distal radius fractures

Distal Radius Fractures

Outline

Epidemiology

Anatomy

Classification

Imaging

Treatment

Complications

Conclusions

Epidemiology

Distal radius fractures1/6th of all #’s treated in ED450,000 annually in US in elderly 2nd only to hip #Lifetime risk = 15% women; 2% menBimodal distribution (ages 6-10 & 60-69)

Older population = women, postmenopausal osteoporosis, caucasian, family history

Mechanism of Injury

ElderlyFOOSH in osteoporotic bone (insufficiency #)

YoungHigh-energy with marked comminution and wide

displacementE.g. MVC, fall from height, sports

AnatomyDistal radius consists of

MetaphysisScaphoid facetLunate facetSigmoid notch

TFCC – from distal edge of radius to base of ulnar styloidStabilizes DRUJ

80% of axial load supported by DR, and 20% by ulna/TFCC

AnatomyMetaphysis

Primarily cancellous boneFlared distally with thinner cortical bone lying dorsally +

radially # ’s typically collapse dorsoradially

Cross-Sectional AnatomyRadial styloid angles

volarly

Extensor tendons in direct contact with bone

Layer of fat between flexor tendons and bone

VOLAR

DORSAL

Clinical Evaluation

Physical Exam Wrist typically swollen, with ecchymosis, tenderness and painful

ROM Deformity of the wrist/Displacement of the hand in relation to the

wrist E.g. dorsal displacement, radial shortening

Open injury Soft tissue injury typically palmarly + ulnarly (result of distal ulna)

Associated injuries Examine ipsilateral shoulder & elbow

E.g. # radial head Carpal #’s

Neurovascular status Carpal tunnel compression symptoms in 13% to 23% Result of displacement of median N, direct trauma from # fragments, or

hematoma in carpal tunnel Symptoms should improve with reduction of #

Imaging

X-raysStandard View (PA, lateral, oblique views)Contralateral wrist views

May assess pt’s normal ulnar variance + SL angle

CT ScanDemonstrate extent of intra-articular involvement

Normal Radiographic Parameters

Radial Inclinationavg = 23˚ (range 13-30˚)

Radial LengthAvg = 11 mm (range, 8-

18mm)

Ulnar varianceAvg = 1 mm ulnar

negative

Normal Radiographic Parameters

Volar TiltAvg = 11-12˚ (range 0-

28˚)

Classification

Extra-articular vs intra-articular

Degree of comminution

Dorsal vs volar displacement

Open vs Closed

Classification Systems

MultipleFrykman Jupiter & FernandezMeloneAO classification

None frequently used

Frykman Classifcation8 categories based on

Intra-articular extension (radiocarpal or DRUJ)

# of ulnar styloid process

Does not consider displacement nor comminution

Jupiter & Fernandez

Based on mechanism I) Metaphyseal bending

# II) Shearing # III) Compression # of

articular surface IV) Avulsion # or

radiocarpal #-dislocation V) High-energy,

combined mechanism

Melone ClassficationBased on number of parts

1 = radial shaft 2 = radial styloid fragment 3 = volar lunate fossa 4 = dorsal lunate fossa

Medial lunate complex (3+4) are important for radiocarpal + DRUJ function

AO classification

Management

Non-operativeReduction + Casting

OperativePercutaneous PinningEx-fixORIF

Factors affecting treatment

Fracture pattern

Fracture stability

Patient factors

Factors affecting treatment

Fracture pattern ACCEPTABLE RADIOGRAPHIC CRITERIA

Radial Length = < 5 mm radial shortening Volar tilt = neutral (0 deg) Intra-articular step-off/gap < 2mm Radial Inclination > 10 deg

Fracture stability

Patient factors

Radial Shortening

Accept < 5 mm radial shortening

Palmer & Werner (Clin Orthop 1984) Increase of 18% to 42% in force

borne by distal ulna, with a relative radial shortening of 2.5 mm

TFCC becomes tighter, and DRUJ is disrupted, leading to pain & loss of forearm rotation

Shortening of 6-8 mm causes ulnocarpal impingement

Dorsal Angulation

Accept neutral tilt (young) or <10˚ dorsal tilt (elderly)

As DA increases, load distribution shifts from volar-radial to dorsal-ulnar

Load thru ulna increased to 50% at 30˚ dorsal tilt (Short et al.)

Loss of normal tilt affects grip strength

Radial Inclination

Affects grip strength, ROM in radial/ulnar deviation, distribution of load in wrist

Pogue et al (JHS 1990)- increased load borne by lunate facet

Articular congruency

Knirk & Jupiter (JBJS 1986)> 2 mm of intra-articular step-off increased rate of

symptomatic post-traumatic OA in young adults

Some other studies quote > 1 mm step-off or > 2 mm gap at risk for arthrosis

In elderly, radiographic arthrosis may not be symptomatic

Factors affecting treatment

Fracture pattern

Fracture stability Initial dorsal angulation >20˚ *** Comminution (especially dorsal) *** Intra-articular involvement Associated ulna # Age > 60 yrs *** Radial shortening > 5 mm

3+ RF = high likelihood of collapse

Patient factors

Factors affecting treatment

Fracture pattern

Fracture stability

Patient factors Physiologic patient age Lifestyle Occupation Hand dominance Associated medical

conditions Associated injuries

FRACTURE TYPES:Extra-articular

75%-80% of stable fractures treated closed

Signs of instability:Dorsal comminutionSignificant

displacementVolar displacement

Colles #Described by Abraham Colles in

1813

Classic definitionTransverse #2.5 cm proximal to radio-carpal

jointDorsally displaced & dorsally

angulated

“Dinner-fork” deformity

From FOOSH onto a dorsiflexed wrist with forearem pronated

FRACTURE TYPES: “Colles Type”: Dorsally displaced

Treatment algorithm:Hematoma block/ conscious sedationClosed reduction

In-line traction relying on “ligamentotaxis” Exaggerate deformity (increase dorsal angulation to

unlock volar cortex) Direct pressure on distal fragment to correct angulation

3 point casting

FRACTURE TYPES: “Colles Type”: Dorsally displaced

FRACTURE TYPES: “Colles Type”: Dorsally displaced

Use finger traps OR assistant for counter traction

Traction

Traction

Traction

When you think you have enough….more traction

FRACTURE TYPES: “Colles Type”: Dorsally displaced

FRACTURE TYPES: “Colles Type”: Dorsally displaced

FRACTURE TYPES:Extra-articular Stable

Post reduction xrays

Careful evaluation of anatomy

Careful patient instructionsTight cast necessary

Close follow-upXrays and evaluation weekly for three

weeksArgument about length of immobilization4-6 weeks

FRACTURE TYPES:Extra-articular Unstable

Smith’s # “reverse Colles #”volar angulation/displacement of

distal fragmentFOOSH onto hyperflexed or

supinated wristVery unstable #Rx’ed with ORIF (volar plating)

FRACTURE TYPES:Extra-articular Unstable

Surgical Treatment Options CR

Percutaneous k-wire fixation (+/- Kanpandji technique) Casting

External fixator +/- k-wire fixation Careful attention to soft tissue/overdistraction

ORIF Dorsal plating Volar fixed angle plating

Percutaneous Pinning Good results in lower energy injuries

At least 0.062 size

Technique: 1 radial styloid pin (avoid first ext

compartment) directed ulnarly 1 pin from dorsal-ulnar corner (b/w 4th and 5th

ext compartments) directed volarly + radially Advance to penetrate cortex of radial shaft

proximal to zone of metaphyseal comminution Augment prn

Apply plaster or fibreglass cast

Remove pins at 4-6 weeks

Kapandji technique

“intra-focal” pinning

Traps distal fragment by buttressing it from displacing

Pin is placed thru the # site and maneuvered to elevate the fragment

Once adequate reduction achieve, pin is driven thru opposite cortex to achieve stability

Can restore radial inclination + volar tilt

External-FixationCan restore radial length and radial

inclination, or if soft tissue problems

Provides traction Excessive traction associated with CRPS

(look for increased intercarpal distance on fluorscopy)

Some loss of volar tilt Supplement with percutaneous pinning

Associated with loss of ROM vs. ORIF

Risk of pin site infections

External Fixation

Pin placement 2 pins on ‘bare area’ of

radius just proximal to 1st

dorsal compartment outcroppers, b/w ECRB + ECRL

Watch for superficial radial N

2 pins in second MC

ORIFDorsal vs Volar plating

Locking vs non-locking plates

DORSAL PLATING

Excellent exposure to articular surface

Avoids neurovascular structures

Fixation on compression side of #, acts a buttress against collapse

Early plate designs bulky

Increased wrist stiffness and extensor tendon problems

Smaller implants in evolution

DORSAL APPROACH

Between 3rd + 4th dorsal extensor compartments

Do not violate ECRB subsheathRepair retinaculum

VOLAR PLATING

Early return of function

Improved ROM

No extensor tendon problems

Easier reduction: less comminution volarly

Fixed angle implants (locking)Not reliant on distal screw purchaseSupports subchondral plateAble to maintain # reduction in presence of dorsal

comminution

VOLAR APPROACH

Interval b/w FCR + radial artery

Palmar cutaneous branch of median N. at risk (b/w FCR and PL)

Elevate pronator quadratus with intent to repair!

Release of BR for exposure, partial or full

VOLAR PLATING

Early return of function

Improved ROM

No extensor tendon problems

Easier reduction: less comminution volarly

Fixed angle implantsNot reliant on distal screw purchaseSupports subchondral plate

FRACTURE TYPES:Intra-articular fracture CHAUFFEUR’S FRACTURE:

Avulsion # with extrinsic ligaments remaining attached to radial styloid

Associated with backfiring of automobile crank starters

Direct axial compression of scaphoid into radial styloid with wrist in dorsiflexion + ulnar deviation

Associated injries Scapholunate dissociation Perilunate dislocation

ORIF often necessary

FRACTURE TYPES:Intra-articular fracture

BARTON’S FRACTURE: shear # of dorsal or

volar rim of distal radius, with associated subluxation of carpus

Volar (“reverse”) type more common

Principles of intraarticular fractures apply

ORIF on side of fracture

FRACTURE TYPES:Barton’s Fracture

Buttress plate, does not need to have fixation in fragment

Indirect reduction of articular surface via volar approach

Dorsal approach allows visualization of articular surface

FRACTURE TYPES:Intra-articular

Two part: Die-punch

Impaction from lunate, causes depression of lunate facet

Three part: Scaphoid facet, lunate facet,

sigmoid knotch

Four part: Split in lunate facet

FRACTURE TYPES:Intra-articular

Can be very complex fracture patterns.

Articular surface WILL NOT be visible via volar side

Pre-op CT helps with planning

FRACTURE TYPES:Intra-articular

ORIF is standard of tx

Maximum of 1-2 mm of gap, 1 mm of step

Indirect reduction in volar approach

Post-traumatic OA in inadequate reduction.

GOALS OF ORIFYoung, active

Articular step/ gap < 1mm Radial shortening < 2mm Neutral volar tilt Radial inclination >10˚

Elderly, sedentary <10˚ dorsal tilt 2mm shortening Reduced RIA <2mm step

Arthroscopically-guided reduction

Arthroscope placed in dorsal 3,4 portal

Probe inserted in dorsal 4,5 portal

Radial styloid fragment stabilized with percutaneous K-wires

ULNAR STYLOID

Injured in 50-70% of cases

Review papers have shown that presence/non-union does not affect long term outcome

BASE OF STYLOID:Associated with detachment of TFCCDRUJ instabilityTension band wire/small fragment screw

COMPLICATIONS:Nerve Injuries

Median Nerve:Initial sensory loss can be observed if not

progressiveAny progressive changes/unremitting pain

Immediate carpal tunnel release If concern about forearm compartments,

fasciotomyNerve can be explored/released at time of

OR if any concernLate median nerve symptoms associated

with CRPS

COMPLICATIONS:Tendon Adhesions/Ruptures

Casting must leave MCPs free for ROM

Tenosynovitis can involve any dorsal compartmentMost common in first

EPL ruptureFirst 8 weeksIschemic/mechanical mechanismEIP to EPL rupture unless discovered acutely

COMPLICATIONS:Malunions

Treatment depends on:Patient demandsLocation of symptomsNature of malunion

>15 degrees of dorsal angulation in young person:Opening wedge dorsal osteotomyRequires significant planning to address

multiplanar deformity (RIA, Tilt, Length)

COMPLICATIONS:Malunions

Ulnar sided impingment/pain:Most common complaint from malunionMultiple options dependent on nayure of problem:

Ulnar shortening osteotomy Hemiresection arthroplasty for DRUJ malunion Many procedures described

Do we have evidence to justify our current practice?

Review of case lists of applicants of American Board of Orthopaedic Surgery from 1999-2000Proportion of DR#’s

treated with Open treatment vs Closed percutaneous fixation increased from 42% in 1999 to 81% in 2007

Koval, JBJS 2008

Do we have evidence to justify our current practice?

Biomechanical Dorsal plating (locked and not locked) stronger than

volar in cadaveric studyClinical implications?

Trease, J of Hand Surg, 2005

Do we have evidence to justify our current practice?

RECENT PUBLICATIONS:Do we have evidence to justify our current practice?

New dorsal plates:Universally good functional outcomes23 % had plate removal for extensor tenosynovitis

+/- limitation in flexionAuthor’s recommended plate removal

Khandjula, Acta Orthopeadica Scan, 2005

RECENT PUBLICATIONS:Do we have evidence to justify our current practice?

Volar locked plating:Universally good functional outcomesAll dorsally displaced fractures in the elderly12 month follow-upNo comparison arm

Wong, JOT, Aug 2005

THE END