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Distal radius
- 1. AOTrauma Principles Course TadashiTanaka, JP Rami Mosheiff , IL Distal radius
- 2. Objectives Pathology • Overview - Radiologicalevaluation - Classification • Treatment - Treatment algorithm - Surgical procedures - Complications • Summary
- 3. Distal radial fracture Themost common fracture in all generations
- 4.
- 5. Spectrum Simple fractures - Highenergy - Younger population - Shortening and collapse - Carpal instability Complex fractures
- 6. Spectrum Simple fractures - Minimallydisplaced - Extraarticular fractures - Impacted stable fractures high-energy Complex fractures
- 7. Distal radial fracture—themost common bony lesion in all generations Associated injuries: • SL (scapho-lunate) ligament injury • LT (lunato-triquetral) ligament injury • TFCC (triangular fibrocartilage complex) lesion • Scaphoid fracture
- 8. Radiological evaluation—remember the normalanatomy 1. Palmar tilt average 11°(1–21) → dorsal tilt 2. Radial tilt average 23°(13–30) 3. Radial length average 10 mm 4. Ulnar variance 0±2 mm (comparison with the intact side) 1 2 3 4
- 9. Radiological evaluation 1. Radialshift (comparison with the intact side) 2. Articular congruity (step-off) 5 6
- 10. Eponymic descriptions—unhelpful Chauffeur • Driveris injured when turning a handle • Impaction by lunate (Sheck) Colles Dorsal Barton Smith Palmar (reverse) Barton Die-punch
- 11. Colles’ fracture “One consolationonly remains, that the limb will, at some remote period, enjoy perfect freedom in all its motion, and be completely exempt from pain. The deformity, however, will remain undiminished through life.” Prognostic significance of articular involvement pointed out by Gartland (1951) Abraham Colles, 1814
- 12. Müller AO Classification TypeA : Extraarticular Type B : Partial articular Type C : Complete articular Distal segment Bone -2 3 Type BType A Type C
- 13. Type A Extraarticular Type B Partialarticular A1 A2 A3 B1 B3B2 sagittal frontal multifrag.simple rim palmar (reverse-B))dorsal (Barton) C1 C2 ulna radius metaphyseal simple multifrag. articular simple articular multifrag. C3 Type C Complete articular
- 14. Melone Classification 1993 •Identified impaction-type injury • Observed four components
- 15. The three-column concept Radialcolumn (RC) Intermediate column (IC) Ulnar column (UC) RC IC UC
- 16. The three-column concept DRikli et al (1996) J Bone Joint Surg Br Sigmoid notch Lunate Scaphoid
- 17. stable unstable 2nd displaced 2nd displaced ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticular (A2) Intraarticular (B1,C1) Extraarticular (A3) Intraarticular ClosedreductionClosed reduction Partial (B1, B2, B3) Complete (C2, C3) Cast or splint Cast or splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percutaneous pinning Percutaneous pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft
- 18. stable unstable 2nd displaced 2nd displaced ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticular (A2) Intraarticular (B1,C1) Extraarticular (A3) Intraarticular Closed reduction Closed reduction Partial (B1,B2,B3) Complete (C2,C3) Castor Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percut. pinning Percut. pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft
- 19. Treatment—conservative Obsolete procedure + Cotton-Loder position Currenttechniques Gentle traction (Chinese finger trap ) + Atraumatic reduction Neutral position (forearm & wrist joint) Sugar-tongs splint, cast
- 20. Unstable fractures • Comminution: -dorsal: more than 50% of diameter - palmar: metaphyseal • Initial displacement - dorsal tilt 20°≧ - translation 10 mm≧ - shortening 5 mm≧ • Intraarticular disruption • Associated ulnar fracture - Massive osteoporosis • Initial closed reduction would not be maintained by a splint or cast
- 21. stable unstable 2nd displaced 2nd displaced ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticular (A2) Intraarticular (B1,C1) Extraarticular (A3) Intraarticular Closed reductionClosedreduction Partial (B1,B2,B3) Complete (C2,C3) Cast or Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percutaneous pinning Percutaneous pinning Extern al fixator ± bone graft Plate Extern al fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator ± bone graft Plate External fixator ± bone graft Plate
- 22. Percutaneous pinning (K-wires) 23-C1fracture, 48-year-old man
- 23. Percutaneous pinning (K-wires) 23-C1fracture, 48-year-old man • Minimally invasive • Less expensive After 10 months: • Unstable fixation? • Migration • Immobilization (4–6 weeks)
- 24. stable unstable 2nd displaced 2nd displaced ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticular (A2) Intraarticular (B1,C1) Extraarticular (A3) Intraarticular ClosedreductionClosed reduction Partial (B1,B2,B3) Complete (C2,C3) Cast or Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percut. pinning Percut. pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft
- 25. stable unstable 2nd displace. 2nd displace. ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticul ar (A2) Intraarticular (B1,C1) Extraarticular (A3) Intraarticular ClosedreductionClosed reduction Partial (B1,B2,B3) Complete (C2,C3) Cast or Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percut. pinning Percut. pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft Metaphyseal comminution Soft tissue injury Limited open pin placement Full flexion of MP-J during pin insertion No overdistraction if necessary, add K-wire or other procedures
- 26. stable unstable 2nd displace. 2nd displace. ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticul ar (A2) Intraarticula r (B1,C1) Extraarticular (A3) Intraarticular ClosedreductionClosed reduction Partial (B1,B2,B3) Complete (C2,C3) Cast or Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of distal radiusFracture of distal radius Percut. pinning Percut. pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft Smith, Barton Radial shift of radial styloid Depression of joint surface (die-punch, etc)
- 27. stable unstable 2nd displace. 2nd displace. ReducibleReducible Irreducible/unstableIrreducible/unstable Extraarticula r (A2) Intraarticul ar (B1,C1) Extraarticular (A3) Intraarticular ClosedreductionClosed reduction Partial (B1,B2,B3) Complete (C2,C3) Cast or Splint Cast or Splint ORIF K-wires Screw Plate Tension band ORIF K-wires Screw Plate Tension band Functional aftertreatmentFunctional aftertreatment NondisplacedNondisplaced DisplacedDisplaced Fracture of DistalFracture of Distal RadiusRadius Percut. pinning Percut. pinning External fixator ± bone graft Plate External fixator ± bone graft Plate External fixator Limited ORIF Bone graft K-wires Plate & Bone graft External fixator Limited ORIF Bone graft K-wires Plate & Bone graft Autograft or bone substitute ( Bone cement, HA, etc) Prevention of late collapse
- 28. 23-C3 fracture, 54-year-oldwoman 1 month after surgery • Limited ORIF, hydroxyapatite (Norian) graft, • K-wires & external fixator
- 29. 23-C3 fracture, 54-year-oldwoman 1 year and 8 months postoperative
- 30. 23-C2 fracture, Gustilotype IIIA 66-year-old woman External fixator K-wire bone graft
- 31.
- 32. Plate fixation • Dorsalor palmar approach? • Depends on fracture type
- 33. Dorsal approach—which compartment? Radialstyloid Which compartment? • Dorsal metaphysis • Central articular surface • - Ulnar styloid process • - Ulnar head TFCC
- 34. Palmar approach Classical Henryapproach Extended carpal tunnel approach
- 35. 23-B3 fracture (reverseBarton) Simple buttress plate
- 36. 23-C3 fracture, 84-year-oldwoman • Palmar shear + dorsal metaphyseal fractures • Palmar reconstruction: buttress plate • Dorsal reconstruction: external fixator Cast
- 37. 23-C3 fracture, 84-year-oldwoman 2 years and 1 month posteroperative
- 38. 23-C3 fracture, 84-year-oldwoman 2 years and 1 month postoperative
- 39. Distal radius plateand LCP The “locking plate” has changed the way to treat distal radial fractures
- 40.
- 41. 23-C3 fracture, 58-year-oldman • Even in a severely multifragmentary fracture stabilty is satisfactory with the distal radius plate 1 year and 4 months postoperatively
- 42.
- 43. 23-C3 fracture, 57-year-oldfemale • Direct visualization • More irritation of the extensor tendons • Risk of secondary tendon rupture
- 44. Complications • Median nervecompression • RSD (reflex sympathetic dystrophy) / finger stiffness • Pin site infection • Late collapse • Tendon rupture - External fixator: prolonged use (6 weeks), unphysiological position, overdistraction
- 45. Radiological evaluation functional impairment •Dorsal tilt : 10°≧ • Radial tilt : 10°≦ • Radial shift : 2 mm≧ • Radial shortening: 6 mm≧ • Plus variant : 3 mm≧ • Step-off : 2 mm≧
- 46. Summary 1. Pathology - Radiologicalevaluation - Classification 2. Treatment - Treatment algorithm - Surgical procedures - Complications
- 47. Summary • Treatment ofdistal radius fractures, in particular, of intraarticular fractures • Anatomical restoration is of extreme significance for prognosis • It can be achieved by proper operative procedures - external, internal fixation & bone graft - locking plate