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Distal Radius.Fractures
The document discusses distal radius fractures, including their classification, management, and research. It describes the most common classification systems, which classify fractures based on joint involvement, mechanism of injury, and severity. Management options include closed reduction and casting for non-displaced fractures, as well as percutaneous pinning, external fixation, and open reduction internal fixation for displaced or unstable fractures. Complications and the importance of anatomic restoration and early motion are also covered.
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Distal Radius.Fractures
- 1. DISTAL RADIUS FRACTURES ANATOMY ,MANAGEMENT AND RESEARCH SUSHANT S SONARKAR
- 2. AIMS INTRODUCTION. CLASSIFICATIONS. RADIOGRAPHIC PARAMETERS. MANAGEMENT. (Non-operative andOperative) COMPLICATIONS. RESEARCH. SOME INTERESTING CASES.
- 3. INTRO Most common orthopaedicinjury with a bimodal distribution o younger patients - high energy, intra-articular o older patients - low energy / falls, extra-articular, metaphyseal 50% intra-articular Associated injuries o DRUJ injuries must be evaluated o radial styloid fx - indication of higher energy Osteoporosis o high incidence of distal radius fractures in women >50 o distal radius fractures are a predictor of subsequent fractures
- 4. 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
- 7. CLASSIFICATION Ideal system shoulddescribe: Type of injury Severity & Mechanism Treatment Prognosis
- 8. CLASSIFICATIONS Universal (treatment algorithm) Frykman(joint involvement pattern) Fernandez (mechanism) Melone (lunate impaction injury- intraarticular) Column theory (anatomical) AO (severity)
- 9. FRYKMAN (joint involvementpattern) Extra- articular Radio-carpal joint Radio-ulnar joint Both joints { Same pattern as odd numbers, except ulnar styloid also fractured
- 10. FERNANDEZ ( mechanism) BENDING-metaphysisfails under tensile stress (Colles, Smith), Includes DRUJ injury SHEARING-fractures of articular surface (Barton, radial styloid)
- 11. FERNANDEZ (cont) COMPRESSION- intraarticular fracture withimpaction of subchondral and metaphyseal bone (die- punch) AVULSION-fractures of ligament attachments (ulna, radial styloid), radiocarpal dislocation COMBINED/COMPLEX- high velocity injuries
- 12. MELONE (lunate impactioninjury- intraarticular) Type I: Stable, without commination Type II: Unstable “die punch” dorsal or volar Type IIA: Reducible Type IIB: Irreducible (central impaction fracture) Type III: “Spike” fracture. Unstable. Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation of the distal and palmar fragments Type V: Explosion injury
- 14. Group A Extraarticular GroupB Partially intraarticular GroupC Completely intrarticular AO Associationfor Osteosynthesis CLASSIFICATION (severity)
- 15. Universal classification A) Extraarticularfarcture Type 1-undispced and stable Type2-dispalced a)Reducible and staleb b)reducible and unstable c)irreducible B) Intraarticular fracture Type1-undisplaced and stable Type 2-Displaced a)Reducible and stable b)Reducible and unstable c)irreducible d)complex
- 16. TYPES OF FRACTURES-EPONYMS Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius Barton's fx Fx dislocation of radiocarpal joint with intra- articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx) Chauffer's fx Radial styloid fx Colles' fx Low energy, dorsally displaced, extra-articular fx Smith's fx Low energy, volar displaced, extra-articular fx
- 17. COLLE’S FRACTURE Most frequentlyencountered injury to the distal forearm in older people. Fall on the outstretched hand with forearm pronated, wrist in dorsiflexion/extension injury Age usually above 50y; F>M. Extraarticular 2-3 cm away from articular surface of radius (CORTICO- CANCELLOUS JUNCTION). (Combination of dorsal angulation , dorsal displacement, radial shift and radial shortening) Associated # of ulnar styloid. DINNER FORK DEFORMITY
- 19. SMITH’S FRACTURE –REVERSE COLLE’S Fracture of the distal radius with volar displacement and angulation of the distal fragment Flexion injury or a direct blow to the dorsum of the hand/ fall on back of hand. Garden-spade deformity Modified Thomas Classification of Smith's Fracture: Type I: Extraarticular Type II: Crosses into the dorsal articular surface Type III: Enters the radiocarpal joint (equivalent to volar barton fracture dislocation)
- 20. Fracture dislocation ofradiocarpal joint with intra-articular fracures involving the volar or dorsal lip Dorsal Barton fracture Volar Bartons fracture BARTON’S FRACTURE
- 21. CHAUFFEUR’S FRACTURE • Involvesthe lateral margin of the distal radius, extending through the radial styloid process into the radiocarpal articulation . • Best seen in PA view
- 22. RADIOGRAPHIC PARAMETERS View MeasurementNormal Acceptable criteria AP Radial height 13 mm <5 mm shortening Radial inclination 23 degrees change <5° Articular step off congruous <2 mm step off LAT Volar tilt 11 degrees dorsal angulation <5° or within 20° of contralateral distal radius
- 23. Normal parameters Radial inclination= 23° Radial height/length = 13mm Volar tilt = 11° Scapholunate angle = 60° +/- 15°
- 25. CT SCAN: Intra-articular fractureswith multiple fragments Occult fractures DRUJ incongruity Post op; fracture healing MRI: Soft tissue injury Nerve, tendons, ligaments Scaphoid , lunate necrosis
- 26. MANAGEMENT AIMS Efficient andfunctional wrist Accuracy of articular reduction (to reduce degeneration) Restoration of anatomy Radial alignment and length (joint stability) Early motion of wrist and fingers Promote bone healing Avoid complications
- 27. MANAGEMENT OPTIONS Conervative: Closed reductionand immobilization with cast Operative: Closed reduction and Percutaneous pinning (CRPP) External fixation (EF) , spanning/nonspanning ORIF with plate fixation dorsal /volar Arthroscopically assisted reduction and Ex. Fixation of intraarticular fracture. Bone grafting In malunion, corrective bone osteotomy Rehab and follow up: Subjective assessment tools ,PRWE, DASH.
- 29. Closed Reduction andcast Low-energy fracture Low-demand patient Medical co-morbidities Minimal displacement- acceptable alignment most extra-articular fxs repeat closed reductions have 50% less than satisfactory results
- 30. After-treatment Watch for mediannerve 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; Release required Follow-up x-rays needed in 1-2 weeks to evaluate reduction. Short-arm cast after 2-3 weeks, continue until fracture healing. Redisplacement: Repeat reduction and casting – high rate of failure Repeat reduction and percutaneous pinning, External Fixation Or ORIF
- 31. OPERATIVE INDICATIONS Surgical fixation(CRPP, External Fixation, ORIF) radiographic findings indicating instability (pre-reduction radiographs best predictor of stability) displaced intra-articular fx, Step-off volar or dorsal comminution DRUJ Incongruity Open and high energy fractures Associated neurovascular injury/tendon injury severe osteoporosis dorsal angulation >5° or >20° of contralateral distal radius >5mm radial shortening Failed closed reduction and casting associated ulnar styloid fractures do not require fixation
- 32. CRPP (CLOSED REDUCTION& PERCUTANEOUS PINNING) Indications can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex cannot maintain length/alignment when unstable or comminuted volar cortex Techniques Kapandji intrafocal technique In conjunction with external fixation (Augmented external fixation) Rayhack technique with arthroscopically assisted reduction Outcomes 82-90% good results if used appropriately
- 34. Complications Mal-union ( mayneeds augmentation with additional casting) Pin track infection RSD Finger stiffness Loss of reduction more common than plating Tendon rupture nerve injury
- 35. External Fixation 1. Spanning,2. Nonspanning Indications alone cannot reliably restore 10 degree palmar tilt therefore usually combined with percutaneous pinning technique or plate fixation Technical considerations relies on ligamentotaxis to maintain reduction place radial shaft pins under direct visualization to avoid injury to superficial radialnerve nonspanning ex-fix can be useful if large articular fragment avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation limit duration to 8 weeks and perform aggressive OT to maintain digital ROM Outcomes important adjunct with 80-90% good/excellent results Complications stiffness and decreased grip strength pin complications (infections, fx through pin site, skin difficulties) neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
- 36. Spanning ( Ligamentotaxis) Aspanning fixator isone which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals
- 37.
- 38. Open Reduction InternalFixation Indications significant articular displacement (>2mm) dorsal and volar Barton fxs volar comminution metaphyseal-diaphyseal extension associated distal ulnar shaft fxs die-punch fxs preference of early mobilization (ref: Bone and Joint; distal radius fracture, current concepts & Mx)
- 39. SURGICAL APPROACHES Volar approachDorsal approach
- 40. VOLAR PLATING volar platingpreferred over dorsal plating volar plating associated with irritation of both flexor and extensor tendons rupture of FPLis most common withvolar plates associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons new volar locking plates offer improved support to subchondral bone
- 41. DORSAL PLATING dorsal platinghistorically associated with extensor tendon irritation and rupture dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal comminution can combine with external fixation bone grafting if complex and comminuted studies showed improved results with arthroscopically assisted reduction volar lunate facet fragments may require fragment specific fixation to prevent early post-operative failure
- 42. Universal classification basedOptions TYPE TREATMENT 1)Non articular undisplaced Cast/splint 2)Non articular displaced Close reduction and cast application Percutaneous pin fixation/external fixation 3)Articular undisplaced Cast/percutaneous pin fixation 4)Articular displaced A)Reducible,stable Cast/percutaneous fixation/external fixation B)Reducible,unstable External fixation/ex fix with percutaneous pin fixation C)Irreducible ORIFwith plate External fixation Combined external and internal fixation
- 43. Complications Unsightly scar Tendon rupture(flexor or extensor) Some patients may require implant removal Implant cost Technically more difficult Median nerve neuropathy (CTS) most frequent neurologic complication 1-12% in low energy fxs and 30% in high energy fxs prevent by avoiding immobilization in excessive wrist flexion treat with acute carpal tunnel release for: progressive paresthesias paresthesias do not respond to reduction and last > 24-48 hours
- 44. Ulnar nerve neuropathy seenwith DRUJ injuries EPLrupture nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon. treat with transfer of extensor indicis proprius to EPL Radiocarpal arthrosis (2-30%) 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm may be nonsymptomatic
- 45. Malunion and Nonunion Intra-articularmalunion treat with revision at > 6weeks Extra-articular angulation malunion treat with opening wedge osteotomy with ORIFand bone grafting Radial shortening malunion radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs treat with ulnar shortening ECU or EDM entrapment entrapment in DRUJinjury Compartment syndrome RSD/ CRPS
- 46. BMC Musculoskelet Disord.2013; 14: 170. Published online 2013 May 22. doi: 10.1186/1471-2474-14-170 PMCID: PMC3665633 Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs Annechien Beumer, Tommy R Lindau, and Catharina Adlercreutz CONCLUSION: The present study showed that post-traumatic ulna fracturesare the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too.
- 47. JHand Surg Am.2013 Aug;38(8):1469-76. doi: 10.1016/j.jhsa.2013.04.039. Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study. Williksen JH1, Frihagen F,Hellund JC,Kvernmo HD, Husby T. CONCLUSIONS: Although we did not find a significant difference between the groups for the QuickDASH score, we believe that our results support the use of VLPs for the treatment of unstable distal radius fractures. A serious concern is that some patients will have to have their plates removed; therefore, improving the surgical technique is important.
- 49. CASE 1- DISTALRADIUS FRACTURE 31 YEARS OLD SERVING ARMY SOLDIER TRANSFFERED TO 5AFH FROM 162 MH ,HISTORY OF FALL ON OUTSTRECHED HAND LEADING DEFORMITY TO RIGHT WRIST. ON EXAMINATION: PAINFULL ROM DEFORMITY SWELLING NO DNVD
- 50. MODIFIED HENRY’S APPROACH -FLEXORCARPI RADIALIS TENDON -FLEXOR POLOSIS LONGUS -PRONATOR QUADRATUS -MEDIAN NERVE -RADIAL ARTERY
- 51. PRE AND POSTOPERATIVE XRAYS
- 55. CASE 2- COMMINUTEDDISTAL RADIUS FRACTURE 34 YEARS OLD SERVING AIR WARRIOR TRANSFFERED TO 5AFH FROM 22WG , SUSTAINING INJURY TO HIS RIGHT WRIST. ON EXAMINATION: CREPITUS RESTRICTED ROM DEFORMITY SWELLING NO DNVD
- 58. CASE 3- COMMINUTEDDISTAL RADIUS FRACTURE 68 YEARS OLD WIFE OF RETD AIR WARRIOR, SUSTAINING INJURY TO HIS RIGHT WRIST. ON EXAMINATION: CREPITUS RESTRICTED ROM GROSS DEFORMITY SWELLING ++ NO DNVD
- 61. CASE 4- INTRA-ARTICULARDISTAL RADIUS FRACTURE WITH DRUJ DISLOCATION 46 YEARS OLD SERVING ARMY OFFICER, SUSTAINING INJURY TO HIS RIGHT WRIST DUE TO FALL ON BACK OF HAND WHILE RUNNING. ON EXAMINATION: PIANO SIGN + CREPITUS RESTRICTED ROM GROSS DEFORMITY SWELLING ++ NO DNVD
- 62. PRE OP CTIMAGES