IC 24: What You Don't Know About Distal Radius Fractures

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IC 24: What You Don't Know About Distal

Radius Fractures

Moderator(s): Julie E. Adams, MD

Faculty: Julie E. Adams, MD, Ruby Grewal, MD, MSc, FRCS(C), Jerry I. Huang, MD,

Juan Manuel Breyer, MD

Session Handouts

Friday, September 06, 2019

74TH ANNUAL MEETING OF THE ASSH

SEPTEMBER 5 – 7, 2019

LAS VEGAS, NV

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

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The Lost and Found Art of Non-Operative Treatment:Are We too Aggressive w Surgery?

Ruby Grewal, MD, FRCSCAssociate Professor, Division of Orthopedics, University of Western Ontario, London, ON

Disclosure• I have no conflicts to Disclose

Are We too Aggressive w Surgery?

• Two Undeniable Facts

1) there are more elderly citizens than ever before

2) they are more active than ever before

Elderly Population Growing Rapidly

More Seniors than Children

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Falls Very Common in this Age Group Elderly are More Active than Ever Before

• Over the past 40 years, the proportion of older adults in the general population is increasing

• They are maintaining a higher level of activity

• Nellans KW, Kowalski E, Chung KC: The epidemiology of distal radius fractures. Hand Clin 2012;28(2):113-125.

Incidence of DRF is Increasing

• Second most commonly fractured bone in older adults

• Most common fracture in women >50 years of age• Levin et al. J Am Acad Orthop Surg 2017;25: 179-187

Are We Operating More?

ORIF increased from 3% to 16%

CR decreased from 82% to 70%

JBJS Am 2009

Treatment Trends

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Treatment Trends Treatment Trends

BUT Are We Operating TOO MUCH?…..it depends

Who is an “Older” Patient?

VS.

Low Demand Elderly

• No Advantage to operative fixation

• No advantage to Closed Reduction

• Operative Rates are Decreasing

Are we Operating on too Many DRF’s?

Young and Rayan 2000Chang 2001Beumer and McQueen 2003Hevonkorpi 2018

Decreasing Incidence of Operative Tx in patients >80 years

Hevonkorpi 2018

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What about Younger Patients?

Hevonkorpi 2018

AAOS CPG 2009 – Indications for ORIF

• the benefits exceed the harm• but the strength of the supporting

evidence is not as strong• Implications: Practitioners should

generally follow a Moderaterecommendation but remain alertto new information and besensitive to patient preferences.

• post-reduction radial shortening >3mm• dorsal tilt >10 degrees• intra-articular displacement or step-off >2mm

Moderate

AAOS Clinical Practice Guidelines - 2009

Patients > 55 years

Inconclusiveunable to recommend for or against operative

treatment for patients older than age 55 with DRF

What’s Changed Since 2009?

Egol et al. JBJS 2010• Case-control study, unstable DRF >age 65 • Operative (n=44) vs. Non-operative treatment (n=46)

• Radiographic outcome Better with ORIF

• Wrist Extension 8.5° Better with ORIF at 6 m

Egol et al. JBJS 2010• At 1 Year

• No Difference DASH, complications

• Supination 3.3° advantage ORIF

• Grip Strength 5 kg advantage ORIF

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• Surgical treatment was not standardized• Either ORIF (VLP) or ExFix and pins

• Selection Bias• Non-operative group offered surgery, but declined• Did they self select into group that can tolerate malunions?

Egol et al. JBJS 2010Arora et al. JBJS 2011

• prospective randomized trial• ORIF with VLP (n=36)• CR + cast (n=37)• Primary outcome: PRWE, DASH • Other outcomes: ROM, complications, x-ray

• Inclusion• independent living patients• without systemic medical conditions • Able to travel on their own to the clinic

• Excluded patients with low functional demands

Arora et al. JBJS 2011 • Radiographic Outcomes better with ORIF

• Dorsal tilt, radial inclination, radial shortening

• More complications with ORIF • 13 vs. 5 (p <0.05)

Arora et al. JBJS 2011

• No Difference (at all time points)• Level of pain• Range of motion

Arora et al. JBJS 2011 • Grip Strength

• Better with ORIF at all time points • 3.7 kg advantage at 6 months• 3.4 kg at 1 year


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• PROM’s (DASH and PRWE)

• Short term à better with ORIF (6w, 12 w)

• Long term à no difference (6m, 1y)


• Results – comparison between surgical and non-surgical groups

• DASH (6 studies)• No significant difference between the surgical and nonsurgical groups• pooled standard difference in means = −0.08 (95%CI −0.25 - 0.09, p=0.36)

• VAS Pain (3 studies)• No significant difference • pooled standard difference in means = 0.22 (95%CI −0.32 - 0.76, p= 0.42)

• Grip Strength (4 studies)• no difference in grip strength • pooled standard difference

in means = 0.23• 95%CI −0.26 - 0.73, p=0.35

• ROM• No significant difference in extension, pronation, supination, ulnar deviation• More flexion, radial deviation

Flexion Radial Deviation

• Conclusions• Surgical and Non-Surgical methods

produce similar results in the treatment of DRFs in the elderly

• Minor objective functional differences did not impact subjective functional outcome and quality of life.

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AAOS CPG 2009 – Casting Guidelines

Cast for Unstable Fractures that are initially adequately reduced

Evidence does not allow for a recommendation for or against• Exercise judgement, consider patient preference, consider new evidence

Inconclusive• Ages 18-75• VLP vs. Cast • AO type A2 and A3• n=92• 1 year follow-up

J Bone J Surg 2019;101(9):787-96

DASH Scores

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6 we ek s 3 m on ths 6 m on ths 12 mo nth s

VLP Cast p <0.05

DASH Scores

0

5

10

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20

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30

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40

45

50

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60


VLP Cast p <0.05

15

10

5

0

PRWE Scores

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VLP Cast p <0.05

Best Evidence – Advantages w Surgery

• Better short term outcomes• DASH and PRWE 6 weeks and 3 months

• Possibly a marginal advantage w objective measures• Flexion • Radial deviation• Extension and supination in some studies • Grip strength in some studies (<5kg)

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Disadvantages of Surgery• Cost

• Complications• Greater complication rates• With questionable benefit in certain patients

• Malunion doesn’t seem to matter• Some can tolerate a malunion while others can’t• How do we differentiate between these patients?

The Cost of Distal Radius Fractures

• Internal Fixation costs Medicare nearly 3X more than cast treatment

Levin et al. J Am Acad Orthop Surg 2017;25: 179-187

• Complications (p=0.03)• Operative 37/129 (29%) • Non-Operative 22/129 (17%)

• Most Common Complications• Median Neuropathy: Operative – 8, Non-Operative – 14• Surgical Site Infection: 16 (12/16 were pin site infections)• CRPS: Operative – 4, Non-Operative – 3

Operative Non-Operative

Re-Operation Rate 11 (9%) 7 (5%)

Malunion 29% 69%PRWE 16.9 15.7 p=0.80

p<0.001

p=0.33

• Retrospective Review 2007-2014 Closed vs. Open treatment• n = 155,353 majority treated w CR• Increase in rate of ORIF between 2007-2014

• For all age groups• Largest increase (11%) in 70-79 year age group

• Trend towards decreasing complications rates as age increased• comorbidities were more strongly associated with the risk of developing

complications than age.

In what situations can malunion be tolerated?

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012345678910

40 45 50 55 60 65 70

2 2 2 2 2 2 23

4 4 45

810

belo w age cu t-o ff abov e age cut -of f

NNH

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2

8

age < 65 age > 65

NNH

Limitations of our Literature

• Depend on Chronological age and not Physiologic age

• How to determine physiologic age?• Future studies need to take this into account • Performance based metrics for frailty

• 4 or 6 minute walk test, timed up and go, grip strength• Nutritional Status

• BMI, Weight loss

Is Casting a Lost Art?

Pearls of Non-Operative Treatment

• Is this a lost art?• Focus during residency à mastering surgical techniques

• Nuances of conservative treatment are often overlooked.

• casts are routinely applied by cast technicians, physician assistants• further decreasing the amount of training residents receive in casting.

• Despite these limitations in training and exposure, cast immobilization remains a mainstay of treatment

• Non-invasive, cost effective, low morbidity

Recognize Stable vs. Unstable Fractures• Unstable

• >20˚ Dorsal (or volar) angulation on initial x-rays• Displacement of more than 2/3 the width of the shaft in any direction• Metaphyseal comminution• >5mm shortening• Intra-articular component• Associated ulnar fracture• Advanced osteoporosis

• High risk for secondary displacement in a cast• despite acceptable initial reduction and correct plaster techniques

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Good Anesthesia is the Key! Hematoma Block +/- Sedation Longitudinal Traction

Closed Reduction Don’t Use too Much PaddingBony prominences and cast edges must be well padded

More skin irritation from shear stress at skin/padding interface

Too much Padding

Loose Cast

Loss of Reduction

3 Point Mold + Casting Well Molded doesn’t mean TIGHT!

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Cast Index• Cross section of cast – oval not a circle• Sagittal to coronal ratio should be 0.7 (<0.8 in some studies)

58yo F, FOOSH on Ice

Week 1 Week 1

Week 2 Features of a Good Cast

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Casting Pitfalls• Don’t Dimple the cast

• Causes high pressure areas under cast

• No Direct contact between skin and casting material

• Don’t move the limb position after cast has started to set• Will cause bunching of cast material and increased pressure in flexion

crease

Follow-Up Routine

• Week 1• Week 2• Week 3

• Cast change as needed in first 3 weeks• For cast change - suspend unstable fractures in finger traps to prevent

loss of reduction • Week 6

• Removal of cast

• Early Instability • Predicted by degree of radial shortening and volar tilt (p<0.05)• Dorsal comminution approaching significance (p=0.06)

• Late Failure• Predicted by inclination, age, shortening, volar tilt were predictive (p<0.05)

• 1/3 of undisplaced fractures went on to fail• most occurred in patients over the age of 65 years.

Prepare for Cosmesis of the Malunion• Warn patients about the ‘look’ of their arm – It may look crooked but will likely

work just fine!

Are we operating on too many DRF’s? • Summary

• When to Operate?• Consider instability of fracture pattern, cost of treatment, complications

• Consider physiologic vs. chronologic age• and other patient factors – hobbies, hand dominance

• Pearls of non-operative management• Well molded cast is key• Follow weekly for first 3 weeks, change cast if loose• Prepare older patient for asymptomatic malunion

Julie E. Adams MD

Professor of Orthopedic Surgery

ASSH 2019 Annual Meeting

[email protected]

What you don’t know about distal radius fractures can hurt you

Julie E. Adams MD

Professor of Orthopedic Surgery

Mayo Clinic Health System

ASSH 2019 Annual Meeting

[email protected]

Beyond Just the Bone: Decision Making and Avoiding Complications

Arthrex

Acumed

Zimmer Biomet

Disclosures

• Everyone in this room is an expert in treatment of

distal radius fractures

• It is easy to be carried away by the mundane.

• When is that simple distal radius fracture not so

simple? What pearls and pitfalls can be shared about

distal radius fractures & wrist trauma?

• How can we avoid unpleasant surprises?

Introduction

#1

• Pitfall: Failing to put hands on the patient

• Your physical exam is better than Xrays

DORSAL

• Lister’s tubercle• Radius• 3rd DEC • SL• Midcarpal joint• Lunate• 4th and 5th DEC• CMCs• Distal ulna

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• Avoid by immobilizing and repeating films in 1 week….

• Avoid by immobilizing and repeating films in 1 week…

#1 Occult distal radius fracture

Occult distal radius fracture #2 Avoid the temptation of always pursuing operative treatment

• Closed reduction & casting is EFFECTIVE for most patients – Howard JBJS-B 1989: RCT ex fix vs nonop 19/24 excellent

results– Arora JOT 2009: RCT CRC vs plating in pts > 70 yo – no

difference in functional outcomes

Literature

• AAOS Clinical Practice Guidelines:– 29 recommendations about care– Recommended: “assess post-reduction/final lateral films to ensure

DRUJ reduced”– “Due to current limitations, further study is required…regarding

surgical vs nonsurgical treatment as preferred treatment of elderly and sedentary patients”.

So, how do you decide on treatment?

• La Fontaine’s criteria…– Risk factors associated with re-displacement of successfully reduced distal

radius fractures… if > 3 factors present, high risk of displacement

• Dorsal angulation of > 20 degrees• Comminution• Intra-articular involvement• Distal ulna fracture• Age > 60 years

– Add: osteoporosis. (Dias, Wray, Jones: osteoporosis is a factor leading to greater progression of deformity following casting)

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So, how do you decide on treatment?

• Follow weekly with serial xrays x first 3 weeks to ensure displacement does not occur !!

• If cast treatment chosen….– Typically 6 weeks total in SAC

– Digital motion encouraged

– If they are tentative, therapy (don’t neglect the shoulder)

• I accept a lot of deformity in frail/ elderly / infirm patients

• Caveats with nonoperative fractures…

• Beware EPL rupture

Snake #3

• Nondisplaced DRF• Up to 5% incidence (Roth et al 2012)• Watershed nutritional zone (Hirasawa)• ? Pathophysiology

– Fracture fragment– Injury at time of fracture– Vascular phenomenon

• Prodromal symptoms may be present

EPL rupture-distal radius fracture

Diep & Adams, Fromison, Wolfe, Huang & Strauch. Choi

et al.

Case: 39 yo woman FOOSH Initial X rays

• Immobilized x 6 weeks

• Cast removed, very painful

Case: patient with non displaced DRF

• Treated elsewhere with SAC x 6 weeks

• Cast removed, very painful


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• Still painful at about 8 weeks post injury

• MRI ordered

• Referred with “TFCC tear” and “membranous

SL tear”

Case: patient with non displaced DRFMRI

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• Exam: WE/WF: 20/20 vs 70/70 on right• Sup/pro 60/60 vs 85/85• Painful over Lister’s and over EPL • Pain with thumb extension


• WALANT release of EPL

• EPL thinned, typical tendinopathy appearance (pale, thinned, nearly translucent)

• Followup at 4 weeks: no pain with EPL, intact EPL function

Case: patient with non displaced DRFEPL

Proximal

Distal

Radial wrist extensors

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#4 Pitfall: having only one arrow in your quiver

Literature

• Koval et al: Fractures of the Distal part of the Radius: The evolution of practice over time. Where’s the evidence?

• ABOS part 2 candidates• Open surgical treatment 42% (1999) to 81% (2007)• Largely related to enthusiasm for Volar locked plates• Despite lack of improvement in surgeon-perceived

functional outcomes• …Or clear evidence of improved outcomes…

Koval, Harrast, Anglen, Weinstein JBJS 2008

Literature

AAOS 2009

Pitfall: failing to use that “arrow” appropriately

PROBLEMS

• Dorsally prominent screws

• Irritation of flexor tendons

• Intra-articular screws

• Mal-reduction

Arora et al JOT 2007

Volar plating cannot treat every fracture

DRUJ- dorsal subluxation of ulna

Volar Subluxation

Volar ulnar fragment

Courtesy of MDP

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Volar plating cannot treat every fracture

Courtesy of MDP

Advantages of external fixation

• Maintain axial length

• Minimal exposure

• No retained Hardware

• Quick! (27-36 min in one series)

• Acceptable complication rate

• Widely available

• Easily learned and adaptable

• Minimal OR staff education

• DRUJ, digits mobile

External fixation

Perceived barriers to external fixation….

• “Difficult”• “pin pull out in osteoporotic bone”• Pin site issues• Extensor tendon issues• RSD• Limited number of fractures amenable

McQueen et al

In Edinburgh study 77% put in by residents(none in series of 588 cases)

(60%-McQueen, high percentage -McKee)

(similar incidences in ExFix vs Cast vs ORIF-- Kreder et al JOT 2006, McQueen et al)

(1%) No higher than with other techniques

most minor and adequately treated if needed with oral antibiotics

Alternative: Spanning internal fixator

• Popularized by Ruch and Hanel

• Conceptually neutralize forces on the wrist

allowing healing

• Advantages: no external hardware

• Good for comminuted and osteoporotic or high

energy fractures

• Remove hardware in 3-4 months

• Motion of wrist surprisingly good in published

series.

Case

• 62 year old Caucasian slender Female

• FOOSH ground level height. Right distal radius

fracture, Left radial head fracture

• History of Left hip fracture 2 yrs prior

• Hep C, hypothyroidism

• Smoker

Case






• Smoker

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Case






• Smoker

Point:

• Don’t forget alternatives to volar plating.

• Be vigilant about appropriate technique for volar plating.

• Recognize and promptly treat associated nerve issues

#5

• 33 yo man bicyclist vs road curb

• FOOSH bilaterally

• CHI, intoxicated at scene

• Bilateral DRF

• Back pain

Case

• closed reduction performed on Right

• Endorsed N/T bilaterally

• First responder documents 2 point pre/post reduction in median nerve on R as “1cm”

• Patient admitted to ICU

Case

• Seen daily in ICU

• 2 point documented at 1 cm in median nerve

• Discharged and told to followup with hand surgeon

• Seen at 12 days post injury

Case

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• Dense median neuropathy on Right

• Digital stiffness, hypersensitivity and pain

• Trophic changes

• Absent sensibility in median nerve

• Absent APB function

• Burning dysesthesias

Case

• ORIF Right DRF + CTR– Nerve in continuity

• CRIF Left DRF

• Early supervised therapy program

• Vitamin C and gabapentin prescribed….

• …..But…

Case

• Seen in followup over next 3 months

• Hand cuffed and with 2 guards (parole violations)

• Digital stiffness, hypersensitivity and pain

• Trophic changes

• Absent sensibility in median nerve

• Absent APB function

Case

• Still resolving 5 months post injury

• EMG: “likely permanent APB /motor branch changes….little potential for resolution…”

• 2 point > 1 cm in thumb and index, 8 mm in long finger

• APB atrophy

Case

• Point: even neurapraxia treated promptly can take time to resolve.

• Don’t be part of the “problem” – be part of the “solution”

• Compression of nerve can be a source of permanent sequelae and a source of CRPS type 2

• Presence of nerve symptoms that worsen or do not resolve are an indication for surgical release

• When is DRUJ instability a problem?

• An ulnar styloid fracture is not in itself an indication for treatment, but can be indicative of DRUJ instability

6 – Don’t forget about “the other bone”

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• 27 year old RHD woman

• Rollerblading FOOSH with grade 1 open DRF

• Absent Ulnar nerve sensation and function distally

Case Case

Closed reduction, no change in ulnar nerve symptoms

ORIF

Nerve contused but intact. DRUJ unstable all positions

ORIF

Final followup 13 months… Grip R/L 60/60#

Ulnar nerve symptoms completely resolved…. 3 months after surgery…

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Closed reduction, no change in ulnar nerve symptoms

ORIF

• Ulnar styloid basal fractures and radial translation /increased DRUJ gap may be indicative of postop DRUJ instability

• Algorithm: Fix DRF anatomically

• Assess DRUJ stability

• If unstable – and cannot identify a stable position, must do “something”

Point:

• May et al: ulnar styloid base fracture and significant displacement of ulnar styloid fracture increase risk of DRUJ instability

*Contrast: Kim et al JBJS 2010

Showed NO correlation of risk of

Instability to displacement of styloid

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• Radial translation is the best predictor of DRUJ instability

• Fujitani et al JHS 2011

Risk factors for DRUJ instability #7 There is a big picture. Don’t miss it!

#8 Don’t miss the big picture

• Distal radius fractures are often fragility fractures

• A prior fragility fx is the among the best predictors of a future event– Prior low energy fx is a 2-6 fold increased risk of future

fracture and risk of significant disability (AAOS)

– The orthopedic/plastic/hand surgeon is often the first and or only physician to see these patients.

– Interventions include Ca, Vit D, prevention programs or pharmacologic agents to decrease risk by up to 50%

Don’t miss the big picture

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Evaluation Bone Mineral Density assessment in:

• Women > 65 or men > 70 with or without risk factors

• PMP women < 65 or men < 70 with > 1 risk factor– Low body weight

– Prior fx

– High risk medication use

– Disease/condition associated with bone loss

• Adults with a fragility fracture

• All patients with multiple risk factors

ISCD 2013

Interventions

• Dietary

• Exercise

• Fall prevention

• Bisphosphonates

• You don’t have to initiate TREATMENT…but you do need to start the CONVERSATION.

Case






• Smoker

Case






• Smoker

T Score of -3.3

#8 Pitfall: not recognizing “host” issues

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Sadly, we are overwhelmingly: sedentary

overweight(36.5% obesity rate in USA per CDC)

adequate (excessive) calories, inadequate nutrition

typical American …

• Vitamin D deficiency is endemic and epidemic

• 1000-2000 IU daily

Be aware of “host” issues!

• Serum level of 25(OH) D should be 30-100 ng/ml– 40-60 is “ideal”

• Moderate deficiency: 21-29 ng/ml

• Deficiency associated with cancers, CV disease, peripartum issues, hypertension, increased mortality, CNS issues, autoimmune disorders, insulin abnormalities, and BONE HEALTH, most issues likely associated with PTH

#8 Be holistic

Grober et al:Vitamin D Dermatoendocrinol 2013

• > 35th parallel from Oct - Mar, insufficient UV exposure for vitamin D metabolism

• UV index of <3, no vitamin D synthesis in skin

• i phone app: Dminder.info

#8 Be holistic


RX:

• All fractures take 2000IU daily empirically

• Oral vitamin D2 or D3 is effective

• Cumulative dosing is fine (ie, once a week or once a month)

• Strategy for grossly deficient: 50,000 IU weekly x 8-12 weeks. Once sufficient, can do 50,000 IU q 2 wkindefinitely without toxity

#8 Be holistic


Who gets a vitamin D level tested in my practice?

• “at risk”– Autoimmune or absorption issues

• DM 1, Celiac, eating disorders, “different” diets

– Medically ill or elderly

– Ethnic population

• “intuition”

#8 Be holistic


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• Vitamin C

• 500 mg daily x 50 days

• CRPS (?)

• Controversial

• Based on few studies AAOS Guidelines

• Stay tuned…recent data demonstrates no difference!

#8 Be holistic

• Smoking cessation counseling

• May be linked to your reimbursement / ratings in the future…

#8 Be holistic

#9 Not everything that hurts in the wrist is a fracture….

• Derm resident

• Foosh off scooter

• Pain at base of 5th mc

• Pain over wrist

• Pain dorsally with Watson’s

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5th MC base fx, SL injury

Detection

• Rule in/out fracture, ligament injury

• Provocative maneuvers

• Location of tenderness

• Plain film xrays

• ? Advanced imaging studies

Detection of “other” injuriesSummary

• Wrist trauma is often straightforward– but not always….

• Careful attention to potential patient/injury/fracture factors as pitfalls

• Have more than one “arrow” in your quiver

Summary

Ulnar NeuropathyDecompression vs. Transposition

• They make (us) look good– Hand therapists

– Clinic nurses / MA’s / LPNs / RNs, PAs and NPs / Support staff

– Administrative assistants

THANK YOU

#10- Don’t forget your team –

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8/17/19

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Dorsal'Spanning'Bridge'Plate'for'Distal'Radius'Fractures:

Indications'and'Surgical'PearlsJerry'I.'Huang,'MDAssociate'Processor

Dept of'Orthopaedics and'Sports'MedUniversity'of'Washington'Medical'Center

ASSH'2019'ICL'

Vakshori et+al.+HAND+2018

“Declining+Use+of+Spanning+Wrist+ExAFix”

• NIS+database• 40,000A50,000/+yr• ExAFix+applicationdecline 17%+to 5%

• More+in+rural,+nonA

teaching hospital

External)Fixation)Distal)Radius

• CR#+Cast• ORIF#+#bone graft• External fixation• Ex6Fix#w/#early ROM

• No difference at 6#wks,#3#months,#1#year• Negative#predictor:#Carpal Malalignment

52#yo F#s/p#MCA 38#yo M#s/p#MCA

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Indications*for*External*Fixation• Extra*or Simple*Intra5articular DRFx• Comminuted intra5articular DRFx• Very distal*fx or radiocarpal dislocation• Unstable internal fixation• Open*fx w/*extensive*soft*tissue injury

• 3.5$mm$DCP$plate• Originally described byBurke$and Singer$1998• Internal$ExBFix

Spanning'Bridge'Plate'vs.'Ex4Fix• Internal:'no pin tract infections and longerduration before hardware removal

• Increased length and rigidity for fractureswith meta4diaphyseal extension

• Polytrauma'or bilateral'Fx for early WB'andeasier bed to chair transfer?

23#yo Male#Polytrauma s/p#MCA

Spanning'Bridge'Plate'+'Repair'

Volar'RC'Ligaments

6"Weeks"Post*Op"Volar"Plating

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Revision(ORIF(w/(Allograft 56#yo Male#s/p#FOOSH

Lost%to%FU:%%4%Months%Later Techniques*for*Comminuted*IA*FxOption*#1• CRPP*or Limited*ORIF• External Fixator*to maintain reductionOption*#2• External Fixator*for ligamentotaxis• CRPP*+*Limited*ORIF*for articular fragments

69#yo Male#Fall#Off#Ladder Dorsal'Buttress'Plate

8/17/19

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Bridge'Plate:'Axial'Stability Intra&Op)Fluoro

Intra&Op)Fluoro! 3)Months)Post&Op

• Which Finger*is Better?• Index*vs.*Middle MC

• Slide&plate retrograde&under ECRL/B

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• 3"plate breakage in"middle and 2"distal"screw failure• Complication rate"higher if HWR">"16"weeks (20.8%"vs."8.5%)

Avoid&Over*Distraction

Courtesy,*Doug*Hanel,*MD

• Chinese&fingertraps&at 10#• Set&tension with fingers closed• Midcarpal joint space

• 11"pts w/"mean age 72"y/o• Immediate"unrestricte WB"with affected UE• 2"plate fractures• Recommend plates w/o"the central holes

52#yo Female#s/p#MCA

8/17/19

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52#yo Female#s/p#MCA 44"yo Male"Mortar"Blast"Injury

Spanning'Bridge'Plate:''Building'Block Summary• Anatomic reduction and stable fixation is moreimportant vs.7Volar7Plate7vs Ex;Fix• Beware SRN7and over;distraction in7Ex;Fix• Spanning bridge plate =7Internal7Ex;Fix• Ex;Fix7+7Spanning plate restores length +7axial7stability,7not7volar7tilt or articular congruity

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IC 24: What You Don't Know About Distal Radius Fractures