Clinical evaluation to management protocol

1. DISTAL RADIUS FRACTURE
By Atanu Kayal
JR, dept of orthopaedics
BMCH
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2. HISTORY
• The Colles fracture is named
after Abraham Colles who first
described it in 1814 by simply
looking at the classic deformity
before the advent of X-rays.
• Xray discovery Dec 1895
• February 1896 Xray application
to diagnose colles fracture( USA)
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3. EPIDEMIOLOGY
 Comprises 17.5% of all fractures in adults
 bimodal distribution
 younger patients due to high energy mechanisms
 older patients due to low energy mechanisms (i.e.
FOOSH)
 Sex - M:F = 1:2-3
 50% are intra-articular
 39.4% are unstable
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4. CLINICAL ANATOMY
Distal radius responsible for 80% of axial load
articulates with scaphoid ,lunate and distal ulna
comprised of 3 columns
radial column
intermediate column
ulnar column
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5. RADIOLOGICAL
MEASUREMENTS

6. CLASSIFICATION
• More than 20 classification systems have been
proposed.
• Gartland and werley: Metaphyseal communition, intra
articular extension and fragment displacement.
• Frykman : based on joint involvement (radiocarpal
and/or radioulnar) +/- ulnar styloid fracture
• Melone : divides intra-articular fractures into 4 types
based on displacement
• Fernandez : based on mechanism of injury
AO : comprehensive but cumbersome

7. GARTLAND AND WERLEY(1951) classification
Group 1: simple colles fracture
Group 2: Comminuted colles fracture, undisplace intra articular
fragment.
Group 3: Comminuted colles fracture, displace intra articular
fragment

8. FRYKMAN -1967
• I=RXTRA ARTICULAR #
• III= INTRA ARTICULAR
+RADIOCARPAL
• V= INTRA ARTICULAR+ DISTAL
RADIOULNAR JOINT
• VII= INTRA ARTICULAR+
RADIOCARPAL+ DISTAL
RADIOULNAR JOINT.
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11. EPONYMS of distal radius fractures
• DIE-PUNCH FRACTURE: Depressed fracture of the lunate fossa of the
articular surface of the distal radius.

12. BARTONS #: Fracture-dislocation of radiocarpal joint with intra-
articular fracture involving the volar or dorsal lip (volar Barton or
dorsal Barton )

13. CHAUFFERS FRACTURE: Radial styloid
fracture
SMITHS FRACTURE: Low energy ,
volarly displced extra articular #

14. COLLES FRACTURE
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15. Clinical presentation
History
usually a fall onto outstretched hand (FOOSH)
Symptoms
wrist pain , swelling and deformity
Physical exam
inspection
ecchymosis & swelling , diffuse tenderness and visible
deformity if displaced
motion
limited by pain

16. RADIOGRAPH
AP, LATERAL
and OBLIQUE VIEW.
CT : Evaluation of intra
articular involvement
MRI: SOFT TISSUE INJURY
EVALUATION
TFCC injuries
scapholunate ligament
injuries (DISI)
lunotriquetral injuries

17. ASSESSMENT of STABILITY of DISTAL RADIUS#
LaFontaine et al. identified five
factors indicative of instability:
(1) initial dorsal angulation of more than 20 degrees (volar tilt);
(2) dorsal metaphyseal comminution;
(3) intraarticular involvement;
(4) an associated ulnar fracture;
(5) patient age older than 60 years

18. Guidelines for treatment decision making
There are no definitive criteria or guidelines to guide treatment
decision making,
 Factors must be considered in developing a treatment plan
 initial injury characteristics,
alignment after reduction,
 patient age, bone quality,
Patient demand, and expected outcome.

19. TREATMENT OPTIONS
CLOSED TREATMENT
Splint followed by cast
Percutaneous pinning
External Fixation
OPEN REDUCTION AND PLATE FIXATION
Dorsal ;plating
Volar plating
Others: Distraction plate fixation and fragment specific internal
fixation

20. CLOSED TREATMENT-SPLINT/CAST
Stable fractures can be successfully treated with closed reduction
and immobilization, initially with a splint followed by a cast, and weekly
radiographic evaluation for 3 weeks.
Significant changes in
radial length,
 palmar tilt, or
 radial inclination
should prompt consideration of
operative treatment

21. PERCUTANEOUS PINNING
Done after closed reduction and
useful for distal radial fractures with
metaphyseal instability,
simpler intraarticular displacement.
Complications:
tendon tethering,
injury, or rupture; pin migration;
nerve injury; and pin site infections.
Intrafocal pins (Kapandji
technique) can be added to provide
a dorsal buttress for distal fragment.
Lesser incidence of stiffness.

22. EXTERNAL FIXATION
• The external fixator neutralizes
the axial load placed on the distal
radius by physiologic activity
of the forearm musculature. It can
be placed in a bridging
or nonbridging (does not cross the
wrist joint) technique, with or
without supplemental stabilization
with K-wires.
Spanning and nonspanning
external fixation device available.
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23. EXTERNAL FIXATOR
• Bridging external fixator: to overcome metaphyseal collapse and
shortening defect.
• External fixator NOT used for:
Volar barton fracture
Lunate fossa depression
Articular communition

24. OPEN REDUCTION and PLATE FIXATION
• DORSAL PLATING.............
INDICATIONS: with low profile
plate for
Dorsal die-punch fractures
Fractures with displaced dorsal
lunate facet fragments
Complications:
• Tendon dysfunction and rupture.

25. VOLAR PLATING.....First gen:volar non locking t plate
second gen: plate with locking screw
third gen: poly axial holes/ variable angle plate
• Indications: volar bartons #
• Complications: Tendon ruptures and tenosynovitis from prominent
screw.
• Screw penetration at radiocarpal joint.

26. Volar plate fixation of fracture of distal radius

27. Distraction plate fixation
• As an alternative to external fixation of highly comminuted fractures
of the distal radius, Burke and Singer described the use of a
distraction plate as an internal fixator.
• The plate is applied to the dorsal surface of the hand, wrist, and
distal forearm using three small incisions.
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28. Fragment specific open reduction and internal
fixation of comminuted distal radius fracture
• Recognizing the pitfalls of Kirschner wire fixation and plate and screw
fixation when used alone for repair of comminuted intraarticular
distal radial fractures, Medoff developed a wrist fixation system that
combines both methods for stable reconstruction of the distal radius.

29. COMPLICATIONS
• COMPLICATION INCIDENCE (%)
• Arthritis/arthrosis 7-65
• Loss of motion 0-31
• Implant complications 1.4-26
• Nerve compression/neuritis 0-17
• Osteomyelitis 4-9
• Dupuytren contracture 2-9
• Persistent pain/pain syndromes (CRPS) 0.3-8
• Tendon (rupture, lag, trigger, tenosynovitis) 0-5
• Delayed union/nonunion 0.7-4
• Radioulnar (synostosis, disturbance) 0-1.3

30. . . . will at some remote period again enjoy perfect freedom in
all of its motions and be completely exempt from pain.
Abraham Colles, 1814
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