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Title: Distal Radius Fractures


1
Distal Radius Fractures
  • John T. Capo, MD
  • Original Author Thomas F. Varecka, MD March
    2004
  • New Author John T. Capo, MD Revised January
    2006

2
The Problem of Distal Radius Fractures
  • Common injury gt450,000/yr. in USA
  • High potential for functional impairment and
    frequent complications

3
Introduction
  • 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.

4
Introduction
  • Classified by
  • presence or absence of intra-articular
    involvement,
  • degree of comminution,
  • dorsal vs. volar displacement,
  • involvement of the distal radioulnar joint.

5
Diagnosis 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.

6
Diagnosis 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.

7
Treatment Goals
  • Preserve hand and wrist function
  • Realign normal osseous anatomy
  • promote bony healing
  • Avoid complications
  • Allow early finger and elbow ROM

8
Osseous Anatomy
  • Distal radius 80 of axial load
  • Scaphoid fossa
  • Lunate fossa
  • Sigmoid notch DRUJ
  • Distal ulna

9
Anatomy
  • 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

10
Radiology
  • Radial inclination 22
  • Radial length 12mm
  • ulnar neutral
  • Palmar tilt 11-14
  • Scapho-lunate angle 47 /- 15

11
Measurement of Radial Length and Inclination
Inclination 23 degrees
12
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13
Scapholunate 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
14
Computed 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
15
Classification of Distal Radius Fractures
  • Ideal system should describe
  • Type of injury
  • Severity
  • Evaluation
  • Treatment
  • Prognosis

16
Common Classifications
  • Gartland/Werley
  • Frykman
  • Weber (AO/ASIF)
  • Melone
  • Column theory
  • Fernandez (mechanism)

17
Frykman Classification
Extra-articular
Radio-carpal joint

Same pattern as odd numbers, except ulnar styloid
also fractured
Radio-ulnar joint
Both joints
18
AO/ OTA Classification
Group A Extra-articular
Group B Partial Intra-articular
Group C Complete Intra-articular
19
Column Theory
3 Columns radial, intermediate, medial
Rikli Regazzoni, 1996
20
Classification Fernandez (1997)
  • I. Bending-metaphysis fails under tensile stress
    (Colles, Smith)
  • II. Shearing-fractures of joint surface (Barton,
    radial styloid)

21
Classification 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

22
Assessment 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

23
Dorsal angulation and comminution
24
Volar subluxation of carpus with fracture fragment
25
Options 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

26
Indications for Closed Treatment
  • Low-energy fracture
  • Low-demand patient
  • Medical co-morbidities
  • Minimal displacement- acceptable alignment
  • Match treatment to demands of the patient

27
Closed 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.

28
Technique 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!

29
Acceptable 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

30
After-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.

31
Management of Redisplacement
  • Repeat reduction and casting high rate of
    failure
  • Repeat reduction and percutaneous pinning
  • External Fixation
  • ORIF

32
Treatment Choice
  • Depends on assessment of fracture stability
  • Indicators of instability are
  • Shortening
  • Comminution
  • Reversal of normal volar angulation
  • Articular involvement

33
Indications 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

34
Evidence of High-Energy Injuries
  • Irreducible fracture
  • Unable to maintain reduction
  • Significant initial displacement
  • Comminution extending from dorsal to volar
  • Significant Soft tissue disruption

35
Operative Management of Distal Radius Fractures
36
External fixation The treatment of choice for
distal radius fractures in the 1980s
37
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38
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39
Literature Articles Discussing External Fixation
1999
1974
1980
1986
40
External Fixation Where Do We Stand Now??
41
Types of External Fixation
  • Spanning
  • Dynamic
  • Clyburne
  • Agee
  • Pennig
  • Static
  • AO
  • Ace
  • Non-spanning
  • Hoffman 2
  • Cobra
  • Zimmer
  • AO

42
Spanning
  • A spanning fixator is one which fixes distal
    radius fractures by spanning the carpus I.e.,
    fixation into radius and metacarpals

43
Non-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.

44
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45
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46
Courtesy of Hill Hastings,MD
47
Factors 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
48
Factors 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

49
Fixator Type vs. Restoration of Outcome Factors
Type Length Radial Tilt
Volar Tilt Gap Step-off SPANNING
---------
-------- NONSPANNING

50
Reduction 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

51
Ligamentotaxis
  • 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

52
Ligamentous Anatomy
  • Volar ligaments
  • Straight
  • Stout
  • Tighten readily
  • Dorsal ligaments
  • Zig-zag
  • Elastic
  • Tighten slowly

53
Dorsal ligaments more lax, zig-zag
54
Ligamentotaxis
  • 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

55
Non-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

56
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58
Complications
  • 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

59
Complications
  • 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)

60
Percutaneous 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)

61
Percutaneous Pins
62
Percutaneous Pins
63
Percutaneous 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

64
Percutaneous Pinning-Kapandji
  • intrafocal pinning through fracture site
  • buttress against displacement
  • good results in literature
  • -Greatting Bishop, OCNA 1993

65
Internal 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.

66
Selection 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
-
68
VOLAR
Classical Henry approach
Extended carpal tunnel approach
69
Distal Radius-volar barton
  • 64 yo M, MVA, contralateral tibial shaft Fx

70
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72
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73
Volar Henry Approach
74
Radial to FCR
75
Elevate Pronator Quadratus
76
Dorsal Fracture
77
CT Scan
78
Dorsal Plating, PCP and Ex Fix
79
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80
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81
Volar Plating for Dorsal Fractures
-less tendon irritation than dorsal - Indirect
reduction -better tolerated than Ex
fix
82
Fixed angle locked screws
83
Courtesy J. Orbay, MD
84
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85
Courtesy J. Orbay, MD
86
Three Column Theory
  • Radial Column
  • Lateral side of radius
  • Intermediate Column
  • Ulnar side of
  • radius
  • Ulnar Column
  • distal ulna

87
Fragment Specific System
88
Radial and Ulnar Columns
-Pin plates -90-90 plating technique
89
Focal Plating Radial Styloid Fragment Dorsal
ulnar fragment
70 90 degrees apart
90
Dorsal Fracture
Radial Styloid and dorsal-ulnar corner
91
Dorsal Case focal plating
92
Radial shortening, comminution
Dorsal angulation
Indication for Volar and Dorsal Plating
93
Volar approach, application buttress plate
94
Dorsal approach, application of 2 L buttress
plates
95
EPL Tendon
96
Extensor retinaculum repaired beneath EPL to
prevent erosion against plate- EPL left transposed
97
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98
Advanced TechniquesArthroscopic-Assisted
  • reduce articular incongruities
  • also diagnose associated soft tissue lesions
  • minimally invasive

99
Arthroscopic-Assisted
Culp and Osterman, OCNA 26(4) 1995
100
Malunion of Distal Radius Fractures
  • Changes load-bearing patterns on the distal
    radius and load sharing between the radius and
    ulna.
  • Can lead to arthrosis.

101
X-ray 4 months later shows malunion
Injury X-Ray
102
Lateral X-Ray of another patient 6 months after
injury demonstrating dorsal angulation of the
distal radius
103
Normal loading patterns
104
Malunion loading patterns
105
Altered Load through Ulna with Radial Shortening
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108
Conclusions
  • 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.

109
Conclusions
  • 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)

110
Conclusions
  • 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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