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Distal Radius Fractures
Outline
Epidemiology
Anatomy
Classification
Imaging
Treatment
Complications
Conclusions
Epidemiology
Distal radius fractures1/6th of all #’s treated in ED450,000 annually in US in elderly 2nd only to hip #Lifetime risk = 15% women; 2% menBimodal distribution (ages 6-10 & 60-69)
Older population = women, postmenopausal osteoporosis, caucasian, family history
Mechanism of Injury
ElderlyFOOSH in osteoporotic bone (insufficiency #)
YoungHigh-energy with marked comminution and wide
displacementE.g. MVC, fall from height, sports
AnatomyDistal radius consists of
MetaphysisScaphoid facetLunate facetSigmoid notch
TFCC – from distal edge of radius to base of ulnar styloidStabilizes DRUJ
80% of axial load supported by DR, and 20% by ulna/TFCC
AnatomyMetaphysis
Primarily cancellous boneFlared distally with thinner cortical bone lying dorsally +
radially # ’s typically collapse dorsoradially
Cross-Sectional AnatomyRadial styloid angles
volarly
Extensor tendons in direct contact with bone
Layer of fat between flexor tendons and bone
VOLAR
DORSAL
Clinical Evaluation
Physical Exam Wrist typically swollen, with ecchymosis, tenderness and painful
ROM Deformity of the wrist/Displacement of the hand in relation to the
wrist E.g. dorsal displacement, radial shortening
Open injury Soft tissue injury typically palmarly + ulnarly (result of distal ulna)
Associated injuries Examine ipsilateral shoulder & elbow
E.g. # radial head Carpal #’s
Neurovascular status Carpal tunnel compression symptoms in 13% to 23% Result of displacement of median N, direct trauma from # fragments, or
hematoma in carpal tunnel Symptoms should improve with reduction of #
Imaging
X-raysStandard View (PA, lateral, oblique views)Contralateral wrist views
May assess pt’s normal ulnar variance + SL angle
CT ScanDemonstrate extent of intra-articular involvement
Normal Radiographic Parameters
Radial Inclinationavg = 23˚ (range 13-30˚)
Radial LengthAvg = 11 mm (range, 8-
18mm)
Ulnar varianceAvg = 1 mm ulnar
negative
Normal Radiographic Parameters
Volar TiltAvg = 11-12˚ (range 0-
28˚)
Classification
Extra-articular vs intra-articular
Degree of comminution
Dorsal vs volar displacement
Open vs Closed
Classification Systems
MultipleFrykman Jupiter & FernandezMeloneAO classification
None frequently used
Frykman Classifcation8 categories based on
Intra-articular extension (radiocarpal or DRUJ)
# of ulnar styloid process
Does not consider displacement nor comminution
Jupiter & Fernandez
Based on mechanism I) Metaphyseal bending
# II) Shearing # III) Compression # of
articular surface IV) Avulsion # or
radiocarpal #-dislocation V) High-energy,
combined mechanism
Melone ClassficationBased on number of parts
1 = radial shaft 2 = radial styloid fragment 3 = volar lunate fossa 4 = dorsal lunate fossa
Medial lunate complex (3+4) are important for radiocarpal + DRUJ function
AO classification
Management
Non-operativeReduction + Casting
OperativePercutaneous PinningEx-fixORIF
Factors affecting treatment
Fracture pattern
Fracture stability
Patient factors
Factors affecting treatment
Fracture pattern ACCEPTABLE RADIOGRAPHIC CRITERIA
Radial Length = < 5 mm radial shortening Volar tilt = neutral (0 deg) Intra-articular step-off/gap < 2mm Radial Inclination > 10 deg
Fracture stability
Patient factors
Radial Shortening
Accept < 5 mm radial shortening
Palmer & Werner (Clin Orthop 1984) Increase of 18% to 42% in force
borne by distal ulna, with a relative radial shortening of 2.5 mm
TFCC becomes tighter, and DRUJ is disrupted, leading to pain & loss of forearm rotation
Shortening of 6-8 mm causes ulnocarpal impingement
Dorsal Angulation
Accept neutral tilt (young) or <10˚ dorsal tilt (elderly)
As DA increases, load distribution shifts from volar-radial to dorsal-ulnar
Load thru ulna increased to 50% at 30˚ dorsal tilt (Short et al.)
Loss of normal tilt affects grip strength
Radial Inclination
Affects grip strength, ROM in radial/ulnar deviation, distribution of load in wrist
Pogue et al (JHS 1990)- increased load borne by lunate facet
Articular congruency
Knirk & Jupiter (JBJS 1986)> 2 mm of intra-articular step-off increased rate of
symptomatic post-traumatic OA in young adults
Some other studies quote > 1 mm step-off or > 2 mm gap at risk for arthrosis
In elderly, radiographic arthrosis may not be symptomatic
Factors affecting treatment
Fracture pattern
Fracture stability Initial dorsal angulation >20˚ *** Comminution (especially dorsal) *** Intra-articular involvement Associated ulna # Age > 60 yrs *** Radial shortening > 5 mm
3+ RF = high likelihood of collapse
Patient factors
Factors affecting treatment
Fracture pattern
Fracture stability
Patient factors Physiologic patient age Lifestyle Occupation Hand dominance Associated medical
conditions Associated injuries
FRACTURE TYPES:Extra-articular
75%-80% of stable fractures treated closed
Signs of instability:Dorsal comminutionSignificant
displacementVolar displacement
Colles #Described by Abraham Colles in
1813
Classic definitionTransverse #2.5 cm proximal to radio-carpal
jointDorsally displaced & dorsally
angulated
“Dinner-fork” deformity
From FOOSH onto a dorsiflexed wrist with forearem pronated
FRACTURE TYPES: “Colles Type”: Dorsally displaced
Treatment algorithm:Hematoma block/ conscious sedationClosed reduction
In-line traction relying on “ligamentotaxis” Exaggerate deformity (increase dorsal angulation to
unlock volar cortex) Direct pressure on distal fragment to correct angulation
3 point casting
FRACTURE TYPES: “Colles Type”: Dorsally displaced
FRACTURE TYPES: “Colles Type”: Dorsally displaced
Use finger traps OR assistant for counter traction
Traction
Traction
Traction
When you think you have enough….more traction
FRACTURE TYPES: “Colles Type”: Dorsally displaced
FRACTURE TYPES: “Colles Type”: Dorsally displaced
FRACTURE TYPES:Extra-articular Stable
Post reduction xrays
Careful evaluation of anatomy
Careful patient instructionsTight cast necessary
Close follow-upXrays and evaluation weekly for three
weeksArgument about length of immobilization4-6 weeks
FRACTURE TYPES:Extra-articular Unstable
Smith’s # “reverse Colles #”volar angulation/displacement of
distal fragmentFOOSH onto hyperflexed or
supinated wristVery unstable #Rx’ed with ORIF (volar plating)
FRACTURE TYPES:Extra-articular Unstable
Surgical Treatment Options CR
Percutaneous k-wire fixation (+/- Kanpandji technique) Casting
External fixator +/- k-wire fixation Careful attention to soft tissue/overdistraction
ORIF Dorsal plating Volar fixed angle plating
Percutaneous Pinning Good results in lower energy injuries
At least 0.062 size
Technique: 1 radial styloid pin (avoid first ext
compartment) directed ulnarly 1 pin from dorsal-ulnar corner (b/w 4th and 5th
ext compartments) directed volarly + radially Advance to penetrate cortex of radial shaft
proximal to zone of metaphyseal comminution Augment prn
Apply plaster or fibreglass cast
Remove pins at 4-6 weeks
Kapandji technique
“intra-focal” pinning
Traps distal fragment by buttressing it from displacing
Pin is placed thru the # site and maneuvered to elevate the fragment
Once adequate reduction achieve, pin is driven thru opposite cortex to achieve stability
Can restore radial inclination + volar tilt
External-FixationCan restore radial length and radial
inclination, or if soft tissue problems
Provides traction Excessive traction associated with CRPS
(look for increased intercarpal distance on fluorscopy)
Some loss of volar tilt Supplement with percutaneous pinning
Associated with loss of ROM vs. ORIF
Risk of pin site infections
External Fixation
Pin placement 2 pins on ‘bare area’ of
radius just proximal to 1st
dorsal compartment outcroppers, b/w ECRB + ECRL
Watch for superficial radial N
2 pins in second MC
ORIFDorsal vs Volar plating
Locking vs non-locking plates
DORSAL PLATING
Excellent exposure to articular surface
Avoids neurovascular structures
Fixation on compression side of #, acts a buttress against collapse
Early plate designs bulky
Increased wrist stiffness and extensor tendon problems
Smaller implants in evolution
DORSAL APPROACH
Between 3rd + 4th dorsal extensor compartments
Do not violate ECRB subsheathRepair retinaculum
VOLAR PLATING
Early return of function
Improved ROM
No extensor tendon problems
Easier reduction: less comminution volarly
Fixed angle implants (locking)Not reliant on distal screw purchaseSupports subchondral plateAble to maintain # reduction in presence of dorsal
comminution
VOLAR APPROACH
Interval b/w FCR + radial artery
Palmar cutaneous branch of median N. at risk (b/w FCR and PL)
Elevate pronator quadratus with intent to repair!
Release of BR for exposure, partial or full
VOLAR PLATING
Early return of function
Improved ROM
No extensor tendon problems
Easier reduction: less comminution volarly
Fixed angle implantsNot reliant on distal screw purchaseSupports subchondral plate
FRACTURE TYPES:Intra-articular fracture CHAUFFEUR’S FRACTURE:
Avulsion # with extrinsic ligaments remaining attached to radial styloid
Associated with backfiring of automobile crank starters
Direct axial compression of scaphoid into radial styloid with wrist in dorsiflexion + ulnar deviation
Associated injries Scapholunate dissociation Perilunate dislocation
ORIF often necessary
FRACTURE TYPES:Intra-articular fracture
BARTON’S FRACTURE: shear # of dorsal or
volar rim of distal radius, with associated subluxation of carpus
Volar (“reverse”) type more common
Principles of intraarticular fractures apply
ORIF on side of fracture
FRACTURE TYPES:Barton’s Fracture
Buttress plate, does not need to have fixation in fragment
Indirect reduction of articular surface via volar approach
Dorsal approach allows visualization of articular surface
FRACTURE TYPES:Intra-articular
Two part: Die-punch
Impaction from lunate, causes depression of lunate facet
Three part: Scaphoid facet, lunate facet,
sigmoid knotch
Four part: Split in lunate facet
FRACTURE TYPES:Intra-articular
Can be very complex fracture patterns.
Articular surface WILL NOT be visible via volar side
Pre-op CT helps with planning
FRACTURE TYPES:Intra-articular
ORIF is standard of tx
Maximum of 1-2 mm of gap, 1 mm of step
Indirect reduction in volar approach
Post-traumatic OA in inadequate reduction.
GOALS OF ORIFYoung, active
Articular step/ gap < 1mm Radial shortening < 2mm Neutral volar tilt Radial inclination >10˚
Elderly, sedentary <10˚ dorsal tilt 2mm shortening Reduced RIA <2mm step
Arthroscopically-guided reduction
Arthroscope placed in dorsal 3,4 portal
Probe inserted in dorsal 4,5 portal
Radial styloid fragment stabilized with percutaneous K-wires
ULNAR STYLOID
Injured in 50-70% of cases
Review papers have shown that presence/non-union does not affect long term outcome
BASE OF STYLOID:Associated with detachment of TFCCDRUJ instabilityTension band wire/small fragment screw
COMPLICATIONS:Nerve Injuries
Median Nerve:Initial sensory loss can be observed if not
progressiveAny progressive changes/unremitting pain
Immediate carpal tunnel release If concern about forearm compartments,
fasciotomyNerve can be explored/released at time of
OR if any concernLate median nerve symptoms associated
with CRPS
COMPLICATIONS:Tendon Adhesions/Ruptures
Casting must leave MCPs free for ROM
Tenosynovitis can involve any dorsal compartmentMost common in first
EPL ruptureFirst 8 weeksIschemic/mechanical mechanismEIP to EPL rupture unless discovered acutely
COMPLICATIONS:Malunions
Treatment depends on:Patient demandsLocation of symptomsNature of malunion
>15 degrees of dorsal angulation in young person:Opening wedge dorsal osteotomyRequires significant planning to address
multiplanar deformity (RIA, Tilt, Length)
COMPLICATIONS:Malunions
Ulnar sided impingment/pain:Most common complaint from malunionMultiple options dependent on nayure of problem:
Ulnar shortening osteotomy Hemiresection arthroplasty for DRUJ malunion Many procedures described
Do we have evidence to justify our current practice?
Review of case lists of applicants of American Board of Orthopaedic Surgery from 1999-2000Proportion of DR#’s
treated with Open treatment vs Closed percutaneous fixation increased from 42% in 1999 to 81% in 2007
Koval, JBJS 2008
Do we have evidence to justify our current practice?
Biomechanical Dorsal plating (locked and not locked) stronger than
volar in cadaveric studyClinical implications?
Trease, J of Hand Surg, 2005
Do we have evidence to justify our current practice?
RECENT PUBLICATIONS:Do we have evidence to justify our current practice?
New dorsal plates:Universally good functional outcomes23 % had plate removal for extensor tenosynovitis
+/- limitation in flexionAuthor’s recommended plate removal
Khandjula, Acta Orthopeadica Scan, 2005
RECENT PUBLICATIONS:Do we have evidence to justify our current practice?
Volar locked plating:Universally good functional outcomesAll dorsally displaced fractures in the elderly12 month follow-upNo comparison arm
Wong, JOT, Aug 2005
THE END