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Distal radius fractures
- 1. Management of Distal Radius Fractures Dr Vivek Singh All India Institute Of Medical Sciences,Rishikesh 10/6/2017
- 2. Introduction 15-20% of all fractures Average age 55 yrs, 70% in Women 75% as a result of a fall, <1% open
- 3. Anatomy Articular Surface Scaphoid fossa Lunate fossa Sigmoid notch
- 4. Column Theory Rikli & Regazzoni, 1996 3 Columns: radial, intermediate, medial
- 5. RADIOLOGY Radial inclination (22deg) Volar inclination (11deg) Radial length (11mm) Ulnar variance (+ / - 1mm)
- 6. AO/ OTA Classification Group A: Extra- articular-48% Group B: Partial Intra- articular-10% Group C: Complete Intra- articular-42%
- 7. Factors predictive of poor outcome Radial shortening >3mm Dorsal tilt > 12 degrees Intra-articular incongruity
- 8. Assessment of X-Rays Assess involvement of dorsal or volar rim Any dorsal or volar shear fracture Comminution mainly volar or dorsal “die-punch” lesions of scaphoid or lunate fossa Assess amount of radial shortening Look for DRUJ involvement
- 9. Computed Tomography-Indications: Intra-articular fractures Suspected “die punch” fragments DRUJ incongruity Volar ulnar column Cole et al: J Hand Surg, 1997
- 10. Management Recent surge in the operative management No new level 1 evidence supporting this trend Insufficient evidence to decide best practices in management
- 11. Closed Reduction Almost all fractures,warrant a closed reduction. Repeat radiographic assessment of fracture alignment is mandatory.
- 12. Acceptable Reduction < 5 mm shortening compared to opposite wrist. No dorsal angulation > 15 degrees of inclination Articular step-off < 2mm DRUJ congruent
- 13. Closed Reduction Many reductions are acceptable yet fall out of alignment at follow-up. The question remains, will these patients develop post-traumatic osteoarthritis?
- 15. Arora;JBJS;2011
- 16. External Fixation/Percutaneous Fixation Treatment of choice for DER fractures in the 1980’s Rely on ligamentotaxis to provide stability and reduction Fixation augmented with percutaneous pins for articular fragments and sheared components
- 18. Non-spanning
- 19. External Fixation Modern indications Polytrauma patients-temporary fixation Transferring patients to a higher level of care Initial treatment of severe open fractures To supplement sub-optimal internal fixation
- 20. External Fixation Contraindications(Relative) Volar or dorsal shear fractures,
- 21. External Fixation-Complications Pin track infections(30%) Pin loosening causing tendon or nerve irritation Overdistraction of the carpus-responsible for poor results
- 22. Results of External Fixation-mixed Margaliot;JHS;2005
- 24. Richard;JHS:2011
- 25. Volar Plates 21st century-paradigm shift in the treatment of DER fractures with the use of locked volar plating. Use of volar plates is increasing at a rapid rate But we still need rigorous scientific trials to validate their utility
- 26. Volar Plates-Current indications Unstable fractures in younger patients Volar shear fractures Die-punch fractures Intraarticular step off (>2 mm) that cannot be con- trolled with closed reduction Radial shortening greater than 3 mm Dorsal tilt greater than 10* from neutral
- 27. Advantages of Volar Plates Less disruptive to the extrinsic tendons Covered with pronator quadratus, minimizing tendon irritation. Volar cortical surface not routinely comminuted Effective in dorsally displaced, unstable fractures Not routinely removed
- 28. Volar Plates-Disadvantages Placement beyond the watershed line results in excessive plate prominence Lack of direct visualization of articular fragments Screw penetration irritating extensor tendons
- 29. Watershed line
- 31. Volar Plates-Disadvantages Some highly comminuted and distal fractures may not be amenable to volar plate fixation Dorsal shear fractures Fractures involving the distal volar ulnar corner.
- 33. Koenig;JBJS:2009
- 34. Dorsal Plating 1990s, dorsal plate fixation increasingly used To minimize morbidity & stiffness of external fixator High rate of hardware complications, including extensor ten-don irritation Refinements have made the plates lower in profile
- 35. Dorsal Plating-current indications Comminuted dorsally displaced fractures that cannot be controlled with volar plates Dorsal shear fractures I/A fractures requiring direct visualization of the joint Fractures associated with other carpal injuries requiring a dorsal approach
- 37. Take Home Message Shred decision making Discuss both operative and nonoperative options Closed reduction, external fixation, and ORIF each have advantages and disadvantages Literature is inconclusive regarding the superiority of one treatment option over the other.
Editor's Notes
- Lateral, or radial,column is an osseous buttress for the carpus and is an attachment point for the intracapsular ligaments; The intermediate column functions in primary load transmission The medial column serves as an axis for forearm rotation as well as a post for secondary load transmission.
- Dorsal tilt > 12 degrees from normal carpal malalignment Studies of cadavers have demonstrated an increase in radiocarpal contact areas and pressures with radial shortening; dorsoulnar migration of contact pressures with increased dorsal inclination;
- Surge in the oper-ative management in past decade.
- Almost all fractures, excluding unstable shear fractures, warrant a closed reduction.
- Recent literature shows that many DER fractures in the elderly may be treated conservatively, even after a loss of initial closed reduc-tion.14 The radiographic may be better in the operative treatment group, this did not correspond to subjective outcomes.
- Ligamentotaxis transmitted through radioscaphocapitate and long radiolunate ligaments.
- Temporizing polytrauma patients Extremely unstable fracture to supplement sub-optimal internal fixation
- Superficial branch of radial nerve This distraction leads to intrinsic tightness, finger stiffness, in-creased carpal tunnel pressures, and a higher incidence of complex regional pain syndrome. Early motion at the MCP joint may partially prevent some of these complications.
- Margaliot, Chung and colleagues28 did not detect a significant difference in grip strength, wrist range of motion, radiographic alignment, pain, and physician-rated outcomes between external or internal fixation of distal radius fractures However, external fixation was associated with higher rates of infection, hardware failure, and nerve irritation than internal fixation.
- Kreder and colleagues22 reviewed the results of ORIF versus external fixation augmented with pinning and found that there was no statistically significant difference in the radiological alignment or range of motion at 2 years. The investigators also found that external fixation and pinning provided a more rapid return of function and better functional outcome than ORIF in cases whereby intraarticular step-off and gap were minimal.
- More recently, Richard and colleagues29 reviewed 59 patients treated with external fixation and 56 with volar plates for comminuted intraarticular distal radius fractures and found that volar plate fixation had an overall decreased incidence of complications and better wrist motion than external fixation. The investiga-tors also found that patients with volar plates had less pain and better functional outcomes at 1 year.
- In the early part of the 21st century, volar plating paved the way for a paradigm shift in the operative treatment of distal radius fractures, with the use of locked volar plating.
- Volar cortical surface not routinely comminuted, and precontoured plates can be applied to facilitate accurate and anatomic reduc-tion.
- Placement beyond the watershed line results in excessive plate prominence, with the potential for increased contact pressure on volar tendons and subsequent tendon irritation or rupture.
- Windisch et al. [3] were the first to describe an area where the capsule inserts between two lines and two contours on the distal radius. A few years later he published another paper describing a protuberance which he called the promontory of the radius. The geometry of this protuberance varies greatly [4]. In 2005, Nelson introduced the concept of the watershed line by describing the most distal line on the radius. He also described a more proximal line which corresponds to the distal part of the pronator quadratus (Figure 3) [5]. The pronator quadratus line marks the highest part of the epiphysis and helps the surgeon visualize the patient-specific radius curvature. If an implant goes beyond this line when viewed on lateral X-rays, there is potential for impingement with the thumb and finger flexor tendons. The watershed line marks the most distal edge of the epiphysis; sometimes it is as high as the pronator quadratus line, sometimes it is higher. A small 3–5 mm thick strip of bone separates these two lines. Going past the watershed line will land you in the joint!
- the distal portion of the plate must absolutely not exceed the watershed line and be perfectly at the line of the pronator quadratus, the length of the distal epiphyseal screw should not exceed 22 mm (although check the gauge and under fluoroscopy when measures are higher), the plates that mimic the best anatomy of the distal radius (latest generation plates) are those that respect the double distal radial and ulnar different curvature, the materials used must continue to take into account the important biomechanical forces into play in this anatomical region without losing sight of the need of minimal thickness: balance thinness of the plate/resistance of the material is important.
- Andermahr et al40 evaluated the volar lunate facet and found that the facet is on average 5 mm thick and projects 3 mm anterior (16% of the dorsal-volar height) to the volar surface. The small size and projection of this fragment may lead to increased susceptibility to injury and subsequently to inadequate fixation, resulting in volar subluxation of the carpus.10 Besides wrist instability, failure to anatomically reduce a large lunate facet that contributes to the sig-moid notch may result in distal radioulnar joint in-congruity and subsequent arthritis.
- When counseling patients with distal radius frac-tures, especially low-energy fragility fractures, the caregiver should discuss both operative and nonoperative options because the literature is inconclusive regarding the superiority of one treat-ment option over the other.