Distal radius fracture

DISTAL RADIUS FRACTURES

Dr barun kumar patel

Dnb orthopedic

Distal Radius Fractures

Common injury

Potential for functional impairment and frequent complications

HISTORY

First surgeon to recognize these injuries was Pouteau 1783. his work was not widely publicized.

Later Abraham Colles 1814 gave the classic description of fracture

Dupuytren brought to the world attention that it is a fracture rather than a dislocation as it was previously assumed.

Goyrond 1832 differntiated between dorsal and volar displacement.

Barton 1838 described wrist subluxation consequent to intraarticular fracture of radius which could be dorsal or volar.

Smith described fracture of distal radius with ‘forward’ displacement.

Advent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.

Incidence

One sixth of all fractures treated in the Emergency Room

Bimodal distribution less than 30 years (70% men)

over 50 years (85% women) Males age 35 or older - 90 per 100,000 population

Introduction

Occurs through the distal metaphysis of the radius

May involve articular surface.

FOOSH

forced extension of the carpus,

impact loading of the distal radius.

Associated injuries may accompany distal radius

fractures.

Diagnosis: History and Physical Findings

History of a FOOSH

Wrist is typically swolen with ecchymosis and tender

Visible deformity of the wrist, with the hand most commonly displaced in the dorsal direction less comonly in volar direction

Movement of the hand and wrist are painful.

Adequate and accurate assessment of the neurovascular status of the hand is performed, before any treatment is carried out.

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-pa and lat view , oblique view

CT scan of the distal radius to know extent of intrarticular involvement

Osseous Anatomy

Distal radius – 80% of axial load Scaphoid fossa Lunate fossa Sigmoid notch – DRUJ

Distal ulna

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

Anatomy

Articular Surface

Scaphoid facet

Lunate facet

Sigmoid notch

Normal range of movement

RADIOLOGY

Ulnar inclination (avg 23deg)

Volar inclination (avg 11 to 12deg)

Radial length (avg 11mm)

Ulnar variance (+ / - 1mm)

Measurement of Radial Length and Inclination

Inclination = 23 degrees

1: Line connecting dorsal and volar tip of lunate

2: Line perpendicular to lunate

3: Line along axis of scaphoid

Scapholunate angle measured between lines 2 and 3

(normal 47 ± 15 degrees)

Computed TomographyIndications:

Intra-articular fxs with multiple fragments

centrally impacted fragments

DRUJ incongruity

Cole et al: J Hand Surg, 1997

Classification of Distal Radius Fractures

Ideal system should describe: Type of injury Severity Evaluation Treatment Prognosis

Common Classifications

Column theory

Gartland/Werley Frykman Weber (AO/ASIF) Melone Fernandez (mechanism)

Frykman Classification

Extra-articular

Radio-carpal joint

Radio-ulnar joint

Both joints

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

AO/ OTA Classification

Group A: Extra-articular

Group B: Partial Intra-articular

Group C: Complete Intra-articular

Gartland and Werley classification

Depends on three basic components of injury

1-metaphyseal comminution 2-intra articular extension 3-displacement of the fragment

Group i- simple colles # with no involvement

of radial articular surface Group ii- colles # with intra articula extension

without displacement Group iii- comminuted colles # with intra

articular extension with displacemet Group iv- extra articular undisplaced

COONEY (1990) UNIVERSAL CLASSIFICATION

Type I Extraarticular, undisplaced Type 2 Extraarticular, displaced Type 3 Intraarticular, undisplaced Type 4 Intraarticular, displaced

MODIFIED AO

Type A Extraarticular Type B Partial articular B1–radial styloid fracture B2–dorsal rim fracture B3–volar rim fracture B4–die-punch fracture Type C Complete articular

Melone classification

Depends on the impaction of the lunate on radial articular surface

Type i- stable # without displacement Type ii-unstable ‘die punch’ with

displacement of the characteristic fragment and comminution of the ant and post cotices

type ii A – reducible type iiB --irreducible

Type iii- ‘spike fracture’ ,unstable. Displacement of the articular surface and also proximal spike of radius

Type iv- ‘split’ fracture, unstable medial complex that is severly comminuted with separation and or rotation of the distal and proximal fragments

Type v- explosion injury

Column Theory

Rikli & Regazzoni, 1996

3 Columns: radial, intermediate, medial

Three Column Theory

Radial ColumnLateral side of radius

Intermediate ColumnUlnar side of

radius Ulnar Column

distal ulna

Radial column

Intermediate column

Ulnar column

Classification – Fernandez (1997)

I. Bending-metaphysis bending with loss of palmar tilt and radial shortening ,DRUJ injury(Colles, Smith)

II. Shearing-fractures of joint surface (Barton, radial styloid)

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

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

EPONYMS

COLLES #-extra articular or intra articular distal

radius # with various combination of dorsal angulation, dorsal displacement radial shift , and radial shortening-clinicaly described as dinner fork deformity-mechanism---fall on to an hyper

extended ,radialy deviated wrist with the forearm in pronation

SMITH #(REVERSE COLLES #)

# distal radius with volar angulation or volar displacement of the hand and distal radius

mechanism—fall on to a flexed wrist with the forearm fixed in supination

unstable pattern often requires ORIF because of difficulty in maintaining closed reduction

BARTON #

# disdlocation or subluxation of wrist in which the dorsal or volar rim of distal radius is displaced

mechanism-fall on to a dorsiflexed wrist with the forearm fixed in pronation

unstable # requires ORIF

RADIAL STYLOID #(CHAUFFEUR’S #, BACKFIRE #,HUTCHINSON #

Avulsion # with extrinsic ligaments remaining attached to styloid fragment

Mechanism-compression of scaphoid against styloid with the wrist in dorsiflexion and ulnar deviation

Often associated with intercarpal ligament injury

Requires ORIF

ASSESSMENT OF STABILITY

five factors indicative of instability (1)initial dorsal angulation of more than 20

degrees (volar tilt),(2) dorsal metaphyseal comminution,(3) intraarticular involvement, (4) an associated ulnar fracture, and(5) patient age older than 60 years

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

Treatment Goals

Preserve hand and wrist function

Realign normal osseous anatomy

promote bony healing

Avoid complications

Allow early finger and elbow ROM

Indications for Closed Treatment

Low-energy fracture

Medical co-morbidities

Minimal displacement- acceptable alignment

Closed Treatment of Distal Radial Fractures

Obtaining and then maintaining an acceptable reduction.

Immobilization: long arm short arm adequate for elderly patients

Frequent follow-up necessary in order to diagnose redisplacement.

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!

Acceptable Reduction Criteria

Radial length- within 2-3 mm of the controlateral wrist

Palmar tilt- neutral tilt(o degree ) intrarticular step-off or gap< 2mm Radial inclination <5 degree loss Carpal malalignment – absent Ulnar variance- no more than 2 mm of

shortening compare to ulnar head

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.

Management of Redisplacement

Repeat reduction and casting – high rate of failure

Repeat reduction and percutaneous pinning External Fixation ORIF

Indications for Immediate 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

Operative Management of Distal Radius Fractures

External fixation:

The treatment of choice for distal radius fractures

in the 1980’s

Types of External Fixation

Spanning Dynamic

Clyburne Agee Pennig

Static AO Ace

Non-spanning Hoffman 2 Cobra Zimmer AO

Neutralize the axial load imparted by physiologic forearm musculature

Spanning ( Ligamentotaxis)

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

Use for comminuted fracture

Used to restore radial length and radial inclination but palmer tilt is rarely restored

Supplemental k wire fixation is needed to prevent loss of palmer tilt and some degree of colapse

Pins are retained for 6 to 8 weeks Overdistraction results in finger stiffness

Complications

Mal-union Pin track infection Finger stiffness Loss of reduction; early vs late Tendon rupture

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.

Indicated for extra articular or minimal intra articular dorsaly displaced fracture

Minimum 1 cm of intact volar cortex is required to give purchase for the pins

Better to preserve volar tilt and carpal malalignment

Courtesy of Hill Hastings,MD

External Fixation- Disadvantages -

Bulky

Poor screw hold in porosis and comminution

Screws do not buttress

Cutaneous radial nerve injury

Pin tract infection

Reflex sympathetic dystrophy

Postoperative care

Wrist is immobilized in a supinated position with sugar tongue splint for 10 days

External fixator frame is removed at 6 weeks

Any supplemental pins are kept in place for 8 weeks

Active and passive finger motion is begun as soon as the anesthesia wears off

Percutaneous Pins

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 Pinning

2 radial styloid pins- -radial styloid is pinned to proximal

shaft in reduced position excellent anatomic 82% good-excellent functional results 100%

radial styloid with dorsal ulnar – -after radial styloid fixation the

intermediate column is pinned from dorsal ulnar to proximal radial

excellent anatomic results in 90%

Percutaneous Pinning-Kapandji

intrafocal pinning through fracture site

buttress against displacement

Drawback-tendency to translate distal fragment in opposite direction

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

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.

Classical Henry approach(chung)

Extended carpal tunnel approach

VOLAR

Volar –Henry Approach

Radial to FCR

Skin incision

Incision carried to flexor carpi radialis sheath

Flexor pollicis longus muscle belly is partially detached from radius to expose pronator quadratus

Freer elevator is used to elevate pronator quadratus

from radius

Fracture line is exposed

Volar plate positioned, insertion of first screw

Insertion of second screw after release of distal traction on fingers

Pronator quadratus sutured to edge of brachioradialis

Reduction and placement of Kirschner wires for provisional fixation

Courtesy J. Orbay, MD

POSTOPERATIVE CARE

At 1 week, the sutures are removed and active wrist motion is begun when there is confidence in fracture stability

A removable Orthoplast splint is worn for 6 weeks.

-

DORSAL APPROACH

3rd DC –EPL(extensile)1-2nd DC

Dorsal Plating, PCP and Ex Fix

Generally not prefere because of high rate of complication like

- tendon dysfunction and rupture - tenosynovitis of extensor tendons indicated for- dorsal die-punch fractures or

fractures with displaced dorsal lunate facet fragments

DISTRACTION PLATE FIXATION

POSTOPERATIVE CARE

Finger and other joint upper extremity exercises are begun immediately

If a splint was applied, it is removed at 3 weeks

When union is achieved, the distraction plate is removed and range-of-motion exercises are begun

-less tendon irritation than dorsal

Volar Plating for Dorsal Fractures

Fixed angle locked screws ,,variable angle

Fragment Specific System

Five potential fracture fragments

radial column, dorsal cortical

wall, dorsal ulnar split, volar rim, and the central

intraarticular fragment

Radial pin-plate For stabilization of radial column

Ulnar pin-plate for stabilization of dorsal ulnar split fragment

Dorsal cortical wall fragment stabilized by small fragment clamp

simultaneously stabilization of dorsal wall fragment and intraarticular component

Radial shortening, comminution

Dorsal angulation

Indication for Volar and Dorsal Plating

Volar approach, application buttress plate

Dorsal approach, application of 2 “L” buttress plates

EPL Tendon

Extensor retinaculum repaired beneath EPL to prevent erosion against plate- EPL left transposed

Advanced TechniquesArthroscopic-Assisted

reduce articular incongruities also diagnose associated soft tissue

lesions minimally invasive

Indicated for 1-complex articular fracture without

metaphyseal comminution 2-# with evidence of substantial

interosseous ligament or TFCC injury without a large ulnar styloid fragment.

Timing-between 5 to 15 days post injury to prevent extravasation of irrigation fluid into the surrounding soft tissue

Complications After Fracture of Distal Radius

Arthritis/arthrosis Loss of motion Hardware complications Nerve compression/neuritis Osteomyelitis Dupuytren contracture Persistent pain/pain syndromes (CRPS) Tendon (rupture, lag, trigger, tenosynovitis) Delayed union/nonunion/malunion Radioulnar (synostosis, disturbance)

Conclusions

ORIF better in high-energy fractures associated with depression of articular surface

ORIF gives better anatomic restoration, although not necessarily higher patient satisfaction.

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)

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

THANK YOU

Relationship of Anatomy to Function

Colles; “The wrist will regain perfect freedom in all of its motions and be completely exempt from pain” (1814)

Generally true for low demand individuals Direct relation between residual deformity and

disability Quality of reduction more important than

method of immobilisation