgical insult to the delicate extensor tendon sheaths. delicate extensor tendon sheaths.
• Alignment of the articular surface with the shaft Alignment of the articular surface with the shaft fragment is the goal of reduction and comminuted fragment is the goal of reduction and comminuted metaphyseal fragments can be ignored.metaphyseal fragments can be ignored.
• Periosteal attachments of the comminuted dorsal Periosteal attachments of the comminuted dorsal fragments are preserved, fracture healing is fragments are preserved, fracture healing is hastened. hastened.
• Volar scar is more cosmetic and better tolerated Volar scar is more cosmetic and better tolerated • Finally the volar exposure is extensile and allows the Finally the volar exposure is extensile and allows the
management of concomitant scaphoid fractures. management of concomitant scaphoid fractures.
ContdContd……
• Extended form of the flexor carpi Extended form of the flexor carpi radialis (FCR) approach to manage radialis (FCR) approach to manage the more complex articular fracturesthe more complex articular fractures
• Volar access to the dorsal aspect of Volar access to the dorsal aspect of the fracture gainedthe fracture gained
• Addresses each specific articular Addresses each specific articular fragment which extends the reach of fragment which extends the reach of volar fixed angle fixationvolar fixed angle fixation
Figure 1. A 48-year-old woman’s fall from a ladder resulted in a dorsally displaced intra-articular fracture of Figure 1. A 48-year-old woman’s fall from a ladder resulted in a dorsally displaced intra-articular fracture of the distal radius. She was treated with a volar fixed angle plate applied through the extended FCR volar the distal radius. She was treated with a volar fixed angle plate applied through the extended FCR volar approach. approach.
DESIGN OF VOLAR FIXED ANGLE PLATESDESIGN OF VOLAR FIXED ANGLE PLATES
• Volar fixed angle implants should be available in different Volar fixed angle implants should be available in different lengths and sizes to best fit each clinical situation. lengths and sizes to best fit each clinical situation.
• The design is optimized by the accurate positioning of the The design is optimized by the accurate positioning of the pegs in space. pegs in space.
• Pegs should fan out and cover as much area of subchondral Pegs should fan out and cover as much area of subchondral bone as possible to provide broad support in case of bone as possible to provide broad support in case of articular comminution.articular comminution.
• The volar plate should have a volar buttress extension The volar plate should have a volar buttress extension distal to the origin of the pegs for stabilization of volar distal to the origin of the pegs for stabilization of volar marginal fragments; this is especially important for the marginal fragments; this is especially important for the stabilization of the comminuted lunate fossa. stabilization of the comminuted lunate fossa.
• The volar marginal fragment from the lunate fossa is a rare The volar marginal fragment from the lunate fossa is a rare but very serious problem that requires careful attention. but very serious problem that requires careful attention.
ContdContd....
- It should come in - It should come in different sizesdifferent sizes
-It should be strong -It should be strong enough to tolerate the enough to tolerate the forces of rehabilitationforces of rehabilitation
-Should be designed -Should be designed with a large margin of with a large margin of safety to prevent fatigue safety to prevent fatigue failure failure
-The pegs, the plate, and -The pegs, the plate, and proximal fixation should be proximal fixation should be equal in strength equal in strength
-Proximal fixation is into -Proximal fixation is into strong cortical bone, strong cortical bone, therefore standard screw therefore standard screw fixation is adequatefixation is adequate
Dorsal locking nail plateDorsal locking nail plate• In patients with multiple In patients with multiple
medical problems and poor medical problems and poor anesthetic candidates-anesthetic candidates-minimally invasive method is minimally invasive method is often desirable.often desirable.
• A fixed angle implant -rapidly A fixed angle implant -rapidly applied with minimal dissection applied with minimal dissection and under local anesthesia has and under local anesthesia has been developed been developed
• Unique unicortical screws and Unique unicortical screws and a distal portion consisting of a a distal portion consisting of a very narrow fixed angle plate.very narrow fixed angle plate.
Contd…Contd…• Inserted through the fracture & dorsal approach is Inserted through the fracture & dorsal approach is
particularly suited as the dorsal ridge of the radius is particularly suited as the dorsal ridge of the radius is immediately subcutaneous immediately subcutaneous
• Consists of a proximal intramedullary portion that is Consists of a proximal intramedullary portion that is locked using site; the plate portion avoids tendon irritation locked using site; the plate portion avoids tendon irritation
• Allows early functional use of the hand and extends the Allows early functional use of the hand and extends the benefits of fixed angle fixation to the debilitated patients. benefits of fixed angle fixation to the debilitated patients.
(Jorge L. Orbay, MD, is a specialist in hand and microsurgery, and is (Jorge L. Orbay, MD, is a specialist in hand and microsurgery, and is the founder and director of Florida’s Miami Hand Centerthe founder and director of Florida’s Miami Hand Center.).)
Bioabsorbable PlatesBioabsorbable Plates
• Strong enough to fix the Strong enough to fix the fracture to allow fracture to allow immediate mobilizationimmediate mobilization
• Broken down by the body Broken down by the body after about three months after about three months and so hopefully will help and so hopefully will help to avoid the problems with to avoid the problems with the tendons. the tendons.
• These plates are combined These plates are combined with bone substitutes. with bone substitutes.
• Early results are Early results are encouraging but have not encouraging but have not been in use for long been in use for long enough to show that they enough to show that they are better in a scientific are better in a scientific sense than other methods sense than other methods
Hybrid fixation by limited incision Hybrid fixation by limited incision approachapproach
• By use of k wires,low profile plates for fixing different By use of k wires,low profile plates for fixing different fragments,percutaneous screw fixation of ulnar fragments,percutaneous screw fixation of ulnar styloid fracture.styloid fracture.
Contd…Contd…
Fracture Classifications Relative to Fracture Classifications Relative to
Operative IndicationsOperative Indications • Bending fractures (AO Type A) - When Bending fractures (AO Type A) - When
associated with neurologic deficit or seen associated with neurologic deficit or seen late. late.
• Shearing fractures (AO Type B) - definite Shearing fractures (AO Type B) - definite indication indication
• Compression fractures (AO Type C) - 4 part Compression fractures (AO Type C) - 4 part fracture with displaced volar lunate facet. fracture with displaced volar lunate facet.
• Radiocarpal fracture-dislocation - frequent. Radiocarpal fracture-dislocation - frequent.
• Comminuted complex fracture - commonComminuted complex fracture - common
Algorithm Algorithm
Shearing Fracture (AO Shearing Fracture (AO Type B)Type B)
• VolarVolar (AO Group B3). Vast majority (AO Group B3). Vast majority will be split into two or more fragments will be split into two or more fragments (Jupiter et al, (Jupiter et al, Journal of Bone and Joint Journal of Bone and Joint SurgSurg, 78A: 1996.) , 78A: 1996.)
– Operative Approaches - Simple Operative Approaches - Simple – Operative Tactics - buttress plate Operative Tactics - buttress plate – Post-operative Management Post-operative Management -Splint for two weeks, then active assisted -Splint for two weeks, then active assisted
range of motion range of motion – Results favorable: 31 excellent 10 good, 8 fair Results favorable: 31 excellent 10 good, 8 fair
(Jupiter et al., (Jupiter et al., JBJSJBJS, 78A: 1996.) , 78A: 1996.)
Dorsal (AO Group B2) Dorsal (AO Group B2)
– Uncommon Uncommon – More often More often
combination with combination with styloid styloid
Operative Operative approach approach
Operative Operative tactics: Plate tactics: Plate fixation; p fixation; p plate very plate very effective. effective.
Volar neutralization plate Volar neutralization plate fixation for dorsally fixation for dorsally displaced fracturesdisplaced fractures
Radial Styloid (AO Group Radial Styloid (AO Group B1) B1) (Chauffeur's fracture) (Chauffeur's fracture)
– Association with Association with scapholunate scapholunate ligament injury ligament injury
– Styloid often in 2 Styloid often in 2 or more or more fragments fragments
Fixation with Fixation with cannulated cannulated screws screws
Post-Post-operative operative managment managment dependent dependent upon upon ligaments ligaments
Compression FracturesCompression Fractures
• 4-part frature may need volar exposure 4-part frature may need volar exposure (Melone Type IV) (Melone Type IV)
• Many 3-part fractures can be treated with Many 3-part fractures can be treated with percutaneous pins and external fixation. percutaneous pins and external fixation.
• Operative tactics Operative tactics • Reduce and percutaneously fix volar Reduce and percutaneously fix volar
lunate facet with plate or K-wire lunate facet with plate or K-wire • Volar ulnar approach and reduce and fix Volar ulnar approach and reduce and fix
volar lunate facet with plate or K-wire volar lunate facet with plate or K-wire • Manipulate and fix dorsal lunate facet Manipulate and fix dorsal lunate facet
with K-wire. with K-wire. • External fixation is usually necessary. External fixation is usually necessary.
Radiocarpal Fracture-Radiocarpal Fracture-DislocationDislocation
Open high energy trauma Open high energy trauma May have intracarpal May have intracarpal
ligament injury ligament injury Ulnar styloid fracture often Ulnar styloid fracture often
needs fixation needs fixation
Complex Combined Complex Combined FracturesFractures
• Ipsilateral skeletal and ligament Ipsilateral skeletal and ligament injury injury
• Associated complex carpal trauma Associated complex carpal trauma
• Proximal skeletal and articular injury Proximal skeletal and articular injury
• Fractures with bone loss Fractures with bone loss
• Fractures with neurovascular injury Fractures with neurovascular injury
• Compartment syndrome Compartment syndrome
Contd…Contd…
Failure of Prior TreatmentFailure of Prior Treatment
-Malunion -Malunion Operative treatment may Operative treatment may
limit overall disability limit overall disability Applicable, even in an Applicable, even in an
elderly patient elderly patient
3.The Role of Arthroscopic-3.The Role of Arthroscopic-Assisted FixationAssisted Fixation
Advantages Advantages • Ideal view of joint surface with minimal surgical trauma Ideal view of joint surface with minimal surgical trauma • Joint surface viewed under magnification and ample Joint surface viewed under magnification and ample
light light • Osteochondral flaps, loose bodies may be excised Osteochondral flaps, loose bodies may be excised • Associated soft tissue injuries detected and managed Associated soft tissue injuries detected and managed • Evaluate ulnar styloid fragment Evaluate ulnar styloid fragment
Disadvantages Disadvantages • Technical procedure Technical procedure • Expertise neededExpertise needed• Special equipment helpful Special equipment helpful
Surgical TechniqueSurgical Technique
• Arthroscope --- 3-4 portal Arthroscope --- 3-4 portal • Working portal --- 4-5 portal or 6-R Working portal --- 4-5 portal or 6-R
portal portal • Inflow --- 6-R portal Inflow --- 6-R portal • Usually easier to triangulate from 4-5 Usually easier to triangulate from 4-5
portal if fibrin clot/debris obscures vision portal if fibrin clot/debris obscures vision – Easier to elevate fragment with instruments Easier to elevate fragment with instruments
from 4-5 portal from 4-5 portal – Compressive elastic wrap around forearm - Compressive elastic wrap around forearm -
retard fluid extravasation retard fluid extravasation
Contd…Contd…
InstrumentationInstrumentation
• Small joint arthroscope (2.7 mm) Small joint arthroscope (2.7 mm) • Traction tower Traction tower • Motorized shaver Motorized shaver • Fluoroscopy unit Fluoroscopy unit • Traction tower allows manipulation of Traction tower allows manipulation of
wrist to help reduce fragments while wrist to help reduce fragments while maintaining traction maintaining traction
Arthroscopic fixationArthroscopic fixation LandmarksLandmarks• Wrist are very swollen, unable to palpate usual soft Wrist are very swollen, unable to palpate usual soft
tissue landmarks tissue landmarks • Know bony landmarks; metacarpal bases, dorsal lip of Know bony landmarks; metacarpal bases, dorsal lip of
radius, ulnar head usually palpable radius, ulnar head usually palpable • Radial side of long finger, mid axis of ring finger used Radial side of long finger, mid axis of ring finger used
to determine radioulnar location of 3-4 and 4-5 portals to determine radioulnar location of 3-4 and 4-5 portals
Timing of ReductionTiming of Reduction• Between 3 to 7 days Between 3 to 7 days • Earlier attempts may have troublesome bleeding, Earlier attempts may have troublesome bleeding,
obscure vision, fluid extravasation? obscure vision, fluid extravasation? • Later attempts harder to disengage and mobilize Later attempts harder to disengage and mobilize
fragments fragments
INDICATIONSINDICATIONS
• Displaced intraarticular fracture Displaced intraarticular fracture with articular cartilage step-off with articular cartilage step-off of 2 mm or more after closed of 2 mm or more after closed manipulation manipulation
• Intraarticular or extraarticular Intraarticular or extraarticular fracture with suspected carpal fracture with suspected carpal ligamentous injury or distal ligamentous injury or distal radioulnar instability radioulnar instability
CONTRAINDICATIONSCONTRAINDICATIONS
• Compartment syndrome Compartment syndrome
• Open joint with massive soft Open joint with massive soft tissue injury tissue injury
1.RADIAL STYLOID FRACTURES1.RADIAL STYLOID FRACTURES
• Can almost always be reduced anatomically Can almost always be reduced anatomically • In complex fracture patterns provides In complex fracture patterns provides
anatomic landmark to reduce remaining anatomic landmark to reduce remaining fragments fragments
• Radial styloid fragment may be manipulated Radial styloid fragment may be manipulated and pinned under fluoroscopy and reduction and pinned under fluoroscopy and reduction "fined tuned" as viewed arthroscopically "fined tuned" as viewed arthroscopically
• Alternatively, 2 Kirschner wires may be placed Alternatively, 2 Kirschner wires may be placed and used and joysticks to manipulate and and used and joysticks to manipulate and reduce the fragment as seen arthroscopically reduce the fragment as seen arthroscopically
KIRSCHNER WIRE PLACEMENTKIRSCHNER WIRE PLACEMENT
• Stay dorsal in snuffbox so as not Stay dorsal in snuffbox so as not to injure radial artery to injure radial artery
• Protect cutaneous nerves Protect cutaneous nerves
• Place 0.045 Kirschner wires Place 0.045 Kirschner wires through 14-gauge needle through 14-gauge needle
• TIP: Place needle cap over TIP: Place needle cap over exposed wiresexposed wires
2.THREE PART FRACTURES2.THREE PART FRACTURES
• Reduce radial styloid as before Reduce radial styloid as before • Medial fragment can be manipulated up with joysticks Medial fragment can be manipulated up with joysticks • Place needle intraarticularly over displaced fragment Place needle intraarticularly over displaced fragment
to be elevated to be elevated • Helps determine location of the fragment to be Helps determine location of the fragment to be
reduced reduced • Drop down 1-2 cm proximally in line with needle and Drop down 1-2 cm proximally in line with needle and
place Steinmann joystick into fragment to elevate it place Steinmann joystick into fragment to elevate it • Pin transversely just beneath subchondral bone, Pin transversely just beneath subchondral bone,
aiming dorsal ulnar to catch aiming dorsal ulnar to catch "die-"die- punch"punch" fragment fragment • TIP: Pronate/supinate wrist to make sure transverse TIP: Pronate/supinate wrist to make sure transverse
pins do not violate radioulnarpins do not violate radioulnar
3.FOUR PART FRACTURES3.FOUR PART FRACTURES
• Reduce redial styloid fragment as before Reduce redial styloid fragment as before • Limited open reduction, approach volar Limited open reduction, approach volar
medial fragment between ulnar medial fragment between ulnar neurovascular bundle and flexor neurovascular bundle and flexor tendons and buttress plate tendons and buttress plate
• Volar fragment now used as fulcrum to Volar fragment now used as fulcrum to arthroscopically reduce remaining arthroscopically reduce remaining dorsal fragments like a "die punch" dorsal fragments like a "die punch" fracturefracture
4.VOLAR AND DORSAL BARTON'S FRACTURE4.VOLAR AND DORSAL BARTON'S FRACTURE
• Plate as classically described Plate as classically described • Percutaneous pinning does not provide sufficient Percutaneous pinning does not provide sufficient
stability stability • Do not sacrifice stability for an arthroscopic Do not sacrifice stability for an arthroscopic
procedure procedure • Arthroscopically evaluate joint through standard Arthroscopically evaluate joint through standard
portals after plating portals after plating • Alternatively place scope ulnar to long Alternatively place scope ulnar to long
radiolunate ligament after plating of volar radiolunate ligament after plating of volar Barton's fracture as described by Levy and Glickel Barton's fracture as described by Levy and Glickel
5.ULNAR STYLOID FRAGMENT5.ULNAR STYLOID FRAGMENT
• Arthroscopic evaluation provides Arthroscopic evaluation provides rationale for management rationale for management
• Palpate the TFCC, should be taut Palpate the TFCC, should be taut • Taut TFCC, majority of TFCC fibers Taut TFCC, majority of TFCC fibers
still attached to proximal ulna still attached to proximal ulna • Lax TFCC, look for peripheral TFCC Lax TFCC, look for peripheral TFCC
tear, repair if present, consider ORIF tear, repair if present, consider ORIF ulnar styloid fragment if peripheral ulnar styloid fragment if peripheral tear is not present tear is not present
EXTERNAL FIXATIONEXTERNAL FIXATION
• Consider when metaphyseal comminution is Consider when metaphyseal comminution is present present
• May be placed before or after arthroscopic May be placed before or after arthroscopic reduction reduction
• Bone graft added through small incision Bone graft added through small incision between fourth and fifth dorsal between fourth and fifth dorsal compartments compartments
• TIP: TIP: Medial fragmentsMedial fragments may be further may be further stabilized with treaded half pin through free stabilized with treaded half pin through free clamp and attached to frameclamp and attached to frame
4.THE ROLES OF THE DRUJ AND 4.THE ROLES OF THE DRUJ AND REHABILITATION IN OUTCOMEREHABILITATION IN OUTCOME
• The DRUJ/Ulnar Head The DRUJ/Ulnar Head – Point of attachment TFCC Point of attachment TFCC – Direct longitudinal load transmission Direct longitudinal load transmission – Resist transverse compressive forces Resist transverse compressive forces – Requires relaxation of PQ to supinate Requires relaxation of PQ to supinate
• Points of Attachment and Function Points of Attachment and Function TFCC TFCC
Displacement of dorsal band increases Displacement of dorsal band increases with pronation with pronation
Displacement of dorsal palmar band Displacement of dorsal palmar band increases with supination (Acosta)increases with supination (Acosta)
Contd…Contd…
• Importance of the DRUJ and Importance of the DRUJ and rehabilitation related to distal radius rehabilitation related to distal radius fracture management deserves fracture management deserves greater empahsis.greater empahsis.
• Stabilize the DRUJ for all cases.Stabilize the DRUJ for all cases.
• Develop patient/fracture specific Develop patient/fracture specific rehabilitation plansrehabilitation plans
5.Augmentation of Fracture Fixation: Bone Graft and Alternatives
BONE GRAFTINGBONE GRAFTING • Clinical series show improved outcomes with Clinical series show improved outcomes with
earlier motionearlier motion
• Biomechanical work demonstrates sufficient Biomechanical work demonstrates sufficient stability to allow early motion after partial healingstability to allow early motion after partial healing
• Clinical experience; high energy injuries - trend Clinical experience; high energy injuries - trend towards bone graft (50 - 85%) towards bone graft (50 - 85%)
• Results demonstrate 80% and higher restoration Results demonstrate 80% and higher restoration grip and motion in these high energy injuriesgrip and motion in these high energy injuries
Indications Indications
• Articular incongruency Articular incongruency
• High energy injuries, dorsal or High energy injuries, dorsal or metaphyseal commination metaphyseal commination
• Late collapse, unstable extra-Late collapse, unstable extra-articular fracturearticular fracture
Bone graftBone graft - - The "Gold The "Gold Standard"Standard"
• Autogenous GraftAutogenous Graft – AdvantagesAdvantages
• Highest biological activity Highest biological activity • Rapid integration Rapid integration • Can be vascularized Can be vascularized
– Disadvantages Disadvantages • Limited quantity Limited quantity • Donor site morbidity (6 - 30%) Donor site morbidity (6 - 30%) • Increased operative time/blood loss Increased operative time/blood loss • Increased cost/overnight stay Increased cost/overnight stay
Contd…Contd…
AllograftAllograft• Advantages Advantages
– Unlimited supply Unlimited supply – Strong, osteoinductive Strong, osteoinductive
• Disadvantages Disadvantages – Finite risk of disease transmission Finite risk of disease transmission – Immunogenicity highly variable Immunogenicity highly variable
• Fresh-frozen: osteoprogenitor cells killed Fresh-frozen: osteoprogenitor cells killed
• Freeze-dried: lacks structural support Freeze-dried: lacks structural support
Bone Graft "Substitutes”Bone Graft "Substitutes”
• Prerequisite for bone graft substitute Prerequisite for bone graft substitute – Osteoconduction Osteoconduction – Osteoinduction Osteoinduction – Osteogenic cells Osteogenic cells – Structural support Structural support
• Bone graft alternatives Bone graft alternatives – Structural bone substitutes Structural bone substitutes – Osteogenic agents Osteogenic agents – Cancellous bone substitutes Cancellous bone substitutes
Contd…Contd…
Structural bone substitutes Structural bone substitutes (cements(cements) )
-PMMA -PMMA – high rates of thermal necrosis; infection; brittlehigh rates of thermal necrosis; infection; brittle
- Norian SRS - Norian SRS – Injectable ceramic, hardens to 50% strength in one hour Injectable ceramic, hardens to 50% strength in one hour – Multicenter trial results encouraging for extraarticular Multicenter trial results encouraging for extraarticular
fracturesfractures
- Bone Source - Bone Source – can be mixed with blood or marrowcan be mixed with blood or marrow
-TrueBond -TrueBond – Peri-odontal applications; modular biodegradability Peri-odontal applications; modular biodegradability
Contd…Contd…
Osteogenic agents Osteogenic agents • Demineralized bone matrix (Grafton, Dynagraft) Demineralized bone matrix (Grafton, Dynagraft)
– available in gel, strips, powder available in gel, strips, powder – variable osteoinductivity variable osteoinductivity – no structural integrity no structural integrity – may be mixed with marrow may be mixed with marrow
• Bone Morphogenetic Proteins Bone Morphogenetic Proteins – rhBMP-2; Encouraging in vivo results - canine rhBMP-2; Encouraging in vivo results - canine – Osteogenic Protein 1 (OP-1, BMP-7) Osteogenic Protein 1 (OP-1, BMP-7)
• Potent bone induction agent Potent bone induction agent • Laboratory and human defect/nonunion trials promising Laboratory and human defect/nonunion trials promising
– Others Others • Ne-osteon Ne-osteon • Platelet concentrate Platelet concentrate
Cancellous bone substitutesCancellous bone substitutes
• Collagraft (Collagen-HA-TCP composite) Collagraft (Collagen-HA-TCP composite) – mixed with marrow to add osteoinductivity, Osteogenic cells mixed with marrow to add osteoinductivity, Osteogenic cells
• Calcium Phosphate Ceramics Calcium Phosphate Ceramics – TCP; variable biodegradation TCP; variable biodegradation – Synthetic HA; high affinity for bone in growth; non-resorbable Synthetic HA; high affinity for bone in growth; non-resorbable
• Coralline Hydroxyapatite Coralline Hydroxyapatite – Hydrothermal exchange reaction Hydrothermal exchange reaction – Porosity identical to cancellous bone; high affinity for growth Porosity identical to cancellous bone; high affinity for growth
factorsfactors– Brittle, anisotropic Brittle, anisotropic
• Calcium Sulfate (Plaster of paris) Calcium Sulfate (Plaster of paris) – Unpredictable biodegradationUnpredictable biodegradation– Void filler Void filler
Bone grafts and alternativesBone grafts and alternatives
• Customized treatment for high energy Customized treatment for high energy
distal radius fractures distal radius fractures • Bone graft accelerates healing time, Bone graft accelerates healing time,
reduces dependency on ligamentotaxis reduces dependency on ligamentotaxis • Bone graft alternatives backed by clinical Bone graft alternatives backed by clinical
and basic laboratory studies and basic laboratory studies • Rapid osseointegration; cost-effective Rapid osseointegration; cost-effective • Promising future for bone graft Promising future for bone graft
alternatives, bone regeneration alternatives, bone regeneration
PrognosisPrognosis
• Position of the fracture at union than Position of the fracture at union than the position at time of presentation the position at time of presentation has the greatest correlation with has the greatest correlation with long-term functional resultslong-term functional results
• Malunion associated with -poor Malunion associated with -poor function, pain, decreased range of function, pain, decreased range of motion, decreased grip strength, and motion, decreased grip strength, and poor patient function/satisfaction poor patient function/satisfaction leads to poor anatomic results after leads to poor anatomic results after fracture (McQueen M, Caspers J: fracture (McQueen M, Caspers J: Colles' fracture: J Bone Joint Surg Colles' fracture: J Bone Joint Surg 1988;70B:649-651.)1988;70B:649-651.)
SUMMARYSUMMARY
• Fractures of distal radius are Fractures of distal radius are not not simple injuriessimple injuries• The concept of The concept of fragment specific fixationfragment specific fixation
emphasizes the need to fix individual fragmentemphasizes the need to fix individual fragment• Dorsal Dorsal bone graftingbone grafting is an important adjunct in is an important adjunct in
c/o of dorsal comminutionc/o of dorsal comminution• External fixator should be used as a External fixator should be used as a
neutralizationneutralization device device• Every patient is Every patient is uniqueunique,treatment plan should ,treatment plan should
be based on individual needs and expectations.be based on individual needs and expectations.
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