The document presents a journal club discussion on the management of complex distal radius fractures, highlighting anatomy, imaging, and surgical treatment options. Key goals of surgery include achieving proper radial shortening, inclination, and articular alignment through various fixation methods. Understanding the anatomy and reconstruction goals is essential for effective preoperative planning and decision making in these challenging cases.

1. Journal Club
Complex Distal Radius
Fracture
Presented by :
Ibraheim El Wasif
Orthopedic Surgery Resident (R3)
Abdallah Jomaa El Azanki
Orthopedic Surgery As. Lecturer
Cedar Tree of
Lebanon

2. About the article
 Authors :
 Peter Charles Rhee, DO, MS
 Robert J. Medoff, MD
 Alexander Y. Shin, MD
Journal of the American Academy of Orthopedic Surgeons , 2017 .
Department of Orthopedic Surgery, San Antonio Military Medical Center
Department of Orthopedic Surgery, University of Hawaii, Kailua
Department of Orthopedic Surgery, Mayo Clinic

3. Anatomy
Of Distal F.A.
 3 columns :
 Radial
 Intermediate
 Ulnar

4. Radial column
 Formed of :
 styloid radius
scaphoid fossa
Attachment to
 Brachioradialis
 Long radio-lunate ligament
 Radio-scapho-capitate ligament
 Fracture
 Large styloid fragment
 Fracture line extending from interfossal ridge to metadiaphysis

5. Intermediate column
 Function
 Load transmission
 Attachment
 Volar R-U lig + Short RL
Dorrsal R-U lig
Dorsal R-C lig
 Fracture
 Volar rim
 DUC
 Dorsal wall
 Intraarticular fragment

6. Illustration

7. Ulnar column
Formed of :
 Distal ulna
 TFCC
 Attachments :
Dorsal RU lig
Volar RU lig
Function :
 DRUJ stability

8. Pedestal
 “ TheBase” and it refer to the metaphysis of the distal radius
Function
 Support of radial and intermediate column
 Attachment to distal oblique bundle ( DRUJ Secondary Stabilizer )

9. Imaging
 X-ray
 Standard : AP , Lateral , Oblique
 Additional views ( SF , VR ,FIA ,DUC )
CT Scan
 more useful after Closed Reduction
Complex , multi-fragmentary fractures

10. Surgical Treatment
 Goals
 Radial shortening < 5 mm
 Radial inclination > 15
 Articular step-off < 2 mm
 Tilt ( ) 15 dorsal – 20 volar tilt
 Method of fixation
 Volar locking plate fix
 Fragment specific fix
 Ext fix +- PP
 Distraction bridge plate fixation

11.  Fragment specific fix :
 App of individualized low profile implant
 Create multi-planar , load shearing construct
 Useful when # fragments too small or distal
 Volar locking plate :
Fixed angle construct
Mainstay for fix of DRFs
Additional fix may be required

12.  Distraction bridging plate
 Int method of wrist spanning fix
 Used when prolonged immobilization is required
 Augment to VLP
 Ext fix +- pp :
 Highly comminuted DRFs
 Open fracture
 Unfit patient

13. Reconstruction
 Sequence
1. Intermediate
2. Radial
3. Ulnar

14. Volar Rim amenable for internal fixation ?
noyes
DBP
EF +- PP
Stabilized with Volar
Locked Plate?
NOYYES
VLP
F-S FIX
VLP + K wire fix
VLP far distal
Proceed to DUC , DW , FIA
fragments
Algorithm

16. VLP already inserted
NOYES
locking screws into
RC fragment
persistent
instability ?
yes
Stabilization of RC fragment
with F-S FIX or Pin fix
No
Proceed to
ulnar column

17. Unstable DRUJ
NOYES
Stabilize DRUJ
TFCC repair
ORIF of styloid
Assess stability YES Reconstruction
complete
NO
Reduce & fix by Percut. Pin
splint FA in sup

18. Summary
 Surgical treatment of complex DRFs very challenging .
 Understanding anatomy & goals of reconstruction are beneficial in
preoperative planning and decision making .
 Successful surgical management require familiarity of various
surgical methods.