Distal Radial FracturesKeep your options open!

Mr G ShyamalanConsultant Hand Surgeon HEFT

Understanding the radiograph Classification Imaging and consent Approach Surgical case based discussion Classic volar plate Conclusion

Learning Objectives

Gilula’s Lines

Lunate and Scaphoid Facet and Volar side with Radial Styloid

Radial and Volar side

Lateral Vs a True Lateral - Sigmoid notch

True Lateral

Dorsal

Extrinsic Ligaments - Dorsal

Extrinsic Ligaments - Volar

Colles

Classification

Classification Smiths and Bartons

Chauffeur’s and Lunate die punch

Classification

Frykman’s

Classification

Melone’s

Classification

AO – Too complex

Mayo – Extra/Intra-articularReducible/Irreducible

Fernandez – mechanism classification

Classification

Fragment Specific – Robert Medoff (intra-articular fractures)

. Radial styloid, dorsal wall, impacted articular fragments, dorsal ulna corner (die-punch), volar rim fragment (tear drop)

Classification

Daniel Rikli & Pietro Regazzoni Lateral – length and alignment Intermediate – weight bearing and notch Medial - rotation

Columnar Classification

Low energy Vs High Energy Normal Vs Osteoporotic Dominant Vs Non – Dominant Occupation and Functional Demands Soft tissues (skin, nerves, tendons) Pre-morbid conditions including MTS Patient choice! Fracture patterns and mechanism Ulna fracture or carpal injury Timing of consult

Shyam’s Classification

Continued pain Malunion Infection Stiffness Chronic regional pain syndrome (500mg Vitamin

C daily for 6 weeks) Nerve/Vessel/Tendon Injury Non-union Instability carpus and ulna Removal of metal work Carpal Tunnel Syndrome

Consent

Bring the kitchen sink! Volar plates, dorsal straight plates, k-wires,

Ex-fix, hand plating system

What kit do you need?

Volar Henry’s releasing brachioradialis Dorsal Combined

Approach

Volar plate Dorsal plate Fragment specific Percutaneous Wires Bridge plating Ex-fix ? Arthroscopic assisted Bone graft or bone graft substitute Bit of everything Plan for a two stage?!

How to fix

Surgical case 2

Post Fixation – Looks alright

Six weeks post fixation

Look again at the anatomy

Surgical case 2

Look again at the fixation!

6 months post initial injury

Surgical Case 3

Have an assistant who knows what they are doing

Traction the fracture closed Open and Reduce +/- K wire Put plate on shaft and gliding hole screw

and screen Plate can be rotated and pushed up or down

depending on xray Fill ulna holes distally, check lateral and

then put in radial ones and complete proximally

Steps for volar plate

Don’t go bicortical distally Check screw length on xray Angle screws out of joint

Tips

Tips Don’t be afraid to put a K-wire and a plate on

the radial styloid If in doubt do a carpal tunnel decompression Always release brachioradialis If problems with dorsal fragment reduction, put

in screws distally first and reduce fragment onto shaft

Continuous traction or Ex-fix can help with fixation

Multi-fragmentary fractures, intra-articular fractures try bridge plating

Look at scapho-lunate interval on both wrists

Screen in radial and ulna deviation with sometimes compression

Look at ulna position, stress views and examine other side

Have no issues about implant removal If in doubt do nothing and send to specialist

Tips

Theatre films

Conclusion

Fix well or don’t fix at all!