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9/24/2015
1
Current Solutionsin
Orthopedic Trauma
September 19, 2015
Jorge L. Orbay MD.
Distal Radius FracturesState of the Art
Disclosure
Skeletal Dynamics
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6-8 weeks post-op
Two Pervasive Problems
• Volar Marginal Fragment
• Tendon Ruptures
1995
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Extensor Tendon Ruptures
PQ
1997
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1998 - 2013Volar Plate Evolution
Load Transmission Through the Wrist in the Extended Position
Masataka Majima, MD, Emiko Horii, MD, Hiroshi Matsuki, MD, Hitoshi Hirata, MD, Eiichi Genda, MD
( J Hand Surg 2008;33A:182 – 188.)
Ligament Contribution to Patterns of ArticularFractures of the Distal Radius
Daniel G. Mandziak, MBBS, Adam C. Watts, MBBS, Gregory I. Bain, PhD, Journal of Hand Surgery. 2011.07.014
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AMF
PMF
RF
Scaphoid Fossa Lunate Fossa
Scaphoid Fossa Lunate Fossa
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Scaphoid Fossa Fixation
Scaphoid Fossa
Lunate Fossa Fixation
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Lunate Fossa
Watershed Line
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Watershed Line
3 mm
Watershed Line
2 mm
Watershed Line
Watershed Line to Plate Distance
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5 mmVolar Marginal Fragment
Volar Lunate Fragment
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Volar Rim Hook Plate…
Volar Rim Hook Plate…
Extensor Tendon Problems
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Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal
Radius: A Cadaveric Study
Steven D. Maschke & Peter J. Evans & David Schub &
Richard Drake & Jeffrey N. Lawton
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Lister’s Tubercle
EPL
Dorsal Horizon View: Detecting Screw Protrusionat the Distal Radius
Samuel James Joseph, MBBS, Jason N. Harvey, MBBS, FRACS
Dorsal Horizon View: Detecting Screw Protrusionat the Distal Radius
Samuel James Joseph, MBBS, Jason N. Harvey, MBBS, FRACS
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Extended Tangential View
Subchondral Support Line
orSubtract 2mm from DG measurement
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Standard Fixation Technique
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FDP IIFPL
Most Frequently Flexor Ruptured Tendons
#1 #2
Watershed Line
Watershed Line
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--------Volar Rim Lunate Fossa
Volar Radial -------Tubercle
Inter Fossa Sulcus
Bridging Effect
FPL
Tendon Center to Bone 4.5mm
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Tendon Center to Bone 4.5mmPlate to Tendon Surface ≈ 0mm
FPL
Distal Radius Volar Locking Plate Design and Associated Vulnerability of the Flexor Pollicis
Longus
Roongsak Limthongthang, MD, Abdo Bachoura, MD, Sidney M. Jacoby, MD, A. Lee Osterman, MD YJHS March 2014
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Volar Approach for Dorsal Fracture Not Trivial
Two difficult scenarios
• Inveterate fracture (> 2 weeks old)
• Complex articular fracture
Standard Fixation Technique
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Standard Fixation Technique
Removing dorsal hematoma allows reduction
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Extended FCR Approach
• Release FCR tendon sheath
Extended FCR Approach
• Release the radial septum
• Release FCR tendon sheath
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Extended FCR Approach
• Release the radial septum
• Pronate the proximal fragment
• Release FCR tendon sheath
Extended FCR Approach
• Release the radial septum
• Intrafocal Exposure
• Pronate the proximal fragment
• Release FCR tendon sheath
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FCR
Released Flexor
Retinaculum
Distal FCR Release
Intermuscular Membrane
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Release the Brachioradialis
Pronate Proximal Fragment
Fracture Debridement
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Fracture Debridement
Supinate Radius
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Proximal to Watershed Line
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Provisional K-Wire Fixation
K-Wire Guides
2 mm Rule
2 mm
2 mm
1- Reduce and Pin Lunate Fossa
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2- Reduce and Pin the Scaphoid Fossa
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Subchondral Support Scaffold
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Thank You!