Title: Distal Radius Fractures
1Distal Radius Fractures
- John T. Capo, MD
- Original Author Thomas F. Varecka, MD March
2004 - New Author John T. Capo, MD Revised January
2006
2The Problem of Distal Radius Fractures
- Common injury gt450,000/yr. in USA
- High potential for functional impairment and
frequent complications
3Introduction
- Distal radius fractures occur through the distal
metaphysis of the radius - May involve articular surface
- frequently involving the ulnar styloid
- Most often result from a fall on the outstretched
hand. - forced extension of the carpus,
- impact loading of the distal radius.
- Associated injuries may accompany distal radius
fractures.
4Introduction
- Classified by
- presence or absence of intra-articular
involvement, - degree of comminution,
- dorsal vs. volar displacement,
- involvement of the distal radioulnar joint.
5Diagnosis History and Physical Findings
- History of a fall on the outstretched hand or an
episode of trauma - A visible deformity of the wrist is usually
noted, with the hand most commonly displaced in
the dorsal direction. - Movement of the hand and wrist are painful.
- Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out.
6Diagnosis Diagnostic Tests and Examination
- General physical exam of the patient, including
an evaluation of the injured joint, and a joint
above and below - Radiographs of the injured wrist
- Radiographs of other areas, if symptoms warrant.
- CT scan of the distal radius in selected
instances.
7Treatment Goals
- Preserve hand and wrist function
- Realign normal osseous anatomy
- promote bony healing
- Avoid complications
- Allow early finger and elbow ROM
8Osseous Anatomy
- Distal radius 80 of axial load
- Scaphoid fossa
- Lunate fossa
- Sigmoid notch DRUJ
- Distal ulna
9Anatomy
- scaphoid and lunate fossa
- Ridge normally exists between these two
- sigmoid notch second important articular
surface - triangular fibrocartilage complex(TFCC) distal
edge of radius to base of ulnar styloid
10Radiology
- Radial inclination 22
- Radial length 12mm
- ulnar neutral
- Palmar tilt 11-14
- Scapho-lunate angle 47 /- 15
11Measurement of Radial Length and Inclination
Inclination 23 degrees
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13Scapholunate angle measured between lines 2 and
3 (normal 47 15 degrees)
1 Line connecting dorsal and volar tip of lunate
2 Line perpendicular to lunate
3 Line along axis of scaphoid
14Computed TomographyIndications
- Intra-articular fxs with multiple fragments
- centrally impacted fragments
- DRUJ incongruity
- 19 consecutive fx, CT had better sensitivity for
intraarticular frag - management change in 5 pts
Cole et al J Hand Surg, 1997
15Classification of Distal Radius Fractures
- Ideal system should describe
- Type of injury
- Severity
- Evaluation
- Treatment
- Prognosis
16Common Classifications
- Gartland/Werley
- Frykman
- Weber (AO/ASIF)
- Melone
- Column theory
- Fernandez (mechanism)
17Frykman Classification
Extra-articular
Radio-carpal joint
Same pattern as odd numbers, except ulnar styloid
also fractured
Radio-ulnar joint
Both joints
18AO/ OTA Classification
Group A Extra-articular
Group B Partial Intra-articular
Group C Complete Intra-articular
19Column Theory
3 Columns radial, intermediate, medial
Rikli Regazzoni, 1996
20Classification Fernandez (1997)
- I. Bending-metaphysis fails under tensile stress
(Colles, Smith) - II. Shearing-fractures of joint surface (Barton,
radial styloid)
21Classification Fernandez (1997)
- III. Compression-intraarticular fracture with
impaction of subchondral and metaphyseal bone
(die-punch) - IV. Avulsion-fractures of ligament attachments
(ulna, radial styloid) - V. Combined/complex - high velocity injuries
22Assessment of X-rays
- Assess involvement of dorsal or volar rim
- Is comminution mainly volar or dorsal?
- is one of four cortices intact?
- Look for die-punch lesions of the scaphoid or
lunate fossa. - Assess amount of shortening
- Look for DRUJ involvement
23Dorsal angulation and comminution
24Volar subluxation of carpus with fracture fragment
25Options for Treatment
- Casting
- Long arm vs short arm
- Sugar-tong splint
- External Fixation
- Joint-spanning
- Non bridging
- Percutaneous pinning
- Internal Fixation
- Dorsal plating
- Volar plating
- Combined dorsal/volar plating
- focal (fracture specific) plating
26Indications for Closed Treatment
- Low-energy fracture
- Low-demand patient
- Medical co-morbidities
- Minimal displacement- acceptable alignment
- Match treatment to demands of the patient
27Closed Treatment of Distal Radial Fractures
- Depends on obtaining and then maintaining an
acceptable reduction. - Immobilization
- long arm (cast or sugar-tong for high demand)
- short arm adequate for elderly patients
- Frequent follow-up necessary in order to diagnose
redisplacement.
28Technique of Closed Reduction
- Anesthesia
- Hematoma block
- Intravenous sedation
- Bier block
- Traction finger traps and weights
- Reduction Maneuver (dorsally angulated fracture)
- hyperextension of the distal fragment,
- Maintain weighted traction and reduce the distal
to the proximal fragment with pressure applied to
the distal radius. - Apply well-molded sugar-tong splint or cast,
with wrist in neutral to slight flexion. - Avoid Extreme Positions!
29Acceptable Reduction Criteria
- No dorsal angulation
- gt 15 degrees of inclination
- Articular step-off lt 2mm
- lt 5 mm shortening compared to opposite wrist.
- DRUJ congruent
30After-treatment
- Watch for median nerve symptoms
- parasthesias common but should diminish over few
hours - If persist release pressure on cast, take wrist
out of flexion - Acute carpal tunnel symptoms progress CTR
required - Follow-up x-rays needed in 1-2 weeks to evaluate
reduction. - Change to short-arm cast after 2-3 weeks,
continue until fracture healing.
31Management of Redisplacement
- Repeat reduction and casting high rate of
failure - Repeat reduction and percutaneous pinning
- External Fixation
- ORIF
32Treatment Choice
- Depends on assessment of fracture stability
- Indicators of instability are
- Shortening
- Comminution
- Reversal of normal volar angulation
- Articular involvement
33Indications for Surgical Treatment
- High-energy injury
- Open injury
- Secondary loss of reduction
- Articular comminution, step-off, or gap
- Metaphyseal comminution or bone loss
- Loss of volar buttress with displacement
- DRUJ incongruity
34Evidence of High-Energy Injuries
- Irreducible fracture
- Unable to maintain reduction
- Significant initial displacement
- Comminution extending from dorsal to volar
- Significant Soft tissue disruption
35Operative Management of Distal Radius Fractures
36External fixation The treatment of choice for
distal radius fractures in the 1980s
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39Literature Articles Discussing External Fixation
1999
1974
1980
1986
40 External Fixation Where Do We Stand Now??
41Types of External Fixation
- Spanning
- Dynamic
- Clyburne
- Agee
- Pennig
- Static
- AO
- Ace
- Non-spanning
- Hoffman 2
- Cobra
- Zimmer
- AO
42Spanning
- A spanning fixator is one which fixes distal
radius fractures by spanning the carpus I.e.,
fixation into radius and metacarpals
43Non-spanning
- A non-spanning fixator is one which fixes distal
radius fracture by securing pins in the radius
alone, proximal to and distal to the fracture
site.
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46Courtesy of Hill Hastings,MD
47Factors Affecting Functional Outcome
Author Length Radial
Tilt Volar Tilt Gap Step-off ARO
(1988) 0 0 0 VILLAR (!987)
0 0 0 WOLFE (1994)
0 0 0 JUPITER (1986)
0 0 0
BACORN (1953) 0
0 OLDER (1966)
0 0 TRUMBLE (1994) -- --
McQUEEN (1989, 1995) --
TALIESNIK (1984) 0
0 0
48Factors Affecting Functional Outcome
- McQueen (1996) carpal alignment after distal
radius fractures is the main influence on final
outcome - malalignment has significant negative effect on
function - failure to restore volar tilt predisposes to
carpal collapse and carpal malalignment
49Fixator Type vs. Restoration of Outcome Factors
Type Length Radial Tilt
Volar Tilt Gap Step-off SPANNING
---------
-------- NONSPANNING
50Reduction Tactics
- DePalma (1952) introduced traction / distraction
as means of reducing distal radius fractures - Spanning fixator relies on distraction as
principle method of reducing fracture fragments - Distraction (Ligamentotaxis) excellent for
restoring length
51Ligamentotaxis
- Bartosh, J Hand Surg 15A, 1990
- 19 cadaver hands with distal radius osteotomy
- Ligamentotaxis with 10 and 20 of traction _at_
100, 200 and 300 of flexion - volar tilt could not be re-established
52Ligamentous Anatomy
- Volar ligaments
- Straight
- Stout
- Tighten readily
- Dorsal ligaments
- Zig-zag
- Elastic
- Tighten slowly
53Dorsal ligaments more lax, zig-zag
54Ligamentotaxis
- Adverse effect of carpal over-distraction well
documented - Kaempffe (1993) pain, function, grip strength
adversely affected - Gupta (1999) 10 of distraction can induce over
10mm of ligament elongation - Davenport (1999) 10mm carpal distraction
produces gt20 increase in ligament strain
55Non-Spanning vs. Spanning Fixator
- McQueen, JBJS-B, 1998
- Prospectively studied 30 spanning vs 30
non-spanning fixator patients - Non-spanning better preserved volar tilt,
prevented carpal malalignment, gave better grip
strength and hand function (all with plt.001) - Complication rate 50 lower
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58Complications
- Complication rates high in almost all reported
series - Mal-union
- Pin track infection
- RSD / arthrofibrosis
- Finger stiffness
- Loss of reduction early vs late
- Tendon rupture
59Complications
- Complication rates high in almost all reported
series - Szabo ( 1986) 61
- Cooney (1979) 33
- van Dijk (1996) 41
- McQueen (1991) 50 (spanning)
- McQueen (1998) 28 (non-spanning)
- McQueen (1999) 15 (non-spanning)
60Percutaneous Pinning-Methods
- variety described
- most common radial styloid pinning dorsal-ulnar
corner of radius pinning - supplemental immobilization with cast, splint
- in conjunction with external fixation (Augmented
external fixation)
61Percutaneous Pins
62Percutaneous Pins
63Percutaneous Pinning
- 2 radial styloid pins - Mah and Atkinson, J Hand
Surg 1992 - excellent anatomic 82
- good-excellent functional results 100
- radial styloid with dorsal - prospective study,
30 pts (Clancey JBJS 1984) - excellent anatomic results in 90
64Percutaneous Pinning-Kapandji
- intrafocal pinning through fracture site
- buttress against displacement
- good results in literature
- -Greatting Bishop, OCNA 1993
65Internal Fixation of Distal Radius Fractures
-
- Useful for elevation of depressed articular
fragments and bone grafting of metaphyseal
defects - required if articular fragments can not be
adequately reduced with percutaneous methods - Dorsal and/or volar approaches both used.
66Selection of Approach
- Based on location of comminution.
- Dorsal approach for dorsally angulated fractures.
- Volar approach for volar rim fractures
- Radial styloid approach for buttressing of
styloid - Combined approaches needed for high-energy
fractures with significant axial impaction.
67 WHICH APPROACH? DORSAL
3rd DC EPL (extensile)
1-2nd DC
-
68VOLAR
Classical Henry approach
Extended carpal tunnel approach
69Distal Radius-volar barton
- 64 yo M, MVA, contralateral tibial shaft Fx
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73Volar Henry Approach
74Radial to FCR
75Elevate Pronator Quadratus
76Dorsal Fracture
77CT Scan
78Dorsal Plating, PCP and Ex Fix
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81Volar Plating for Dorsal Fractures
-less tendon irritation than dorsal - Indirect
reduction -better tolerated than Ex
fix
82Fixed angle locked screws
83Courtesy J. Orbay, MD
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85Courtesy J. Orbay, MD
86Three Column Theory
- Radial Column
- Lateral side of radius
- Intermediate Column
- Ulnar side of
- radius
- Ulnar Column
- distal ulna
87Fragment Specific System
88Radial and Ulnar Columns
-Pin plates -90-90 plating technique
89 Focal Plating Radial Styloid Fragment Dorsal
ulnar fragment
70 90 degrees apart
90Dorsal Fracture
Radial Styloid and dorsal-ulnar corner
91Dorsal Case focal plating
92Radial shortening, comminution
Dorsal angulation
Indication for Volar and Dorsal Plating
93Volar approach, application buttress plate
94Dorsal approach, application of 2 L buttress
plates
95EPL Tendon
96Extensor retinaculum repaired beneath EPL to
prevent erosion against plate- EPL left transposed
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98Advanced TechniquesArthroscopic-Assisted
- reduce articular incongruities
- also diagnose associated soft tissue lesions
- minimally invasive
99Arthroscopic-Assisted
Culp and Osterman, OCNA 26(4) 1995
100Malunion of Distal Radius Fractures
- Changes load-bearing patterns on the distal
radius and load sharing between the radius and
ulna. - Can lead to arthrosis.
101X-ray 4 months later shows malunion
Injury X-Ray
102Lateral X-Ray of another patient 6 months after
injury demonstrating dorsal angulation of the
distal radius
103Normal loading patterns
104Malunion loading patterns
105Altered Load through Ulna with Radial Shortening
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108Conclusions
- Need to be able to use all tools for treatment of
distal radius fractures - Both external fixation and ORIF are useful.
- ORIF better in high-energy fractures associated
with depression of articular surface - ORIF gives better anatomic restoration, although
not necessarily higher patient satisfaction.
109Conclusions
- External fixators still have a role in the
treatment of distal radius fractures - Spanning ex fix does not completely correct
fracture deformity by itself - Should usually combined with percutaneous pins
(augmented fixation)
110Conclusions
- new plating techniques allow for accurate and
rigid fixation of fragments - Plating allows early wrist ROM
- Volar, smaller and more anatomic plates are
better tolerated - combination treatment is often needed
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