Dr. yt reddy distal radius fractures modified

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Dr. yt reddy distal radius fractures modified

  1. 1. Dr Y Thimma ReddyAssistant Professor & Registrar Department of OrthopedicsOSMANIA MEDICAL COLLEGE
  2. 2. Distal Radius Fractures Common injury Potential for functional impairment and frequent complications
  3. 3. HISTORY First surgeon to recognize these injuries was Pouteau 1783. his work was not widely publicized. Later Abraham Colles 1814 gave the classic description of fracture Dupuytren brought to the world attention that it is a fracture rather than a dislocation as it was previously assumed. Goyrond 1832 differntiated between dorsal and volar displacement. Barton 1838 described wrist subluxation consequent to intraarticular fracture of radius which could be dorsal or volar. Smith described fracture of distal radius with „forward‟ displacement. Advent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.
  4. 4. Incidence  One sixth of all fractures treated in the Emergency Room  Bimodal distribution ○ less than 30 years (70% men) ○ over 50 years (85% women)
  5. 5. Introduction Occurs through the distal metaphysis of the radius May involve articular surface frequently involving the ulnar styloid FOOSH  forced extension of the carpus,  impact loading of the distal radius. Associated injuries may accompany distal radius fractures.
  6. 6. Diagnosis: History and PhysicalFindings History of a FOOSH Visible deformity of the wrist, with the hand most commonly displaced in the dorsal direction. Movement of the hand and wrist are painful. Adequate and accurate assessment of the neurovascular status of the hand is imperative, before any treatment is carried out.
  7. 7. Diagnosis: Diagnostic Tests andExamination General physical exam of the patient, including an evaluation of the injured joint, and a joint above and below Radiographs of the injured wrist CT scan of the distal radius in selected instances.
  8. 8. Osseous Anatomy Distal radius – 80% of axial load  Scaphoid fossa  Lunate fossa  Sigmoid notch – DRUJ Distal ulna
  9. 9. Anatomy scaphoid and lunate fossa  Ridge normally exists between these two sigmoid notch: second important articular surface triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid
  10. 10. Anatomy Articular Surface  Scaphoid facet  Lunate facet  Sigmoid notch
  11. 11. RADIOLOGY  Ulnar inclination (22deg)  Volar inclination (11deg)  Radial length (11mm)  Ulnar variance (+ / - 1mm)
  12. 12. Measurement of Radial Length and InclinationInclination = 23degrees
  13. 13. Scapholunate angle measured between lines 2 and 3 (normal 47 ± 15 degrees) 2: Line perpendicular to 1: Line connecting dorsal and lunate volar tip of lunate 3: Line along axis of scaphoid
  14. 14. Computed TomographyIndications: Intra-articular fxs with multiple fragments centrally impacted fragments DRUJ incongruity Cole et al: J Hand Surg, 1997
  15. 15. Classification ofDistal Radius Fractures  Ideal system should describe:  Type of injury  Severity  Evaluation  Treatment  Prognosis
  16. 16. Common Classifications  Column theory  Gartland/Werley  Frykman  Weber (AO/ASIF)  Melone  Fernandez (mechanism)
  17. 17. Frykman Classification Extra- articularRadio-carpal joint Same pattern asRadio-ulnar joint { odd numbers, except ulnar styloid also fracturedBoth joints
  18. 18. AO/ OTA ClassificationGroup A: Extra-articularGroup B: PartialIntra-articularGroup C:Complete Intra-articular
  19. 19. Column Theory 3 Columns: radial, intermediate, medial Rikli & Regazzoni, 1996
  20. 20. Three Column Theory  Radial Column Lateral side of radius  Intermediate Column Radial column Ulnar column Ulnar side of Intermediate column radius  Ulnar Column distal ulna
  21. 21. Classification – Fernandez(1997) I. Bending- metaphysis fails under tensile stress (Colles, Smith) II. Shearing-fractures of joint surface (Barton, radial styloid)
  22. 22. Classification – Fernandez(1997) III. Compression- intraarticular fracture with impaction of subchondral and metaphyseal bone (die-punch) IV. Avulsion-fractures of ligament attachments (ulna, radial styloid) V. Combined/complex - high velocity injuries
  23. 23. Assessment of X-rays  Assess involvement of dorsal or volar rim  Is comminution mainly volar or dorsal?  is one of four cortices intact?  Look for “die-punch” lesions of the scaphoid or lunate fossa.  Assess amount of shortening  Look for DRUJ involvement
  24. 24. Dorsal angulation and comminution
  25. 25. Volar subluxation of carpus with fracture fragment
  26. 26. Options for Treatment  Casting  Long arm vs short arm  Sugar-tong splint  External Fixation  Joint-spanning  Non bridging  Percutaneous pinning  Internal Fixation  Dorsal plating  Volar plating  Combined dorsal/volar plating  focal (fracture specific) plating
  27. 27. Treatment Goals  Preserve hand and wrist function  Realign normal osseous anatomy  promote bony healing  Avoid complications  Allow early finger and elbow ROM
  28. 28. Indications for ClosedTreatment  Low-energy fracture  Low-demand patient  Medical co-morbidities  Minimal displacement- acceptable alignment
  29. 29. Closed Treatment of DistalRadial Fractures Obtaining and then maintaining an acceptable reduction. Immobilization:  long arm  short arm adequate for elderly patients Frequent follow-up necessary in order to diagnose redisplacement.
  30. 30. Technique of ClosedReduction Anesthesia  Hematoma block  Intravenous sedation  Bier block Traction: finger traps and weights Reduction Maneuver (dorsally angulated fracture):  hyperextension of the distal fragment,  Maintain weighted traction and reduce the distal to the proximal fragment with pressure applied to the distal radius. Apply well-molded “sugar-tong” splint or cast, with wrist in neutral to slight flexion. Avoid Extreme Positions!
  31. 31. Acceptable ReductionCriteria No dorsal angulation > 15 degrees of inclination Articular step-off < 2mm < 5 mm shortening compared to opposite wrist. DRUJ congruent
  32. 32. After-treatment Watch for median nerve symptoms  parasthesias common but should diminish over few hours  If persist release pressure on cast, take wrist out of flexion  Acute carpal tunnel: symptoms progress; CTR required Follow-up x-rays needed in 1-2 weeks to evaluate reduction. Change to short-arm cast after 2-3 weeks, continue until fracture healing.
  33. 33. Management ofRedisplacement  Repeat reduction and casting – high rate of failure  Repeat reduction and percutaneous pinning  External Fixation  ORIF
  34. 34. Indications for ImmediateSurgical Treatment  High-energy injury  Open injury  Secondary loss of reduction  Articular comminution, step-off, or gap  Metaphyseal comminution or bone loss  Loss of volar buttress with displacement  DRUJ incongruity
  35. 35. Operative Management of DistalRadius Fractures
  36. 36. External fixation:The treatment of choice fordistal radius fractures in the 1980‟s
  37. 37. Literature Articles DiscussingExternal Fixation 50 45 40 35 30 25 20 15 10 5 0 No. of Articles 1974 1980 1986 1999
  38. 38. Types of External Fixation Spanning  Non-spanning  Dynamic  Hoffman 2 ○ Clyburne  Cobra ○ Agee  Zimmer ○ Pennig  AO  Static ○ AO ○ Ace
  39. 39. Spanning ( Ligamentotaxis) A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals
  40. 40. Non-spanning A non-spanning fixator is one which fixes distal radius fracture by securing pins in the radius alone, proximal to and distal to the fracture site.
  41. 41. Courtesy of HillHastings,MD
  42. 42. External Fixation- Disadvantages -  Bulky  Poor screw hold in porosis and comminution  Screws do not buttress  More invasive
  43. 43. Ligamentotaxis Adverse effect of carpal over- distraction well documented  Kaempffe (1993): pain, function, grip strength adversely affected  Gupta (1999): 10# of distraction can induce over 10mm of ligament elongation  Davenport (1999): 10mm carpal distraction produces >20% increase in ligament strain
  44. 44. Complications Complication rates high in almost all reported series  Mal-union  Pin track infection  RSD / arthrofibrosis  Finger stiffness  Loss of reduction; early vs late  Tendon rupture
  45. 45. Percutaneous Pins
  46. 46. Percutaneous Pins
  47. 47. Percutaneous Pinning-Methods variety described most common radial styloid pinning + dorsal-ulnar corner of radius pinning supplemental immobilization with cast, splint in conjunction with external fixation (Augmented external fixation)
  48. 48. Percutaneous Pinning 2 radial styloid pins - Mah and Atkinson, J Hand Surg 1992  excellent anatomic 82%  good-excellent functional results 100% radial styloid with dorsal - prospective study, 30 pts (Clancey JBJS 1984)  excellent anatomic results in 90%
  49. 49. Percutaneous Pinning-Kapandji intrafocal pinning through fracture site buttress against displacement good results in literature
  50. 50. Internal Fixation of Distal RadiusFractures Useful for elevation of depressed articular fragments and bone grafting of metaphyseal defects required if articular fragments can not be adequately reduced with percutaneous methods
  51. 51. Selection of Approach Based on location of comminution. Dorsal approach for dorsally angulated fractures. Volar approach for volar rim fractures Radial styloid approach for buttressing of styloid Combined approaches needed for high- energy fractures with significant axial impaction.
  52. 52. VOLARClassical Henry approach Extended carpal tunnel approach
  53. 53. Volar –Henry Approach
  54. 54. Radial to FCR
  55. 55. Elevate Pronator Quadratus
  56. 56. Distal Radius-volar barton 64 yo M, MVA, contralateral tibial shaft Fx
  57. 57. Dorsal Fracture
  58. 58. CT Scan
  59. 59. DORSAL APPROACH 3rd DC –EPL1-2nd DC (extensile) -
  60. 60. Dorsal Plating, PCP and Ex Fix
  61. 61. Volar Plating for Dorsal Fractures -less tendon irritation than dorsal
  62. 62. Fixed angle locked screws ,,variable angle
  63. 63. Courtesy J. Orbay,MD
  64. 64. Courtesy J. Orbay, MD
  65. 65. Fragment Specific System
  66. 66. Radial and Ulnar Columns -Pin plates -90-90 plating technique
  67. 67. Focal PlatingRadial Styloid FragmentDorsal ulnar fragment 70 – 90 degrees apart
  68. 68. Dorsal Fracture Radial Styloid and dorsal-ulnar corner
  69. 69. Dorsal Case: focal plating
  70. 70. Radial shortening,comminution Dorsal angulation Indication for Volar and Dorsal Plating
  71. 71. Volar approach,applicationbuttress plate
  72. 72. Dorsal approach,application of 2 “L” buttressplates
  73. 73. EPL Tendon
  74. 74. Extensor retinaculum repairedbeneath EPL to prevent erosionagainst plate- EPL left transposed
  75. 75. Advanced TechniquesArthroscopic-Assisted  reduce articular incongruities  also diagnose associated soft tissue lesions  minimally invasive
  76. 76. Conclusions Need to be able to use all tools for treatment of distal radius fractures Both external fixation and ORIF are useful.  ORIF better in high-energy fractures associated with depression of articular surface  ORIF gives better anatomic restoration, although not necessarily higher patient satisfaction.
  77. 77. Conclusions External fixators still have a role in the treatment of distal radius fractures Spanning ex fix does not completely correct fracture deformity by itself Should usually combined with percutaneous pins (augmented fixation)
  78. 78. Conclusions new plating techniques allow for accurate and rigid fixation of fragments Plating allows early wrist ROM Volar, smaller and more anatomic plates are better tolerated combination treatment is often needed
  79. 79. Relationshipof Anatomy to Function Colles; “The wrist will regain perfect freedom in all of its motions and be completely exempt from pain” (1814)  Generally true for low demand individuals  Direct relation between residual deformity and disability  Quality of reduction more important than method of immobilisation

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