1. Neglected wrist trauma, especially distal radius fractures, are common injuries that are often overlooked.
2. Malunions of distal radius fractures can lead to deformities like shortening, angulation, and rotational abnormalities that disrupt the biomechanics of the wrist.
3. Surgical management of neglected wrist injuries focuses on correcting deformities through osteotomies and bone grafting, restoring radial length and angle, and addressing ulnar-sided problems through procedures like ulnar shortening. Late stage treatment may require salvage procedures like wrist fusion.
3. OSSAPCON 2012, RAJAHMUNDRY
WRIST&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
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
9. OSSAPCON 2012, RAJAHMUNDRY
‘IT IS WHAT we THINK WE
KNOW
THAT KEEPS US FROM
LEARNING’
----------CLAUDE BERNARD
10. OSSAPCON 2012, RAJAHMUNDRY
OVERLOOKED WRIST TRAUMA
Distal radius malunions
1.Extra articular
A. Dorsal malunion
B. Volar malunion
C. ulnar angulated molunion
2.Intraarticular malunions
3.Rotational malunion
Distal radius nonunoin
11. OSSAPCON 2012, RAJAHMUNDRY
WORK OUT
Radiological examination
PA view &lateral view
Comparative– x-rays in neutral position
CT scan--------rotation of distal fragment
MRI------------carpal abnormalities, TFCC
injuries, DRUJ evaluation
13. OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMY &
PATHOMECHANICS
RADIAL 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. OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMY
RADIAL TILT
11 degree
Acceptable –
dorsal-15
volar-20
<10 degree dorsal angulation-
normal FA rotation
>30 degree gross restriction of
FA
>30 degreewrist motor function
is significantly affected
16. OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMY
ULNAR VARIANCE
Normal-0-neutral
Acceptable—4mm
Aro and Koivunen4 classification
3 types
radioulnar relationships at the
DRUJ after distal radius fractures.
Axial shortening of the radius by
less 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. OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMY
ROTATATIONA
L MOLUNION
Dorsal angulation-
supination deformity
Volar angulation
Pronation deformity
Minimal role in FA
rotations
Soft tissue 38 degr rotation is required is to diagnose
contracture plays rotational mol union by cortical mismatch
major role The Journal of Volar shifting of ulna is an indication of rotational
Hand Surgery / Vol. 29A No. 1 Correction per operative assesment-
January 2004
18. OSSAPCON 2012, RAJAHMUNDRY
wrist instability in
two distinct
patterns:
(1) dorsal radiocarpal
subluxation,
with normal midcarpal
alignment, and
(2) adaptive
midcarpal dorsal
intercalated segment
instability (DISI)
deformity
CARPAL MECHANICS
poor functional outcome, with a radiolunate angle
> 25°
19. OSSAPCON 2012, RAJAHMUNDRY
DRUJ BIOMECHANICS
Axial load at wrist
80%
radius
20%
ulna
Ulnar variance of
>2.5mm increases ulnar
load by 42%
Radial shortening&
Dorsal angulation
shifts center
of rotation proximaxlly
stretches
dorsal radio ulnar
ligaments
20. OSSAPCON 2012, RAJAHMUNDRY
DR 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. OSSAPCON 2012, RAJAHMUNDRY
MANAGEMENT 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 tissue
coverage
volar fixed angle locking
plate
4.Ulnar-side procedures
25. OSSAPCON 2012, RAJAHMUNDRY
OSTEOTOMY &BONE GRAFTING
structural bone graft Non structural bone
from 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. OSSAPCON 2012, RAJAHMUNDRY
ROTATIONAL 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)
28. OSSAPCON 2012, RAJAHMUNDRY
MALUNITED 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. OSSAPCON 2012, RAJAHMUNDRY
ARTICULAR MAL UNION- SURG OPTIONS
AS PER SAFFAR
Description of malunion Surgical options
1.Scaphoid Facet malunion 1.Intra articular osteotomy
2.Radial styloidectomy
3.Proximal Row carpectomy
2. Lunate facet malunion 1.Intra articular osteotomy
2.Radio Lunate Fusion
3. Global wrist arthrosis 1.Early osteotomy
2.Wrist denervation
3.Wrist Arthrodesis
4.Anterior or Posterior Rim 1.Rim excision
malunion
31. OSSAPCON 2012, RAJAHMUNDRY
MALUNITED ARTICULAR FRACTURES
LIMITATIONS
The limitation of
articular access
additional articular
damage
still challenging.
32. OSSAPCON 2012, RAJAHMUNDRY
MALUNITED 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:
37. OSSAPCON 2012, RAJAHMUNDRY
MANAGEMENT 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
44. OSSAPCON 2012, RAJAHMUNDRY
TAKE 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