Dr.y.nageshwarao neglected wrist fractures

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  • Not because fracture has changed, but because of better understanding of biomechanics
  • Radilogy is imp to quantify the deformity& to qualitate joint status
  • contraindications toFAILED osteotomy or in whom attempts atosteotomy have failed or for radiocarpal arthritis
  • Dr.y.nageshwarao neglected wrist fractures

    1. 1. NEGLECTED WRIST TRAUMA Dr.Y.Nageswara rao OSSAPCON 2012 Rajahmundry Organisng secretary Prof.Dr.C.Hanumanta Rao
    2. 2. OSSAPCON 2012, RAJAHMUNDRYNEGLECTED TRAUMA AROUND WRIST Carpal injuriesDistal radius# 20% all skeletal injuries Willful negligence Radius# DRUJ disruption
    3. 3. OSSAPCON 2012, RAJAHMUNDRYWRIST&HAND Highly evolved part of musculoskeletal system It Occupies major part of motor cortex But most common neglected anatomical region in trauma The natural fascination for hip in academics and in practice has kept many sub specialities in low esteem
    4. 4. OSSAPCON 2012, RAJAHMUNDRYWRIST EVOLUTION
    5. 5. OSSAPCON 2012, RAJAHMUNDRYDISTAL RADIUSThe distal end of the radius is the anatomicfoundation of the wrist joint.
    6. 6. OSSAPCON 2012, RAJAHMUNDRYWGLECTED WRIST TRAUMA Willful negligence
    7. 7. OSSAPCON 2012, RAJAHMUNDRY “One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain; the deformity, however, will remain undiminished throughout life.‖1773--1843
    8. 8. OSSAPCON 2012, RAJAHMUNDRY―enjoy perfectfreedom in all . . .motions, and exemptfrom pain,‖ an Exception, rather arule
    9. 9. OSSAPCON 2012, RAJAHMUNDRY ‘IT IS WHAT we THINK WEKNOW THAT KEEPS US FROMLEARNING’ ----------CLAUDE BERNARD
    10. 10. OSSAPCON 2012, RAJAHMUNDRYOVERLOOKED WRIST TRAUMADistal radius malunions 1.Extra articular A. Dorsal malunion B. Volar malunion C. ulnar angulated molunion 2.Intraarticular malunions 3.Rotational malunionDistal radius nonunoin
    11. 11. OSSAPCON 2012, RAJAHMUNDRYWORK OUTRadiological examination PA view &lateral view Comparative– x-rays in neutral position CT scan--------rotation of distal fragment MRI------------carpal abnormalities, TFCC injuries, DRUJ evaluation
    12. 12. OSSAPCON 2012, RAJAHMUNDRYRADIOLOGICAL PARAMETERS
    13. 13. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY & PATHOMECHANICSRADIAL INCLINATION Normal 22degr Acceptable range >15deg Decreasing the radial inclination shifted the load distribution so that there was more load in the lunate fossa and less load in the scaphoid fossa.
    14. 14. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMYRADIAL TILT11 degreeAcceptable – dorsal-15 volar-20 <10 degree dorsal angulation- normal FA rotation >30 degree gross restriction of FA >30 degreewrist motor function is significantly affected
    15. 15. OSSAPCON 2012, RAJAHMUNDRYPATHOANATOMY  RADIAL LENGTH  Normal-11mm  Acceptable-<4mm >4mm increased load on lunate facet
    16. 16. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY ULNAR VARIANCE Normal-0-neutral Acceptable—4mmAro and Koivunen4 classification 3 typesradioulnar relationships at theDRUJ after distal radius fractures.Axial shortening of the radius byless than 3 mm, designated grade 0,. Grade1- 3 to 5 mm of shortening. Grade 2- >5mm poor prognosis >2.5mm ↑40% ulnar load Ulnar impaction syndrome
    17. 17. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMYROTATATIONAL MOLUNIONDorsal angulation-supination deformityVolar angulationPronation deformityMinimal role in FArotationsSoft tissue 38 degr rotation is required is to diagnosecontracture plays rotational mol union by cortical mismatchmajor role The Journal of Volar shifting of ulna is an indication of rotationalHand Surgery / Vol. 29A No. 1 Correction per operative assesment-January 2004
    18. 18. OSSAPCON 2012, RAJAHMUNDRYwrist instability intwo distinctpatterns:(1) dorsal radiocarpalsubluxation,with normal midcarpalalignment, and(2) adaptivemidcarpal dorsalintercalated segmentinstability (DISI)deformityCARPAL MECHANICS poor functional outcome, with a radiolunate angle > 25°
    19. 19. OSSAPCON 2012, RAJAHMUNDRYDRUJ BIOMECHANICS Axial load at wrist 80%radius 20%ulna Ulnar variance of>2.5mm increases ulnarload by 42% Radial shortening&Dorsal angulation shifts centerof rotation proximaxlly stretchesdorsal radio ulnarligaments
    20. 20. OSSAPCON 2012, RAJAHMUNDRYDR ARTICULAR#S&RADIOCARPAL ARTHRITIS step-off of >2 mm 100% incidence of radiological arthritis 93% were said to be symptomatic. AP distance of the injured wrist when healed by >4mm Tear drop angle(normal 70o ) decreased angle in lunate fossa depression
    21. 21. OSSAPCON 2012, RAJAHMUNDRYMANAGEMENT STRATAGIES Surgical management consists four major independent components: 1.Osteotomy, closed or open 2.Bone grafting, structural or nonstructural 3.Fixation, dorsal-more stable volar-better soft tissuecoverage volar fixed angle lockingplate 4.Ulnar-side procedures
    22. 22. OSSAPCON 2012, RAJAHMUNDRYCORRECTIVE OSTEOTOMIES Closing Wedge osteotomies Opening Wedge osteotomies Variations
    23. 23. OSSAPCON 2012, RAJAHMUNDRYCORRECTIVE OSTEOTOMIES Closed wedge osteotomy Open wedge osteotomy
    24. 24. OSSAPCON 2012, RAJAHMUNDRYOSTEOTOMY VARIATIONS Sliding osteotomy for  Trapezoidal osteotomy correction Watson HK,Castle TH Jr: J Hand Surg [Am] 1988;13:837-843. 1998, Thivaios GC, McKee MD: J Orthop Trauma 2003;17:326-333.)
    25. 25. OSSAPCON 2012, RAJAHMUNDRYOSTEOTOMY &BONE GRAFTINGstructural bone graft  Non structural bonefrom graft is equally good the iliac crest in long term results the olecranon resected portion of the distal ulna, local graft from the radius
    26. 26. OSSAPCON 2012, RAJAHMUNDRYROTATIONAL OSTEOTOMY Sagittal rotational malunion after distal radius osteotomy through the ―hinge‖ point, and correcting the dorsal tilt A pure derotational osteotomy corrected the apparent shortening of the radius and restored the volar tilt (Hand Surg Eur Vol April 2009 vol. 34 no. 2 160-165)
    27. 27. OSSAPCON 2012, RAJAHMUNDRYTIMING OF OSTEOTOMY Nascent malunion(8-12wks) Mature malunion long term results are equal
    28. 28. OSSAPCON 2012, RAJAHMUNDRYMALUNITED ARTICULAR FRACTURES The indication for the osteotomy Dorsal or Volar subluxation of radiocarpal joint Articular incongruity of 2 mm as on a PA radiograph surgery is not based on symptoms because,by the time that symptoms develop,there may already be irreversible articular damage
    29. 29. OSSAPCON 2012, RAJAHMUNDRYARTICULAR MAL UNION- SURG OPTIONS AS PER SAFFARDescription of malunion Surgical options1.Scaphoid Facet malunion 1.Intra articular osteotomy 2.Radial styloidectomy 3.Proximal Row carpectomy2. Lunate facet malunion 1.Intra articular osteotomy 2.Radio Lunate Fusion3. Global wrist arthrosis 1.Early osteotomy 2.Wrist denervation 3.Wrist Arthrodesis4.Anterior or Posterior Rim 1.Rim excisionmalunion
    30. 30. OSSAPCON 2012, RAJAHMUNDRYARTICULAR MALUNION
    31. 31. OSSAPCON 2012, RAJAHMUNDRYMALUNITED ARTICULAR FRACTURES LIMITATIONS The limitation of articular access additional articular damage still challenging.
    32. 32. OSSAPCON 2012, RAJAHMUNDRYMALUNITED ARTICULAR FRACTURES CONTRAINDICATIONS for osteotomy Established, advanced arthrosis Low-demand and infirm patients Patients with an age > 70 years have few symptoms and adequate wrist function:
    33. 33. OSSAPCON 2012, RAJAHMUNDRYULNAR SIDE PROCEDURES
    34. 34. OSSAPCON 2012, RAJAHMUNDRYMILCH ULNAR SHORTENING
    35. 35. OSSAPCON 2012, RAJAHMUNDRYDARRACH’S EXCISION
    36. 36. OSSAPCON 2012, RAJAHMUNDRYSAUVE –KAPANDJI PROCEDURE
    37. 37. OSSAPCON 2012, RAJAHMUNDRYMANAGEMENT OPTIONS IN LATE STAGES Other Surgical Options(Salvage options ) Proximal row carpectomy, Radio scaphoid fusion, RadioScaphoLunate fusion Total wrist arthroplasty Total wrist fusion is the ultimate salvage procedure as a last resort. 1
    38. 38. OSSAPCON 2012, RAJAHMUNDRYPROX ROW CARPECTOMY
    39. 39. OSSAPCON 2012, RAJAHMUNDRY
    40. 40. OSSAPCON 2012, RAJAHMUNDRY
    41. 41. OSSAPCON 2012, RAJAHMUNDRY
    42. 42. OSSAPCON 2012, RAJAHMUNDRY
    43. 43. OSSAPCON 2012, RAJAHMUNDRY
    44. 44. OSSAPCON 2012, RAJAHMUNDRYTAKE HOME MESSAGE Clinically asses the functional deficit ―Willful negligence‖ concept to be applied very cautiously Restore radial height, Restore radio ulnar relation Most cases require ulnar side procedure Be aggressive in treating young patients You cannot plead innocence because you are ignorant------it could be legal negligence
    45. 45. OSSAPCON 2012, RAJAHMUNDRY THANK YOU

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