Relavant Anatomy a)Ossification of Radius. One primary centre for shaft appears at 8th wk of IUL One secondary centre for lower end appears at end of I st year of life, fuses c shaft at 18 th year. One secondary centre for upper end appears at 4th year and fuses with shaft at 14-17 th year. FRACTURES OF DISTAL END OF RADIUS
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Relavant Anatomy
a) Ossification of Radius.
One primary centre for shaft appears at 8th wk
of IUL
One secondary centre for lower end appears at
end of I st year of life, fuses c shaft at 18th year.
One secondary centre for upper end appears at
4th year and fuses with shaft at 14-17th year.
FRACTURES OF DISTAL END OF RADIUS
(A) VOLAR SURFACE OF DR Margen surface is covered by pronator Quadratus. The Ridge gives attachment to palmar Radio carpel ligam Lunate surface on Lt. projecting out from surface of Radius. Volar Radial tuberosity at Rt ent.
(B) DORSAL SURFACE OF DR Lister tubercle in the center it receives a strip from ext. Retinaculam
a)Medial to Lister Tubercle is oblique groove for EPLb)Lateral to Lister Tubercle groove for ECRL & ECRBc)Medial to oblique groove groove for Extensor
digitorum and Ext Indices
C) Lateral surface of distal radius There is radial styliod process projecting down wards Anteriorly ther is groove for APL just posterior to that groove for EPB. Surface just above styloid process is insertion of Bracho radials.
D) Ulnar surface There is ulnar notch for articulation c Head of ulna. Below the notch ther is ridge for articular cartillge.
(E) Inferior surface It is divided into medial Quadrilateral and lateral Triangular Area for a ridge. Lateral; Tr Surface articulate c scaphoid medial Quadrangular surface c lateral part of lunate.
Radiographic Anatomy (Page 26,27,28)(a) Radial height Distance between two parallel lines drawn perpendicular to the long axis of Radial shaft – one from tip of Radial styloid process, other from ulnar corner of lunate jossa - Average 12mm.
(B) RADIAL INCLINATIONThe angle between two lines, one line
perpendicular to long Axis of Radius through ulnar croner of lunate fossa, other line passing through the tip of Radial styloid process and ulnar corner of lunate jossa Average: 23o
(C) ULNAR VARIANCE It is the measurement of relative length of radius and ulna at wrist Distance between two parallel lines to drawn perpendicular to the long axis of ulna and radus 60% pts are ulnar neutral.
LATERAL VIEW
PALMER INCLINATION
The angle between two lines – one drawn
perpendicular to long axis of Radius other between
Dorsal and palmar lips of distal articular end of
Radius Average is 12o.
FRACTURES OF THE DISTAL RADIUS
Distal End of Radius subject to six types of Fractures
1. Colle’s # c Dorsal displacement of distal fragment (Cortico cancellos
junction)
2. Smith # c Anterior displacement.
3. Distal fore Arm # in children (Juvenile colles)
4. Radial styloiad #
5. Barton # (# of Dorsal or volar Articular margin of Distal Radius c
Dislocation or subluxation of carpus Dorsally or volar)
6. Comminuted intra Articular #
IN CURRENT PRACTICE THESE EPONYMS ARE
AVOIDED AND THE TERM DRF PROPERLY USES ALL FRACTURES
OF DISTAL ARTICULAR AND METAPLYSEAL AREAS.
FREQUENCY / EPIDEMIOLOGY
1. It represents approximately 1/6th of all #’s
2. There are three main peaks of # distribution.
Ist peak in children between 5 to 14 years.
IInd peak in males under 50 years.
IIIrd peak in females over 40 years.
3. The incidence more in Elderly female followed by younger adult males
The sharpest increase in incidence occurs in elderly women
due to Estrogen withdrawal and low BMD. Risk Factors
Low BMD
Female gender
Hereditory
Early menopaus
ETIOLOGY
1. Younger pts. Have stronger bones so they need more
energy to produce # Eg motorcycle accidents, falls
from height etc.
2. older pts have much weaker bones and needs small
amount of energy to produce #
For Eg. Simple falling on out stretched hand in
ground level fall.
CLINICAL FEATURES / PRESENTATION
1. A through Histry must by take to know the amount of
energy lnvolved , Histry of prior #s should be sought..
2. The Fracured Radius may be shortend relative to the
intact ulna which may lead to radial deviation and Dorsal
prominercy of distal fragment.
3. Median nerve is commonly injuired in distal radial #s.
So median merve function should be assessed.
CLASSIFICATIONMOST FREQUENTLY USED CLASSIFICATIONS FERNANDEZ CLASSIFICATIONIt is based on mechanism of injuiry.
Five types
1. Type I # :- Extra articular metaphysel bending Fractures. Such as colle
(Dorsal angulation) or Smith Fracturs (Volar angulation)
2. Type II # Intra articular and produced by shearing foreces. These are
volar Bartorn, Dorsal Barton and Radial styloid #s
3. Type III #s : It results from compression injuries results in intra articular #
and impaction of metaphyseal bone. These includes complex articular
#s and radial pilon #s.
4. Type IV #s : Are avulsun #s of ligament attachment which occuss c Radio
carpel #
dislocations.
5. Type V #s: These #s arise from high velocity injuries involving multple
forces and extensive injures.
OTHER CLASSIFICATION
• Melone Classification
Which heighlights fragmentation of articular surface
especially dorso ulnar corner of distal radius
• A O Classification
Based on location ie. extra articular, partial articular and
completely articular.
• Three column concept (Picture on Page 3) By Medoff, Rikli & Rigazzoni1. Lateral column (Radial half of radius c slyloid process &
scaphoid facet)2. Central column: Ulnar half of Rdius c lunar facet3. Medial column: (ulna, Triangular Fibro cartillege & Distal
Radio ulnar joint)
INVESTIGATIONIMAGING STUDIESI. X RAYS(A) AP view
1. Fer extra articular #s asses for [a] Radial shortening /
2. For intra articular #s lookfor (a) depression of lunate
facet (b) gap between scaphoid lunate facet (c) Central
impaction of fragments (d) interruption of proximal carpel
row.
B) Lateral view
1. For extra Articular fractures Assess
a)Palmar tlt,
b)Extent of metaphyseal communition
c)Displacement of volar cortex.
d)Scaphoid – lunate angle
e)Position of DRUJ.
2. For intra Articular Fractures Asses
f)Palmar lunate facet
g)Depression of central fragment
h)The gap between palmar and dorsal fragment
i)Rotation of Radial styloid in relation to shaft
(C) OBLIQUE VIEW
1. For extra articular #s asses for Radial communitions
2. For Intra Articular # asses :
Radial styloid for split or depression
Depression of Dorsal lunate facet.
(D) TILTED LATERAL VIEW:
Taken by placing a pad under the hand to incline
the Radius to 220, which eliminates shadow of styloid
process and given clear tangential view of lunate facet.
(E) AP and Lateral traction view to know whether the external
fixation reduce the # sufficiently.
II. CT
Is useful to asses the articular communition.
TREATMENTBASED ON FERNANDEZ TYPES1) Type I # Most pts. with type I # are successfully treated conservativly with closed reduction & immobilsation. Most of “low dement pts.” Needs immobilisation only regardless x-ray findings If reduction needs prolonged immobilstaion or reduction lost early in the treatment percutaneus pinning through stayloid process. When there is significant metaphyseal communition or osteopea External fixation with traction cast or commercially available external fixator is used.
2)Type Ii #s Requires open reductiom and internal fixationalButtress plate fixation is usually done for volar baron #s
3)Type III (Compression #)Operative treatment is necessary for intra Articular damage & if rdial
shortening is severeFixation with multiple K-wire and cancellous is necessary to fill the
impacted areasNow Arthroscopy Assisted K-wire fixation awalable which can
repairTFC and intracarpel tears
4) Type IV # (Avulsion injuries) These #s usually associated c Radio carpel fracture dislocations ie
unstable #sSmall avulsed fragments are sutured. Reduction of carpus to radius
is achied by K-wire fixations
5) Type V # (High velocity injuries)There #s are usually unstable, open and difficult to treat.A combination of percutneus pining and external fixation is usually
needed.
DORSALAND VOLAR BARTON FRACTURES#s involving dorsal articulor surface margin of distal redius c
or without dislocation or subluxation of carpus dorsally is dorsal Barton#s
#s of volar articular margin of radius c volar dislocation subluxation of carpus is volar sarton #s.
These #s can be reduced closed when the marginal # is small and can be manufactured by cast immobilization.
For unstable dorsal Barton #s open reductions c anatomical restoration of articular surface and fixation using k-wires or small screws are used.
Loss of reduction c subluxation of carpus is common with volar Barton fracture, Ellis Buttress plate is used for fixation.
Kirchners wire’s can by used if the marginal
fragments are large and bone is firm.
Fragment specific open reduction and internal fixation of
comminuted DRF
This method was developed by Medoff who cambined
k-wire fixation c plate and screw fixation for stable
reconstruction of distal radius .
FIVE POTENTRAL # FRAGMENTS ARE POSSIBLE
1. Radial column #s: It is fixed by addition of small Butters
plate to radial styloid pin, which prevents collapse and
migration of the fragment. (Picture)
2. Dorsal ulnar fragment is stabilized c an ulnar pin – plate
fixation (picture)
3. Dorsal cortical wall fragment is stabilsed by wire form
implants.
4. Central intra Articular tragments are also fixed by wire form
implants (Trimed system)
5. Volar Rim fragments are fixed c loprofile Butters plate similar
to volar Barton #.
COMPLICATIONS OF DRF
A) EARLY
1) Vascular impairments
2) Nerve injuries :
It is rare, But if occurs median nerve injuiry is common.
It occurs soon after the injuring and symptoms are minimal, it will
resolve with release of dressings and, elevation. If symptoms are
severe transverse ligament should be divided.
3) Reflex sympathetic dystrophy (sudecksatrophy)
B) LATE COMPLICATIONS
1. Malunion
It occus either due to reduction was not complete or due to
displacement within the plaster.
1) For “Low demanding “ like elder parents conservative
management is enough
2) For younger pts. Open wedge osteolomy is needed.
2. Delayed union and Non Union,it is rare
3. Stiffness of shoulder,elbow,fingers and wrist
4. Extensor pollicis longus tendon rupture occurs few Weeks later