distal radial injury

8/7/2019 distal radial injury

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DISTAL RADIAL INJURY

Department of Orthopaedics SGH

Didactic Lecture


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Distal Radial Fracture


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Introduction

Hippocrates and Galen : thought to be dislocations.

Pouteau : fractures in French-speaking world. However, politics and

communications being what they were, the English-speaking world

did not recognize the Pouteau description.

Abraham Colles (1814): based his descriptions on clinical exam alone.

Despite this limitation, his description was quite accurate.

Over time, other eponyms: Smith fracture, Barton fracture, and volar

Barton fractures.


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Posteroanterior radiograph demonstrating the typical features of acommon distal radius fracture: loss of radial length, loss of radial tilt, andcomminution at the fracture line.


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Problem FrequencyProblem

Goal : restore prior level of functioning- not the same in all patients.

Because goals are different, treatment options are different; but also,because people now remain active until an older age, the definition of "prior levelof functioning" is changing.

Treatment goals, therefore, must be tailored to each patient. Specifically, ageshould not determine treatment; activity level should determine treatment.

Frequency

Among most common type of fracture.

Bimodal distribution, peak in younger (18-25 y) and a 2nd peak in old (>65 y).

Mechanism: high-energy injuries more common in young and low-energy injuries inold.


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Presentation

Probable amount of energy involved.

A history of prior fractures vs. fragility fractures helps predict stability

of reduction.

A history of multiple high-energy fractures in young patient predicts

compliance with directions.

Median nerve is always compressed after DRF.


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Presentation

Most treatments have median nerve implications. A cast or splint

without a reduction may result in median nerve compromise due to

pressure.

A reduction, closed or open, involves anesthesia, compromising

median nerve examination.

Documentation of median nerve function at first assessment planning + protecting surgeon from subsequent claims.


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Classification Goals: stratify injuries, guide treatment, facilitate discussion, and

predict outcome.

Frykman, Melone, AO, and Fernandez systems.

Frykman classification highlights injury to DRUJ.

Melone classification, highlights fragmentation of articular surface,especially dorsoulnar corner of distal radius.

AO classification emphasizes location as extra-articular, partialarticular, and completely articular.

Fernandez classification: mechanism of injury, deduced from

displacement of bone and location of fracture lines.


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Classification

3-column concept (Medoff 1994) Rikli and

Rigazzoni.

Each column considered separately as to its needfor reduction and stabilization.

Does not exclude any other approaches but, rather,

is complementary to them.


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Indications for reduction and/or

operative treatment

Goal of treatment is prior level of functioning.

Most authors advocate an anatomic reduction 2 problems.

First, not all pts need an anatomic reduction to resumeactivities.

Second, concept of anatomic reduction not defined.

No authorities advocate operative reduction if stepoff is 0.5mm(not anatomic).

On the other hand, a 20 dorsal tilt is not anatomic, but allows

elderly to return to previous level of functioning.


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Indications for reduction and/or

operative treatment

Treatment needs to be tailored to individual patient.

Anatomic reduction in pts active in recreation (golf / tennis common

activities in elderly pts) or engage in forceful activities at work.

Conversely, if patient sedentary, a lesser reduction may allow return

to full activities.

Usually, 3 parameters are relevant:

intra-articular stepoff,

dorsal tilt, and

radial length.


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Intra-articular stepoff

Most authors 2 mm.

Neutral dorsal tilt but not >10and 2 mm of radial shortening but not

> 5 mm.

Plain XR cannot accurately measure stepoffs wi accuracy of 1 mm.

However, Jupiter (1986): ligamentous injuries may better account forfunctional limitations than intra-articular stepoff.


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Dorsal tilt:

Range of anatomic alignment for dorsal tilt: 0-10, with no proviso forless active pts.

Neutral (0) alignment: 11 loss of volar angulation, so even most

conservative figure is not truly anatomic.

Commonly, some older, inactive pts have full resumption of their

activities with dorsal tilts of 45 or more.

Although orthopedic surgeons may find XR disturbing, pts satisfied

and able to function.

Most authors recommend no more than neutral to 10 of dorsal tilt in

healthy, active individuals.


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Radial length

Shortening of 2 mm of radial length doubles load through TFCC and

ulna.

Additionally, altering radius length relative to ulna affects functionand forces associated with DRUJ.

Most authors would not accept >2-5 mm shortening.


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Stability of reduction

Another topic that has not been resolved is stability of reduction ifperformed in a closed procedure and without operative support.

Authors believe that 30 dorsal tilt or any radial shortening will not

be stable.

XR assessment is required for approximately 3 wks.

Fractures do not commonly subside after3

weeks.

Care must be observed to compare current XR with postreductionXR because subsidence is gradual and can be difficult to detect.


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Relevant Anatomy

Image below shows the volar surface.

The large lunate facet is seen on the left, projecting out from

the surface of the radius.

The volar radial tuberosity is at the right margin of the bone.

The surface is covered with the pronator quadratus (PQ).

The cortical bone is quite thick and is strong, even inosteoporotic patients.


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Image below shows the dorsal surface of the radius. The Lister tubercle is seen in the center. This bone is a thin cortical shell, with little structural strength.


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Image below shows the ulnar surface of the radius, with the sigmoid notch for articulating with the ulna.

Image below shows the radial surface of the radius.


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Image below shows the distal articular surface of the radius. The scaphoid facet is to the right, and the lunate facet is to the left. This bone is the strongest of all the surfaces, and e

Image below shows a normal posteroanterior radiograph of the radius. The ulna is generally within (plus or minus) 2 mm of the radius.


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Image below shows a normal lateral radiograph. Note that the center of the lunate facet overlies the volar surface of the bone.

Image below shows anatomic landmarks important for the volar approach to the radius.


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Workup: Imaging Studies

Plain radiographs are all that is needed for most fractures.

CT : articular fracture lines and degree of comminution,sometimes useful for planning approach.

Plain films underestimate and CT scans overestimate numberof fracture lines.

CT scans are necessary when planning intra-articularosteotomies for nascent malunions and mature malunions.

MRI is not indicated for evaluation of bony anatomy.


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Nonsurgical treatment

Many (DRFs) can be treated nonoperatively.

Fractures that are undisplaced or minimally displaced (definition

controversial and varies with age and activity level) treated in cast

for 6 wks.

In most instances, unless distal ulna is fractured and unstable (type I

and II ulna fractures not usually unstable) short arm cast.


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Nonsurgical treatment

Long arm casts are not required if ulna is stable.

Elderly, low-activity pts can have high function and return to prioractivities even with a significantly displaced fracture.

A 45 dorsal tilt can be highly functional in a pt who drives and is

active but does no sports.


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Volar fixed-angle plate using the Orthofix Contours VPS plate, posteroanterior view. This is a facet posteroanterior view, which is tilted at th

Volar fixed-angle plate using the Orthofix Contours VPS, lateral view. This is not a facet lateral view, and the distal articular surface is not s


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PA view of fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware to the radial side is a radial pin plate. The pins hold the fr

Lateral view of a fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware on the volar side is called a wireform and is support


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Surgical treatment: displaced, irreducible fractures or reducible but

unstable fractures.

One approach becoming more popular surgery if pts cannot or donot want cast treatment because work, or recreational concerns.

No consensus has been reached as to which surgical treatment is

best.

Several options are available, each with its own variations.


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Closed reduction and percutaneous

pinning

Popular for many years and continues to be one of the most popular

techniques internationally.

Several varieties:

Clancey pinning (ie, 0.062-inch wires into radial styloid and dorsal

ulnar corner of radius, crossing fracture site).

Kapandji pinning (ie, wires or arum pins placed into fracture site

dorsally + used as levers to reduce and stabilize fracture.


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Percutaneous pinning with the Clancey technique, posteroanterior view.

Percutaneous pinning with the Clancey technique, lateral view.


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External fixation

Radius-specific fixator by Anderson in 1944.

Proper technique of application defined 1990 by Seitz.

More than 25 brands now on the market testimony topopularity.

Small open incisions avoid injuring sensory branches ofradial nerve and to ensure central placement in 2nd MCP andradial shaft.

This technique continues to be one of the most popular

techniques internationally.


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External fixation

One variation of fixator allowed early motion with fixator still in place.

Axis of motion of fixator placed over center of motion of wrist, (center ofhead of capitate?).

instant center or a constant center? Reliable placement over center ofmotion.

Clinical studies: decrease in final ROM and an increase in complicationsrelated to device; thus, early motion in external fixation has largely been

abandoned.

Some researchers are still investigating this technique, and it is still usedclinically in some regions of the world.


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Dorsal plating

Dorsal plating had its greatest popularity in 1990s, with development

of plates specifically for distal radius.

Technique has lost most of its appeal for most fractures because oftendon irritation problems.


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Fragment-specific fixation

Originated by Fernandez called limited open approach, developed

and popularized by Medoff.

Fragment-specific fixation uses very small, low-profile plates that arespecifically designed for radial column, central column, or ulnar

column.

Technique is difficult to learn and, many times, plates must beremoved.


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Nonspanning external fixation

Nonspanning external fixation was popularized by McQueen and

capitalized on subchondral bone strength and volar cortex.

While proponents touted possibility of early motion, others foundthat ROM was poor.


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Volar plating

Volar plating, especially for dorsally unstable fractures, wasindependently developed by Orbay, Jennings, and Drobetz.

Orbay successfully developed a practical device, promoted itinternationally, and was first to publish information on it.

Orbay is properly considered the grandfather of technique.

It is gaining in popularity, but its complications are nowbecoming recognized.


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Spanning internal fixation plates

Spanning internal fixation plates were originated by Becton and

popularized by Ruch, and several companies make such plates.

The screws are placed into the metacarpals and the midradial shaft,and the plates are removed at 3 months.

This technique is very new and only a few series have been

published.


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Intraoperative Details: Percutaneous

pinning (Clancey technique)

Reduce fracture, and place a 0.062-inch Kirschner wireinto radial styloid.

Drive K wire across fracture site and into (but notthrough) opposite cortex.

2nd pin placed into dorsal ulnar corner of radius.

Drive pin across fracture site and into opposite cortex.

Additional pins can be placed if needed for stability.


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Intraoperative Details: Percutaneous

pinning (Kapandji technique)

Place pins into fracture site dorsally.

Lever distal fragment into place with pin, and thendrive it into volar cortex.

Usually, more than one pin used.

Kapandji has developed special pins called arum

pins for this purpose.


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Volar plating

Skin incision over (FCR) tendon. 10 cm long, does notneed to cross wrist crease.

Mobilize FCR tendon radially, and incise floor of FCR

tendon sheath.

Divide septum between FCR tendon and FPL tendon

distal to wrist crease.

Release muscular fibers of FPL, originating from shaft of

ulna or septum b/w radius and 1st

dorsal compartment.


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Volar plating

PQ is seen, often with a tear in its fascia where shaft

has displaced and torn it at moment of fracture.

Release PQ just 1-2 mm distal to line marked by

distal end of muscular fibers.

Reflect the PQ and release the brachioradialis (BR).

Clear the fat from the volar wrist capsule.


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Volar plating There are 2 different approaches: (1) reduce fracture and place plate or (2)

partially reduce fracture, place distal row(s) of screws, and then use plate toobtain final few degrees of volar tilt.

If unreduced intra-articular comminution is noted, a different approach isrequired.

Release BR, if not released previously.

Release 1st dorsal compartment from radius, and pronate radius shaft awayfrom articular fragments.

Reduce intra-articular fragments, pin and/or bone graft as necessary, andthen supinate radial shaft and continue as above.

Document reduction using facet lateral view and facet PA view with ,aligning view with joint surface, not clinical position of forearm.


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Volar plating

Be careful to assess position of tip of each distal screw.

Radial styloid screw may be either in joint or outside radial cortex radially.

Distal screws should not extend beyond dorsal cortex; indeed, they probably should

be 2 mm short of dorsal cortex.

Dorsal cortex is very thin and usually comminuted; therefore, it provides noincrease in fixation security.

Past-pointing of even 1 mm can shred a dorsal tendon if it is precisely in wrongplace.

Carefully check for past-pointing.

Close the PQ securely with interrupted sutures. No intermediate closure is needed.Close the skin.


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External fixation

Key to external fixation is placing pins through small, open incisions.

Blind percutaneous placement or through small stab incisionsincreases rate of nerve and tendon injury and makes it easier to

create open section defects and off-center placements into bones.

Proximally, plane of dissection should be dorsolateral, through ECRLand ECRB or through ECRB and EDC.

This avoids placing pins near radial sensory nerve and injuring itupon pin insertion or subjecting it to minor cellulitis of pin tract.


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Postoperative Details

Postoperative management varies.

Most casts 6 weeks, but some compressed

fractures splint.

Most EX Fix 6 wks, but 8 wks is also common; andsome fractures still collapse at 3 months.

Spanning internal fixation plates are usuallyremoved at 3 months, and therapy is initiated at

that time.


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Follow-up

Fractures treated with a cast require close follow-up to observefor subsidence. reduced and accepted/not reduced can stillsubside.

XR weekly for 1st 3 wks, being careful to compare current filmwith original reduction film.

A common error is to accept minor increase in loss of reductionat each week, expecting that subsidence will cease, at 3 wksalignment unacceptable + fracture has healed.

Fractures stabilized operatively should be followed at 7-10 days.

Subsidence should not be an issue.


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Complications (DRFs) heal quickly. most common problem is malunion before or after treatment is

initiated.

Careful attention to follow-up radiographs helps avoid this problem.

Percutaneous pinning

2 principal areas of complications:

insertion problems (injury to the radial sensory nerve) and late problems (infectedpin sites).

The former can be mitigated by limiting number of times a pin is placed

the latter, by appropriate pin care.

Early oral antibiotic therapy or prompt pin removal usually cures problem.

Osteomyelitis is rare (


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Complications

External fixation

External fixation also has 2 areas of complications:

insertion problems (injury to the radial sensory nerve,

tendon injuries, open section defects in the bone)

late problems (infected pin sites).

Insertion problems minimized w (Seitz in 1990).

As with percutaneous pinning, early oral antibiotic therapy isusually successful for controlling pin site problems; if not,removal usually cures problem.


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Complications

Dorsal plates

complications : close apposition of extensor

tendons to bone.

While many plates claim to be low profile : 2-mm

plates in a 1-mm space are still too large.

Tendon rupture is also a potential problem.

Many authors routinely remove their plates.


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Complications

Volar plates Classified as dorsal or volar problems.

Dorsal problems are related to past-pointing (screw tips extending beyond bone) ofdistal screws.

Most orthopedic screws are designed with cutting flutes at the tip, and optimum

bicortical purchase requires approximately a screw diameter of past-pointing. However, due to the design of most volar fixation systems in which screws lock to

plate, dorsal cortex does not offer additional fixation.

Additionally dorsal cortex is thin and often comminuted. Secure fixation comesfrom plate and subchondral bone. Any past-pointing of the distal screws endangersthe extensor tendons, which are in close apposition to the bone.

Volar problems with volar plates come from contact of the tendons with the plates,particularly with titanium plates.

This can be due to poor plate design (extension distal to the PQ, out over the volarcapsule; or excessive thickness at the distal margin of the plate such that it extendsvolar to the PQ) or loss of reduction, such that the flexor tendons are forced to usethe plate as a fulcrum.


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Spanning plates

Spanning plates require a second surgical

procedure for plate removal.

While not a complication per se, because it is

planned, it is a downside to the procedure

that is not common to the other techniques.


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Outcome and Prognosis All treatments have percentage of poor results, with

decreased supination, prominent ulnar heads, ligamentousproblems, distal RUproblems (instability), and DJD.

Patients, however, want more concrete prognostic

statements.

Volar fixed-angle plate nonforceful activities of daily living(ADLs) within 3 d to 2 wks.

cast removed at 6 weeks ADLs.

Grip strengthening 2 mo after any type of treatment, butforceful use of hand should be delayed for 3 mo.


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Outcome and Prognosis

Contact sports delayed for approximately 4 mo.

long-term prognosis for a properly treated DRF is good,

even with an intra-articular fracture.

OA is rare if articular surface is not comminuted and isable to be reconstructed.

Wrist ROM will continue to increase, and wristtenderness with forceful use will continue to decrease

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