A Description on the fracture itself followed by a review of literature on the management . Kindly report the flaws.

1. JOURNAL CLUB - 08.12.16
DISTAL RADIUS FRACTURES-
TREATMENT.
Presentor- Dr. REJUL K RAJ
CMCH LUDHIANA

2. OVERVIEW
• Introduction.
• Anatomy.
• Applied anatomy.
• Classification.
• Management options.
• Journal Review.

3. REFERENCES
• ROCK WOOD AND GREENS,
FRACTURES IN ADULTS – VIII th Edition.
• Campbell’s Operative Orthopaedics,
XII th Edition.
• Indian Journal Of Orthopaedics.
• Pub Med
• Cochrane Library.

4. Name. Place. Time. Discovery.
Petit
Pouteau
France 18th Century. fractures rather than dislocations
Colles Ireland 1814 “On the fracture of the carpal extremity
of the radius”
Barton Philadelphia 1938 Concept of types
Dupuytren Paris 1841 “Leçons Orales,”
Malgaigne 1847 Intra and extra articular fractures.
INVENTION OF X RAYS
Carl Beck New york 1901 8 types
Fredrick Cotton Dublin Metaphyseal communition
Champonnièr Massage and early mobilization
ANESTHESIA AND ASEPSIS.
Lambotte 1907 Percutaneous pinning.
Ombredanne Parisian 1929 External fixation – non bridging.
Roger Anderson.
Gordon O’Neill
Seattle 1944 Bridging external fixation
Raoul Hoffman Geneva 1940s External fixator with universal clamps.
Jacques Vidal et al Ligamentotaxis.
Ellis 1965 Plating.
ROCKWOOD AND GREEN, VIII th Edition.

5. ANATOMY
• 2 concave articular surfaces,
– scaphoid
– lunate.
• volar and ulnar inclination.
• The palmar surface
– relatively smooth,
– which allows easy contouring of plates .
• The dorsal surface ,
– convex .
– irregular with Lister’s tubercle- EPL Tendon

8. 3 COLUMN CONCEPT.
• Jakob et al interpreted the wrist as consisting of three distinct
columns.
• subjected to different forces and thus must be addressed as
discrete elements

9. INTRODUCTION
• Most common fracture – 17.5 %.
• F : M = 3 : 1.
• Age and Gender specific distribution curves.
• Males – 40s,Females – 60s.
• Extra articular – 57 to 66 %.
• Metaphyseal comminution – 48 %.
• Low energy fractures.
• BMD – Risk Factor.
Rockwood and Green’s, Fractures in Adults,
8th edition.

10. INJURY MECHANISMS
• Fall on an outstretched hand.
• Dorsifexion – 40 to 90 degrees( Frykman )
• Tensile forces at Volar cortex .
• Compression at dorsal cortex.
Rockwood and Green’s, Fractures in Adults,
8th edition.

11. ASSOCIATED INJURIES
• Interosseous ligaments of the carpus
• Triangular fibrocartilage complex (TFCC).
– ? Clinically significant.
• EPL injuries.
Rockwood and Green’s, Fractures in Adults,
8th edition.

13. SIGNS AND SYMPTOMS
• Pain + swelling – Wrist.
• Visible deformity
– Dinner fork .
– Garden spade.
• Exclude median and ulnar nerve injury.
• Rule out open injuries.
• Rule out compartment
syndrome.
Rockwood and Green’s, Fractures in Adults,
8th edition.

15. IMAGING.
• The standard series of
– posteroanterior (PA),
– lateral.
– Oblique
• CT – 3 D reconstruction.
– Intrarticular
Rockwood and Green’s, Fractures in Adults,
8th edition.

16. nclination

20. • Mishra PK, Nagar M, Gaur SC, Gupta A.
Morphometry of distal end radius in the Indian population:
A radiological study. Indian J Orthop 2016;50:610-5.

28. MANAGEMENT

29. TIME LINE OF TREATMENT
METHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist
Jack multiplanar
ligamentotaxis
1994
HARNESS, N. G., MEALS, R. A.:
The history of fracture fixationof the hand and wrist.
Clin. Orthop., 445: 19–29, 2006.

30. AUTHOR YEAR RESULTS
Abraham Colles . 1814 fractures tended to do well
despite considerable
Deformity.
“. . . will at some remote period again enjoy
perfect freedom in all of its motions and be
completely exempt from pain.”
Cassebaum. 1950 Supported Colles
McQueen and
Caspers .
19c8 Demonstrated Clear
Correlation between
malunion and poor
functional outcomes.

31. TREATMENT OPTIONS.
1. Cast Immobilization
2. Percutaneous Pin Fixation
3. External Fixation
4. Arthroscopicaly Assisted Fixation
5. Open Reduction Internal Fixation
6. Fragment Specific : Internal Fixation.
7. Intramedullary Fixation
8. Bioabsorbable Implants

32. ROCKWOOD AND GREENS, VIII th Edition.

33. ROCKWOOD AND GREENS, VIIIth Edition.

35. An unstable distal radius fracture .
• Distal radius fracture: current concepts and
management. F. Leung , K. Kwan , C. Fang .
2013 The British Editorial Society of Bone and Joint
Surgery

37. 1. CAST IMMOBILIZATION
Indications
– Undisplaced fractures
– Well reduced stable fractures.
– Old age, low functional demand
Pitfalls
– Cumbersome
– Adjacent joint stiffness
– Loss of reduction
– Median nerve neuropathies
– Cast impingement and compartment syndrome

39. FERNANDEZ Et al.

40. 2. PERCUTANEOUS PIN FIXATION
• Indications.
– Reducible extraarticular fractures,
– simple intraarticular fractures that are nondisplaced
with good bone quality.
• Pitfalls
– Additional casting or external fixator often needed
– Pin-tract infections .
– Tendon and superficial radial nerve impalement
– Loss of reduction..

41. • Multiple different techniques.
– pins placed through the radial styloid,
– two or three crossed pins
– across the fracture site, or
– intrafocal pinning within the fracture site.
– Transfixation wires across the distal radioulnar
joint

44. KAPANDJI Double Intrafocal Pinning.
• Indication.
– Noncomminuted extraarticular injuries.
• Technique.
– Kirschner wire into the fracture site in a radial–to–ulnar direction.
– When the wire reaches the ulnar cortex, the wire is used
to elevate the radial fragment and recreate the radial inclination.
– This wire is then driven through the ulnar cortex for stability.
– A second wire is introduced 90 degrees to the first in a similar manner to
restore volar tilt.
KAPANDJI, A. I.: Treatment of non–articular distal radial fractures by
intrafocal pinning with arum pins. In: SAFFER, P.,COONEY, W. P. (eds):
Fractures of the distal radius. Philadelphia, JB Lippincott 1995, 71–83.

46. 3. EXTERNAL FIXATION
• Indications.
– 1. Comminuted intra-articular
– 2. Unstable extra-articular
– 3. Open fractures
– 4. Infected fractures
• Ligamentotaxis
– Maintain fracture reduction.

51. EXTERNAL FIXATION
• Complications
– stiffness
– pin tract infections.
– pin loosening,
– radial sensory Loss.
– nerve injury.

54. • J Bone Joint Surg [Br] 1998;80-B:665-9.
• A randomised, prospective study .
• 60 patients with unstable fractures of the distal radius
• compare bridging with non-bridging external fixation
• The radiological results showed significant improvement in the non-
bridging group.

55. 4. ARTHROSCOPICALY ASSISTED
FIXATION
• Minimally invasive way of monitoring closed
reduction with percutaneous pin fixation.
• Advantages.
– assessment of the articular joint surface
– interosseous carpal ligament or TFCC injury.
– excision of osteochondral flaps and loose bodies.
• Disadvantages .
– the steep learning curve.
– few studies that demonstrate improved functional
outcomes

57. DOI, K., HATTORI, Y., OTSUKA, K., ABE, Y., YAMAMOTO,H.:
Intra–articular fractures of the distal aspects of the radius: arthroscopically
assisted reduction compared with open reduction and internal fixation.
J. Bone Jt Surg., 81–A: 1093–1110, 1999.
• randomized prospective study
• 34 patients .
• 30 month average follow–up -good or excellent results.
• 82% Better ROM and grip strength, improved radiographic
• Concluded that arthroscopically assisted fixation of distal
radius fractures is an effective technique in patients less
than 70 years of age with intraarticular injuries.

58. 5. OPEN REDUCTION INTERNAL FIXATION:
DORSAL AND VOLAR
• Indications
– Unstable fractures
– Intra-articular fractures
– Fractures irreducible by closed means
– Delayed fixation
– Preference for earlier mobilisation

59. • Advantages.
– Direct restoration of anatomy.
– Stable internal fixation.
– decreased period of immobilization
– Earlier return of wrist function
• Pitfalls
– Unsightly scar
– Tendon rupture (flexor or extensor)
– Some patients may require implant removal
– Implant cost
– Technically more difficult

63. Advantages of a volar plating
1. simpler to reduce because the volar cortex is usually
disrupted by a simple transverse line.
2. frestoration of radial length, radial inclination, and
volar tilt.
3. preserve the vascular supply to the dorsal fragments.
4. Implant is separated from the flexor tendons by the
pronator quadratus.
5. shortening and secondary displacement

64. Disadvantages of Dorsal plates
• Need for mobilization of extensor tendons to
achieve proper plate placement.
• Tendon irritation or rupture.
• Additional surgery

67. Dorsal vs volar plating.
RUCH, D. S., PAPADONIKOLAKIS, A.: Volar versus dorsal platingin the management of
intra–articular distal radius fractures.J. Hand Surg. Amer., 31: 9–16, 2006.
• Retrospective review of 34 patients.
• 20 dorsal plating and 14 volar plating.
• RESULTS.
– functional outcome was better in the volar plating group.
– higher rate of volar collapse and late complications in the
dorsal plating group.

68. 6. REDUCTION INTERNAL FIXATION:
FRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally.
(3) Gliding motion of tendons.
(4) The exposure cause minimal soft tissue disruption.
(5) Allow early range of motion.

72. DISTRACTION PLATE INTERNAL FIXATION
• As an alternative to external fixation .
• Highly comminuted fractures of the distal
radius.

74. 7. INTRAMEDULLARY FIXATION
• Intramedullary devices – Advantages.
– Increase fracture stability .
– Allow load transfer across the fracture site.
– Minimize soft tissue problems by minimizing scarring
and adhesions.
– Maintain vascular blood supply to promote fracture
healing.

76. INTRAMEDULLARY FIXATION
• Two implants.
1. Micronail.
2. Dorsal Nail Plate
• Both are used for metaphyseal distal radius fractures .
• Incision made over the radial styloid.

77. INTRAMEDULLARY FIXATION
• Difficulties
– possible soft tissue irritation of the interlocking screws .
– possible screw penetration into the distal radioulnar joint.
– difficulty observing sagittal alignment secondary to use of
the jig

78. 8. BIOABSORBABLE IMPLANTS
• Polylactic acid or polyglycolic acid.
• at least two years to degrade completely within the body.
• contourable after placing in a hot water bath
• The advantages.
– No need for hardware removal in the future
– do not incite an inflammatory response
– MRI compatible.
• Valid concerns
– initial fixation strength,
– slightly thicker than metal counterparts.
– cannot visualize the
– implants on radiographs.

79. Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with
Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three Cases
Chih-Yu Chen et al
J Bone Joint Surg Am, 2010 Nov 17; 92 (16): 2719 -2724

81. AUTHORS RESULTS INTERPRETATION
KNIRK, J. L., JUPITER, J. B.:
Intra–articular fractures of the
distal end of the radius in
young adults.
J. Bone Jt Surg., 68–A:
647–659, 1986.
21.
Absence of joint stepoff
=arthrosis in 11 %.
Stepoffs of 2 mm or
greater=91%
Articular incongruity
predisposed
degenerative joint
disease
CATALANO, L.
results in young adults after
open reduction and internal
fixation.
J. Bone Jt Surg., 79–A: 1290–
1302, 1997.
strong association between
intraarticular stepoff and
degenerative joint disease
.
Found that all patients
presented with good or
excellent outcomes an average
of 7 years
GOLDFARB, C. A., RUDZKI, J.
R., CATALANO, L. W.,
HUGHES, M., BORRELLI, J. Jr.:
Fifteen–year outcome of
displaced
intra–articular fractures of the
distal radius. J. Hand Surg.
Amer., 31: 633–639, 2006.
patients continued to function
at high levels, that strength
and range of motion
measurements
were unchanged, and that the
joint space was
reduced an additional 67%
No correlation was noted
between the
presence or degree of
arthrosis and upper
extremity
function as measured by
DASH scores and the Gartland
and Werley criteria

84. • 581 patients, 133 patients were operated.
• The subjective outcome was measured by DASH.
RESULTS.
• Most patients have residual symptoms at 3 months after the
fracture but are normalized at 1 year.

85. • There is no robust evidence at present to suggest
that any treatment method is superior to any other
in the Cochrane metaanalysis reports, either for
different types of
– Conservative treatment (Handoll and Madhok 2003a)
– or for surgical treatment (Handoll and Madhok2003b).

86. REVIEWS

87. Prediction of Instability in Distal Radial Fractures
• J Bone Joint Surg Am, 2006 Sep; 88 (9): 1944 -1951
• P.J. Mackenney; M.M. McQueen.
• Level of Evidence: Prognostic Level I.
• Methods:
• Data on approximately 4000 distal radial fractures were prospectively
recorded over a 5.5-year period.
• Outcome measures consisted,
– radiographic measurements made at one week and six weeks and
– assessment of carpal alignment at six weeks.

88. Results:
Most consistent predictors of radiographic outcome,
1. Patient age
2. Metaphyseal comminution
3. Ulnar variance

89. A Meta-Analysis of Outcomes of External
Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
• The Journal of Hand Surgery
• Volume 30, Issue 6, November 2005, Pages 1185.e1–1185.
• Zvi Margaliot, MD, , Steven C. Haase, MD, Sandra V.
Kotsis, MPH, H. Myra Kim, ScD, Kevin C. Chung, MD
• 46 articles.
– 28 (917 patients) external fixation studies.(603 patients) internal fixation

90. Conclusions.
• No evidence to support the use of internal
fixation over external fixation for unstable distal
radius fractures.

91. Is Early Internal Fixation Preferred To Cast Treatment
For Well-reduced Unstable Distal Radial Fractures?
• J Bone Joint Surg 2009;91A:2086-2093.
• Koenig KM, Davis GC, Grove MR, Tosteson ANA, Koval
KJ.
• Internal fixation with use of a volar plate for
potentially unstable distal radial fractures provided
a higher probability of painless union on the basis
of available data in the literature, making early
internal fixation the preferred treatment in most
cases.

92. Safety and Efficacy of Operative Versus Nonsurgical
Management of Distal Radius Fractures in Elderly Patients:
A Systematic Review and Meta-analysis.
• J Hand Surg Am. 2016 Mar;41(3).
• Chen Y1, Chen X2, Li Z2, Yan H2, Zhou F2, Gao W2.
• Division of Plastic and Hand Surgery, Department of
Orthopedics, Wenzhou Medical University, Wenzhou, China
• TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III

93. • 60 years and older.
• Two randomized controlled trials and 6 retrospective studies
RESULTS.
• Meta-analysis did not detect statistically significant differences
in pooled data for pain level, functional assessment, and wrist
ROM
• Grip strength was significantly greater in the operative group.
• Radiographic outcomes -significantly better in the operated.

95. Factors associated with one-year outcome
after distal radial fracture treatment.
• Journal of Orthopaedic Surgery 2015;23(1):24-8
• Cowie J, Anakwe R, McQueen M.
• Edinburgh Orthopaedic Trauma Unit, Edinburgh, United Kingdom.
• PURPOSE: To identify factors that affect functional outcome
one year after distal radial fracture treatment

96. • METHODS:
• 521 women and 121 men aged 16 to 92 (mean, 59)
– external fixation (n=123),
– open reduction and internal fixation (n=63),
– a combination of both (n=10),
– Distal radial osteotomy for symptomatic malunion (n=90), or
– Casting with (n=194) or without (n=162) prior closed manipulation under
regional anaesthesia.
• The indication for surgery (rather than casting) was metaphyseal
instability.

97. RESULTS:
• Poorer functional score was associated with,
– increasing age
– dorsal angulation after healing
– presence of volar comminution
– pain
• Poorer grip strength was associated with,
– non-dominant side injury,
– increasing age,
– dorsal angulation after healing,
– positive ulnar variance,
– comminution, and
– pain
• Predicted malunion showed colinearity with
– age
– dorsal comminution
– dorsal angulation
• CONCLUSION:
Understanding factors associated with outcome helps surgeons to make the
treatment decision for distal radial fracture to achieve optimum outcome.

98. The effect of fracture-related factors on the
functional outcome at 1 year in distal radius
fractures
• Injury
• Volume 33, Issue 6, July 2002, Pages 499–502
• Sumit Batra, Ajay Gupta
• Department of Orthopaedics, Maulana Azad Medical College
and Associated Lok Nayak Hospital, New Delhi.
• Sixty-nine cases of distal radius fracture were studied
retrospectively for various factors that might affect the
functional outcome

99. RESULTS:
• The most important factor affecting the functional
outcome was,
– Radial length,
– followed by Volar tilt.

100. Assessing Results After Distal Radius Fracture Treatment
- A Comparison of Objective and Subjective Tools
• Geriatr Orthop Surg Rehabil. 2011 Jul; 2(4): 155–160.
• Iris H. Y. Kwok, Frankie Leung, Grace Yuen.

101. Conclusion:
• Radiological scoring (reflecting anatomical
deformity) was not significantly correlated
with functional outcome.

102. THANK YOU.