Distal radius fracture

Distal Radius Fractures

Distal Radius Fractures• Common injury• Fractures of the distal radius represent approximately 16% of all fractures treated by orthopaedic surgeons

• Three main peaks of fracture distribution: • children age 5-14

• males under age 50 (High velocity)

• females over the age of 40 years (Low velocity)

• Elderly (Most, extrarticular)

• Young (Most, intra articular)

• Elderly patient risk factors : Decreased bone mineral density, female gender and early menopause • High potential for functional impairment and frequent complications

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.

Introduction

Classified by:– presence or absence of intra-

articular involvement,– degree of comminution,– dorsal vs. volar displacement,– involvement of the distal

radioulnar joint.

Diagnosis: History and Physical Findings

• History of mechanism of injury

• A visible deformity of the wrist is usually noted, with the hand most commonly displaced in the dorsal direction. (90% cases)

• The acute shortening of the radius relative to the ulna may manifest as an open wound palmarly and ulnarly where the intact ulna buttonholes through the skin.

• Movement of the hand and wrist are painful.

• Adequate and accurate assessment of the neurovascular status of the hand is imperative. (Median nerve involvement – Carpal tunnel syndrome)

Diagnosis: Diagnostic Tests and Examination

• Evaluation of the injured joint, and a joint above and below (ipsilateral elbow & shoulder joint)

• Radiographs of the injured wrist (PA & Lateral)

• Radiographs of other areas, if symptoms warrant.

• CT scan of the distal radius in selected instances.

Treatment Goals• Preserve hand and wrist function

• Realign normal osseous anatomy – Articular surface

• Promote bony healing

• Allow early finger and elbow ROM

Osseous Anatomy

Distal radius – 80% of axial load– Scaphoid fossa– Lunate fossa

Distal ulna – 20% axial load

Sigmoid notch – DRUJ

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

Radial Inclination• Inclination of radius towards the ulna• measured by the angle between a line drawn

from the tip of the radial styloid to the medial corner of the articular surface of the radius and a line drawn perpendicular to the long axis of the radius

• Average : 23 degree (13-30)

Radial Length• Inclination of radius towards the ulna• measured by a line drawn perpendicular to the

long axis of the radius and tangential to the most distal point of the ulnar head and a line drawn perpendicular to the long axis of the radius and at the level of the tip of the radial styloid

• Average : 11 mm (8-18)

Dorsal/Palmar tilt• A line is drawn connecting the most distal

points of the volar and dorsal lips of the radius. The dorsal or palmar tilt is the angle created with a line drawn perpendicular along the longitudinal axis of the radius

Ulnar variance• A line parallel to the medial corner of the articular

surface of the radius and a line parallel to the most distal point of the articular surface of the ulnar head, both of which are perpendicular to the long axis of the radius

• Measure of radial shortening• Normal : -2 to +2 mm

Carpal Malalignment• In lateral view, one line is drawn along the long axis of the

capitate and one down the long axis of the radius. If the carpus is aligned, the lines will intersect within the carpus. If not, they will intersect outwith the carpus.

• More than 2 mm of intra articular step off leads to articular incongruity

Computed TomographyIndications:

• Intra-articular fxs with multiple fragments

• centrally impacted fragments• DRUJ incongruity

Classification of Distal Radius Fractures

Ideal system should describe:– Type of injury

– Severity– Evaluation– Treatment– Prognosis

Common Classifications

1.Gartland & Werley2.Frykman (radiocarpal & radioulnar)3.AO4.Melone (impaction of lunate)5.Fernandez (mechanism)

Gartland & Werley

1. Simple Colles fracture without intrarticular involvement

2. Comminuted Colles' fractures with intra-articular extension without displacement

3. Comminuted Colles' fractures with intra-articular extension with displacement

4. Extra-articular, undisplaced

Frykman Classification

Extra-articular

Radio-carpal joint

Radio-ulnar joint

Both joints

{Same pattern as odd numbers, except ulnar styloid also fractured

Importance of sigmoid notch articular surface

Melone

Type I: Stable fracture without displacement. This pattern has characteristic fragments of the radial styloid and a palmar and dorsal lunate facet.

Type II: Unstable “die punch” with displacement of the characteristic fragments and comminution of the anterior and posterior cortices

– Type IIA: Reducible

– Type IIB: Irreducible (central impaction fracture)

Type III: “Spike” fracture. Unstable. Displacement of the articular surface and also of the proximal spike of the radius

Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation of the distal and palmar fragments

Type V: Explosion injury

effect of the impaction of the lunate on the radial articular surface to create four characteristic fracture fragments

AO/ OTA Classification

Classification – Fernandez (1997)

I. Bending-metaphysis fails under tensile stress (Colles, Smith)

• extraarticular

II. Shearing-fractures of joint surface • Intra articular

(Barton, radial styloid)

importance of mechanism and energy level of injury

Classification – Fernandez (1997)III. Compression - intraarticular fracture

with impaction of subchondral and metaphyseal bone (die-punch)

• Complex articular fracture & radial pilon fracture

IV. Avulsion- fractures of ligament attachments (ulna, radial styloid)

V. Combined complex - high velocity injuries

Options for Treatment

Casting– Long arm vs. short arm

External Fixation– Joint-spanning– Non bridging

Percutaneous pinningInternal Fixation

– Dorsal plating– Volar plating– Combined dorsal/volar plating– focal (fracture specific) plating

Indications for Closed Treatment

Low-energy fractureLow-demand patientMedical co-morbiditiesMinimal displacement- acceptable

alignment

Closed Treatment of Distal Radial Fractures

Obtaining and then maintaining an acceptable reduction

Acceptable reduction :

Immobilization: – long arm (cast for high demand)– short arm adequate for elderly patients

Frequent follow-up necessary in order to diagnose re-displacement.

Technique of Closed ReductionAnesthesia (pain relief & decrease muscle spasm)

– Hematoma block– Intravenous sedation– Bier block

Traction: finger traps and weightsReduction Maneuver (dorsally angulated fracture):

– hyperextension of the distal fragment, – Correct radial tilt– Maintain weighted traction and reduce the distal to the proximal

fragment with pressure applied to the distal radius.

Apply well-molded splint or cast, with wrist in neutral to slight flexion.

Do check X-ray to confirm the acceptable reduction.

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.

Prediction of Instability

1. Age > 802. Initial displacement of fracture (esp Radial shortening)3. Extent of metaphyseal comminution4. Displacement following closed reduction

Management of Redisplacement

• Repeat reduction and casting – high rate of failure

• Repeat reduction and percutaneous pinning

• External Fixation

• ORIF

Indications for Surgical Treatment

1. High-energy injury with instability

2. Comminuted displaced intraarticular fracture

3. Open injury

4. Radial inclination < 15°

5. Articular step-off, or gap > 2mm

6. Dorsal tilt > 10 °

7. DRUJ incongruity

Operative Management of Distal Radius Fractures

Treatment Options• Type I

– Mostly non operative– Few by external fixation

• Type II– ORIF with buttress plate

• Type III– Fixation with multiple K wires & plates with cancellous bone grafting– Open & closed techniques in combination

• Type IV– Secure reduction of carpus to distal radius by K wires

• Type V– Combination of percutaneous pinning & external fixation

Percutaneous pinning– Manipulate and reduce the fracture.

– Insert two large unthreaded Kirschner wires through the radial styloid across the fracture and into the opposite metaphyseal cortex   

– Confirm good reduction and pin placement with radiographs or image intensification; cut the pins off beneath the skin.

– The arm is immobilized in a cast above the elbow with the forearm and wrist in neutral position.

– K wires removed in 6 weeks and gentle range of motion started.

Percutaneous Pinning-Methods• most common radial styloid pinning + dorsal-

ulnar corner of radius pinning

• supplemental immobilization with cast, splint

in conjunction with external fixation

(Augmented external fixation)

Percutaneous Pins

Percutaneous Pinning

2 radial styloid pins

Crossed Pins

Percutaneous Pinning-Kapandji

• intrafocal pinning through fracture site

• buttress against displacement

Pins & plaster traction– For severely comminuted distal radius fracture unsuitable for K wire fixation

and if commerical external fixator not available.

– insert a 2.4-mm Steinmann pin transversely through the proximal ulna 7.5 to 10 cm distal to the olecranon

– Insert a second pin transversely through the bases of the second and third metacarpals.

– Apply a plaster cast to above the elbow, incorporating the two pins in plaster.

– The pins and cast or fixator are left in place for 8 weeks.

Distraction plate fixation– Alternative to external fixation for highly comminuted

distal radius fracture.

– Distraction plate acts as an internal fixator.

– Advantages:• External pin tract sites complication avoided.

• Secondary bone grafting procedures are done more easily in absence of overlying external fixator.

Barton Fracture– Dorsal Barton Fracture : involves dorsal articular margin of distal

radius & subluxation/dislocation of carpus dorsally.

– Volar Barton Fracture: involves volar articular margin of distal radius & subluxation/dislocation of carpus in volar.

– Closed reduction can be done for small marginal fracture but redisplacement is common.

– Position of immobilization

• Dorsal Barton : Wrist dorsiflex, forearm pronated.

• Volar Barton : Wrist flex, forearm supinated.

– Volar marginal fracture Rx: Volar buttress plate fixation (Ellis technique)

– Dorsal marginal fracture : Open reduction & fixation with K wires/small screws. (Avoid plate & screw immediately under the extensor tendons)

Unstable intra articular distal radius fracture

• The goal of operative treatment of unstable intraarticular distal radial fractures is anatomical reduction of the scaphoid facet, lunate facet, and sigmoid notch of the distal radioulnar joint.

• Volar plating, interfragmentary Kirschner wires, and external fixation all may be necessary for stable fixation.

• 2 types of plates:– Conventional plate: In minimal comminution

– Fixed angled plate : suitable for unstable, comminuted

» Periosteal blood supply is maintained

Internal Fixation of Distal Radius Fractures

• elevation of depressed articular fragments

• required if articular fragments can not be adequately reduced with percutaneous methods

• Volar approaches most common

Selection of Approach

Based on location of fracture and displacement

Volar approach for volar rim fractures and comminuted fractures that can be reduced

Dorsal approach – Occasionally for dorsally displaced fractures that can’t

be reduced from volar approach

Combined approaches needed for high-energy fractures with significant axial impaction.

-

DORSALDORSAL

3rd DC –EPL

(extensile)1-2nd DC

3rd compartment for dorsal metaphysis or central articular surface

between 5th and 6th for ulnar styloid

Classical Henry approach Extended carpal tunnel approach

VOLARVOLAR

Useful for volar ulnar corner fragment or Fxs associated with

CTS

Volar –Henry Approach

Radial to FCR

Elevate Pronator Quadratus

-less tendon irritation than dorsal plating

- indirect reduction

-better tolerated than Ex fix

Volar Plating for Dorsal Fractures

Fixed angle locked screws

Fragment specific ORIF of comminuted distal radius fracture

• Combines both K-wire fixation & plate fixation which enables secure fixation.

• Five potential fracture fragments are possible– Radial column

– Dorsal cortical wall

– Intrarticular

– Dorsal Ulnar split

– Volar rim

• Trans styloid radial K wire has only single point of fixation so it can’t prevent radial drift of distal fracture fragment.

• Pin-plate greatly enhances Kirschner wire fixation. In addition, pin-plate adds buttress to radial column fragment.

External fixation

• Method of choice for fractures with simple intra-articular components and extensive metaphyseal comminution.

• Types– Bridging : Crosses radiocarpal joint

– Non bridging: Doesn’t cross radiocarpal joint

Spanning

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

•Bridging external fixation allows distraction across the radiocarpal joint and directly neutralizes axial load.

•Ligamentotaxis of the fracture fragments

•Adjunctive fixation and supplemental bone grafting results in earlier union.

Reduction Tactics

• 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

Ligamentous Anatomy

Volar ligaments– Straight fibers

– Stout– Tighten readily

Dorsal ligaments– Zigzag– Elastic

– Tighten slowly

Dorsal ligaments more lax, zigzag

Pin Placement

Addition of percutaneous pinning improve the stability of external fixation and prevent loss of reduction

full finger motion

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.

•Indication : extra-articular or minimal intra-articular dorsally displaced fractures with metaphyseal instability

•Contraindication : lack of space for pins in the distal fragment. 1 cm of intact volar cortex required for purchase of pins

Limited indications

But shows good results

Early ROM permitted

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

Non-Spanning vs. Spanning Fixator

McQueen, JBJS-B, 1998Prospectively 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

Complication rate 50% lower

Complications

Complication rates high– Pin track infection

– RSD Finger stiffness

– Loss of reduction; early vs. late

– Tendon rupture

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