1. Dr Y Thimma ReddyAssistant Professor & Registrar Department of OrthopedicsOSMANIA MEDICAL COLLEGE
2. Distal Radius Fractures Common injury Potential for functional impairment and frequent complications
3. HISTORY First surgeon to recognize these injuries was Pouteau 1783. his work was not widely publicized. Later Abraham Colles 1814 gave the classic description of fracture Dupuytren brought to the world attention that it is a fracture rather than a dislocation as it was previously assumed. Goyrond 1832 differntiated between dorsal and volar displacement. Barton 1838 described wrist subluxation consequent to intraarticular fracture of radius which could be dorsal or volar. Smith described fracture of distal radius with „forward‟ displacement. Advent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.
4. Incidence One sixth of all fractures treated in the Emergency Room Bimodal distribution ○ less than 30 years (70% men) ○ over 50 years (85% women)
5. Introduction Occurs through the distal metaphysis of the radius May involve articular surface frequently involving the ulnar styloid FOOSH forced extension of the carpus, impact loading of the distal radius. Associated injuries may accompany distal radius fractures.
6. Diagnosis: History and PhysicalFindings History of a FOOSH Visible deformity of the wrist, with the hand most commonly displaced in the dorsal direction. Movement of the hand and wrist are painful. Adequate and accurate assessment of the neurovascular status of the hand is imperative, before any treatment is carried out.
7. Diagnosis: Diagnostic Tests andExamination General physical exam of the patient, including an evaluation of the injured joint, and a joint above and below Radiographs of the injured wrist CT scan of the distal radius in selected instances.
9. Anatomy scaphoid and lunate fossa Ridge normally exists between these two sigmoid notch: second important articular surface triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid
20. Three Column Theory Radial Column Lateral side of radius Intermediate Column Radial column Ulnar column Ulnar side of Intermediate column radius Ulnar Column distal ulna
21. Classification – Fernandez(1997) I. Bending- metaphysis fails under tensile stress (Colles, Smith) II. Shearing-fractures of joint surface (Barton, radial styloid)
22. Classification – Fernandez(1997) III. Compression- intraarticular fracture with impaction of subchondral and metaphyseal bone (die-punch) IV. Avulsion-fractures of ligament attachments (ulna, radial styloid) V. Combined/complex - high velocity injuries
23. Assessment of X-rays Assess involvement of dorsal or volar rim Is comminution mainly volar or dorsal? is one of four cortices intact? Look for “die-punch” lesions of the scaphoid or lunate fossa. Assess amount of shortening Look for DRUJ involvement
24. Dorsal angulation and comminution
25. Volar subluxation of carpus with fracture fragment
26. Options for Treatment Casting Long arm vs short arm Sugar-tong splint External Fixation Joint-spanning Non bridging Percutaneous pinning Internal Fixation Dorsal plating Volar plating Combined dorsal/volar plating focal (fracture specific) plating
27. Treatment Goals Preserve hand and wrist function Realign normal osseous anatomy promote bony healing Avoid complications Allow early finger and elbow ROM
28. Indications for ClosedTreatment Low-energy fracture Low-demand patient Medical co-morbidities Minimal displacement- acceptable alignment
29. Closed Treatment of DistalRadial Fractures Obtaining and then maintaining an acceptable reduction. Immobilization: long arm short arm adequate for elderly patients Frequent follow-up necessary in order to diagnose redisplacement.
30. Technique of ClosedReduction Anesthesia Hematoma block Intravenous sedation Bier block Traction: finger traps and weights Reduction Maneuver (dorsally angulated fracture): hyperextension of the distal fragment, Maintain weighted traction and reduce the distal to the proximal fragment with pressure applied to the distal radius. Apply well-molded “sugar-tong” splint or cast, with wrist in neutral to slight flexion. Avoid Extreme Positions!
31. Acceptable ReductionCriteria No dorsal angulation > 15 degrees of inclination Articular step-off < 2mm < 5 mm shortening compared to opposite wrist. DRUJ congruent
32. After-treatment Watch for median nerve symptoms parasthesias common but should diminish over few hours If persist release pressure on cast, take wrist out of flexion Acute carpal tunnel: symptoms progress; CTR required Follow-up x-rays needed in 1-2 weeks to evaluate reduction. Change to short-arm cast after 2-3 weeks, continue until fracture healing.
33. Management ofRedisplacement Repeat reduction and casting – high rate of failure Repeat reduction and percutaneous pinning External Fixation ORIF
34. Indications for ImmediateSurgical Treatment High-energy injury Open injury Secondary loss of reduction Articular comminution, step-off, or gap Metaphyseal comminution or bone loss Loss of volar buttress with displacement DRUJ incongruity
35. Operative Management of DistalRadius Fractures
36. External fixation:The treatment of choice fordistal radius fractures in the 1980‟s
39. Spanning ( Ligamentotaxis) A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals
40. Non-spanning A non-spanning fixator is one which fixes distal radius fracture by securing pins in the radius alone, proximal to and distal to the fracture site.
41. Courtesy of HillHastings,MD
42. External Fixation- Disadvantages - Bulky Poor screw hold in porosis and comminution Screws do not buttress More invasive
43. Ligamentotaxis Adverse effect of carpal over- distraction well documented Kaempffe (1993): pain, function, grip strength adversely affected Gupta (1999): 10# of distraction can induce over 10mm of ligament elongation Davenport (1999): 10mm carpal distraction produces >20% increase in ligament strain
44. Complications Complication rates high in almost all reported series Mal-union Pin track infection RSD / arthrofibrosis Finger stiffness Loss of reduction; early vs late Tendon rupture
45. Percutaneous Pins
46. Percutaneous Pins
47. Percutaneous Pinning-Methods variety described most common radial styloid pinning + dorsal-ulnar corner of radius pinning supplemental immobilization with cast, splint in conjunction with external fixation (Augmented external fixation)
48. Percutaneous Pinning 2 radial styloid pins - Mah and Atkinson, J Hand Surg 1992 excellent anatomic 82% good-excellent functional results 100% radial styloid with dorsal - prospective study, 30 pts (Clancey JBJS 1984) excellent anatomic results in 90%
49. Percutaneous Pinning-Kapandji intrafocal pinning through fracture site buttress against displacement good results in literature
50. Internal Fixation of Distal RadiusFractures Useful for elevation of depressed articular fragments and bone grafting of metaphyseal defects required if articular fragments can not be adequately reduced with percutaneous methods
51. Selection of Approach Based on location of comminution. Dorsal approach for dorsally angulated fractures. Volar approach for volar rim fractures Radial styloid approach for buttressing of styloid Combined approaches needed for high- energy fractures with significant axial impaction.
52. VOLARClassical Henry approach Extended carpal tunnel approach
53. Volar –Henry Approach
54. Radial to FCR
55. Elevate Pronator Quadratus
56. Distal Radius-volar barton 64 yo M, MVA, contralateral tibial shaft Fx
57. Dorsal Fracture
58. CT Scan
59. DORSAL APPROACH 3rd DC –EPL1-2nd DC (extensile) -
60. Dorsal Plating, PCP and Ex Fix
61. Volar Plating for Dorsal Fractures -less tendon irritation than dorsal
62. Fixed angle locked screws ,,variable angle
63. Courtesy J. Orbay,MD
64. Courtesy J. Orbay, MD
65. Fragment Specific System
66. Radial and Ulnar Columns -Pin plates -90-90 plating technique
76. Conclusions Need to be able to use all tools for treatment of distal radius fractures Both external fixation and ORIF are useful. ORIF better in high-energy fractures associated with depression of articular surface ORIF gives better anatomic restoration, although not necessarily higher patient satisfaction.
77. Conclusions External fixators still have a role in the treatment of distal radius fractures Spanning ex fix does not completely correct fracture deformity by itself Should usually combined with percutaneous pins (augmented fixation)
78. Conclusions new plating techniques allow for accurate and rigid fixation of fragments Plating allows early wrist ROM Volar, smaller and more anatomic plates are better tolerated combination treatment is often needed
79. Relationshipof Anatomy to Function Colles; “The wrist will regain perfect freedom in all of its motions and be completely exempt from pain” (1814) Generally true for low demand individuals Direct relation between residual deformity and disability Quality of reduction more important than method of immobilisation