3. HISTORY
ο First surgeon to recognize these injuries was Pouteau 1783.
his work was not widely publicized.
ο Later Abraham Colles 1814 gave the classic description of
fracture
ο Dupuytren brought to the world attention that it is a fracture
rather than a dislocation as it was previously assumed.
ο Goyrond 1832 differntiated between dorsal and volar
displacement.
ο Barton 1838 described wrist subluxation consequent to
intraarticular fracture of radius which could be dorsal or volar.
ο Smith described fracture of distal radius with βforwardβ
displacement.
ο Advent of X rays at the end of nineteenth century contributed
much to the understanding of different patterns of injury.
4. Incidence
ο One sixth of all fractures treated in the
Emergency Room
ο Bimodal distribution
β less than 30 years (70% men)
β over 50 years (85% women)
5. Introduction
ο Occurs through the distal metaphysis of the radius
ο May involve articular surface
ο frequently involving the ulnar styloid
ο FOOSH
ο forced extension of the carpus,
ο impact loading of the distal radius.
ο Associated injuries may accompany distal radius
fractures.
6. Diagnosis: History and Physical
Findings
ο History of a FOOSH
ο Visible deformity of the wrist, with the hand
most commonly displaced in the dorsal
direction.
ο Movement of the hand and wrist are painful.
ο Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out.
7. Diagnosis: Diagnostic Tests and
Examination
ο General physical exam of the patient,
including an evaluation of the injured
joint, and a joint above and below
ο Radiographs of the injured wrist
ο CT scan of the distal radius in selected
instances.
9. Anatomy
ο scaphoid and lunate
fossa
ο Ridge normally exists
between these two
ο sigmoid notch: second
important articular
surface
ο triangular fibrocartilage
complex(TFCC): distal
edge of radius to base
of ulnar styloid
14. Scapholunate angle measured between lines 2 and 3
(normal 47 Β± 15 degrees)
2: Line perpendicular to 1: Line connecting dorsal and
lunate volar tip of lunate
3: Line along axis of scaphoid
15. Computed Tomography
Indications:
ο Intra-articular fxs with multiple
fragments
ο centrally impacted fragments
ο DRUJ incongruity
Cole et al: J Hand Surg, 1997
16. Classification of
Distal Radius Fractures
ο Ideal system should describe:
ο Type of injury
ο Severity
ο Evaluation
ο Treatment
ο Prognosis
17. Common Classifications
ο Column theory
ο Gartland/Werley
ο Frykman
ο Weber (AO/ASIF)
ο Melone
ο Fernandez (mechanism)
18. Frykman Classification
Extra-
articular
Radio-carpal joint
Same pattern as
Radio-ulnar joint
{ odd numbers,
except ulnar
styloid also
fractured
Both joints
19. AO/ OTA Classification
Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C:
Complete Intra-
articular
21. Three Column Theory
ο Radial Column
Lateral side of radius
ο Intermediate Column Radial column Ulnar column
Ulnar side of Intermediate column
radius
ο Ulnar Column
distal ulna
22. Classification β Fernandez
(1997)
ο I. Bending-
metaphysis fails
under tensile stress
(Colles, Smith)
ο II. Shearing-fractures
of joint surface
(Barton, radial styloid)
23. Classification β Fernandez
(1997)
ο III. Compression-
intraarticular fracture with
impaction of subchondral
and metaphyseal bone
(die-punch)
ο IV. Avulsion-fractures of
ligament attachments
(ulna, radial styloid)
ο V. Combined/complex -
high velocity injuries
24. Assessment of X-rays
ο Assess involvement of dorsal or volar rim
ο Is comminution mainly volar or dorsal?
ο is one of four cortices intact?
ο Look for βdie-punchβ lesions of the
scaphoid or lunate fossa.
ο Assess amount of shortening
ο Look for DRUJ involvement
27. Options for Treatment
ο Casting
ο Long arm vs short arm
ο Sugar-tong splint
ο External Fixation
ο Joint-spanning
ο Non bridging
ο Percutaneous pinning
ο Internal Fixation
ο Dorsal plating
ο Volar plating
ο Combined dorsal/volar plating
ο focal (fracture specific) plating
28. Treatment Goals
ο Preserve hand and wrist function
ο Realign normal osseous anatomy
ο promote bony healing
ο Avoid complications
ο Allow early finger and elbow ROM
29. Indications for Closed
Treatment
ο Low-energy fracture
ο Low-demand patient
ο Medical co-morbidities
ο Minimal displacement-
acceptable alignment
30. Closed Treatment of Distal
Radial Fractures
ο Obtaining and then maintaining an
acceptable reduction.
ο Immobilization:
ο long arm
ο short arm adequate for elderly patients
ο Frequent follow-up necessary in order to
diagnose redisplacement.
31. Technique of Closed
Reduction
ο Anesthesia
ο Hematoma block
ο Intravenous sedation
ο Bier block
ο Traction: finger traps and weights
ο Reduction Maneuver (dorsally angulated fracture):
ο hyperextension of the distal fragment,
ο Maintain weighted traction and reduce the distal
to the proximal fragment with pressure applied to
the distal radius.
ο Apply well-molded βsugar-tongβ splint or cast, with
wrist in neutral to slight flexion.
ο Avoid Extreme Positions!
32. Acceptable Reduction
Criteria
ο No dorsal angulation
ο
ο > 15 degrees of inclination
ο Articular step-off < 2mm
ο < 5 mm shortening compared to opposite wrist.
ο DRUJ congruent
33.
34. After-treatment
ο Watch for median nerve symptoms
ο parasthesias common but should diminish over
few hours
ο If persist release pressure on cast, take wrist out
of flexion
ο Acute carpal tunnel: symptoms progress; CTR
required
ο Follow-up x-rays needed in 1-2 weeks to evaluate
reduction.
ο Change to short-arm cast after 2-3 weeks, continue
until fracture healing.
35. Management of
Redisplacement
ο Repeat reduction and casting β high rate of failure
ο Repeat reduction and percutaneous pinning
ο External Fixation
ο ORIF
36. Indications for Immediate
Surgical Treatment
ο High-energy injury
ο Open injury
ο Secondary loss of reduction
ο Articular comminution, step-off, or gap
ο Metaphyseal comminution or bone loss
ο Loss of volar buttress with displacement
ο DRUJ incongruity
43. Spanning ( Ligamentotaxis)
ο A spanning fixator is
one which fixes
distal radius
fractures by
spanning the
carpus; I.e., fixation
into radius and
metacarpals
44. Non-spanning
ο 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.
48. External Fixation
- Disadvantages -
ο Bulky
ο Poor screw hold in porosis and comminution
ο Screws do not buttress
ο More invasive
49. Ligamentotaxis
ο Adverse effect of carpal over-
distraction well documented
ο Kaempffe (1993): pain, function, grip
strength adversely affected
ο Gupta (1999): 10# of distraction can induce
over 10mm of ligament elongation
ο Davenport (1999): 10mm carpal distraction
produces >20% increase in ligament strain
50.
51.
52. Complications
ο Complication rates high in almost all
reported series
ο Mal-union
ο Pin track infection
ο RSD / arthrofibrosis
ο Finger stiffness
ο Loss of reduction; early vs late
ο Tendon rupture
55. Percutaneous Pinning-Methods
ο variety described
ο most common radial styloid pinning +
dorsal-ulnar corner of radius pinning
ο supplemental immobilization with cast,
splint
ο in conjunction with external fixation
(Augmented external fixation)
56. Percutaneous Pinning
ο 2 radial styloid pins - Mah and Atkinson,
J Hand Surg 1992
ο excellent anatomic 82%
ο good-excellent functional results 100%
ο radial styloid with dorsal - prospective
study, 30 pts (Clancey JBJS 1984)
ο excellent anatomic results in 90%
58. Internal Fixation of Distal Radius
Fractures
ο Useful for elevation of depressed articular
fragments and bone grafting of
metaphyseal defects
ο required if articular fragments can not be
adequately reduced with percutaneous
methods
59. Selection of Approach
ο Based on location of comminution.
ο Dorsal approach for dorsally angulated
fractures.
ο Volar approach for volar rim fractures
ο Radial styloid approach for buttressing of
styloid
ο Combined approaches needed for high-
energy fractures with significant axial
impaction.
89. Conclusions
ο Need to be able to use all tools for
treatment of distal radius fractures
ο Both external fixation and ORIF are useful.
ο ORIF better in high-energy fractures associated
with depression of articular surface
ο ORIF gives better anatomic restoration,
although not necessarily higher patient
satisfaction.
90. Conclusions
ο External fixators still have a role in the
treatment of distal radius fractures
ο Spanning ex fix does not completely
correct fracture deformity by itself
ο Should usually combined with
percutaneous pins (augmented fixation)
91. Conclusions
ο new plating techniques allow for accurate
and rigid fixation of fragments
ο Plating allows early wrist ROM
ο Volar, smaller and more anatomic plates are
better tolerated
ο combination treatment is often needed
92.
93. Relationship
of Anatomy to Function
Colles; βThe wrist will regain perfect freedom
in all of its motions and be completely
exempt from painβ (1814)
ο Generally true for low demand individuals
ο Direct relation between residual deformity
and disability
ο Quality of reduction more important than
method of immobilisation