APPROCHES TO DISTAL RADIUS FRACTURES-.pptx

Approaches

1. SURGICAL APPROCHES - DISTAL RADIUS FRACTURES

2. Anatomy of forearm Compartments in forearm:

3. Flexor Muscles

4. Extensor Muscles

5. Bony Anatomy

6. Bony Anatomy 3 Column concept: Radial column(RC) – Radial Styloid & Scaphoid fossa . Intermediate (IC)– Lunate fossa and sigmoid notch. Ulna column(UC)- Distal Ulna and TFCC. Under normal condition, large proportion of load is transmitted across lunate fossa to IC The ulnar column terminates distally at the TFCC

7. Bony Anatomy 1 Lister's tubercle 2 Sigmoid notch 3 Ulnar head 4 Ulnar styloid 5 Radial styloid 6 Scaphoid facet 7 Lunate facet 8 Watershed line Margin btw structure which are elevate proximally and palmar wrist extrinsic ligament.

8. Radiological Evaluation AP View : Radial height = 12 mm Radial Inclination = 23* Ulnar varience . Lateral View: Palmar inclination=12* Teardrop angle = 70*

9. Indication for surgery Open fracture Associated with Compartment syndrome/ NVD/ Tendon injury. Radiocarpal fracture dislocation. Compression fracture Palmar /Dorsal shearing fracture. Palmar bending fracture. Dorsal bending fracture with Post reduction displacement : > 3 mm radial shortening. > 10* dorsal tilt. > 2 mm articular displacement.

10. Surgery Volar / Palmar plating Dorsal plating Fragment specific fixation. Pinning External fixation. Volar plating is popular in recent years. Dorsally placed implant has little soft tissue coverage than palmar plating. (Remedy: Low profile locking plates) Earlier Ex-fix is the TOC using ligamentotaxis and distraction to reduce the fracture. Because insufficient purchase of anterior cortex in metaphyseal area by conventional screw. So they used only for buttressing volar shear fragments. Remedy : Double column (RC&IC) Various locking plate system.

11. Palmar plating Indication: Simple unstable extra articular colles # Volar shear # (unstable with palmar subluxation of carpus ) Simple articular # Complex intra articular # with lunate facet. Corrective Osteotomy of malunion . Volar plate need sufficient place to put screws in distal fragment. For small distal fragment , we can use Volar rim plate.

12. Modified Henry’s Approach Longitudinal incision over radial side of FCR tendon  Fascia Tendon sheath of FCRFCR Tendon mobilized ulnarly  Plane between FCR and Radial artery incise the FCR tendon sheath floor Muscle belly of FPL swept into ulnar side L- shaped incision over PQ (horizontal limb place btw PQ & watershed line)Visualize the fracture. This approach expose radial aspect of distal radius with limited view of ulnar side.

13. Modified Henry’s Approach

14. Palmar plating Reduction: Dorsally displaced bending fracture Volar locking plate act as a reduction tool Locking screws placed in subchondral bone Angle of plate to the shaft = angle of displacement of distal fragment Fracture reduction achieved when plate brought onto shaft.

15. Palmar plating Fixation: Start from ulnar side of the radius. In articular fracture – Anatomical reduction of dorsoulnar fragment is very important because it is part of DRUJ and radiocarpal joint. Reduction achieved by Traction, manual compression over palmar fragment and plate. Failure to incorporate lunate facet in fixation lead to loss of fixation.

16. Plaster immobilization Theoretically after plating no need but commonly doing after volar plating. Encourage finger movements ASAP. Discontinued within 2 to 4 weeks. If suspected unstable DRUJ or questionable fixation of comminution , continue for 6 weeks.

17. Extensor compartments of wrist

18. Dorsal Plating Indication: 1. Dorsal shear fracture and radiocarpal dislocation. 2. Displaced dorsolunate fragment 3. Die punch fracture After advent of fixed angle volar locking plate, which can able to maintain reduction of most dorsally displaced fracture, dorsal plating has fallen out of favor.

19. Dorsal Approach Position : Arm pronation + wrist flexion over bump of towel. Incision: Straight skin incision centering Lister’s tubercle- Distally reach upto 1cm proximal to 2nd CMC joint. Proximally 3-4cm along the radius shaft. To approach IC: ER divide along EPL Plane btw 3 rd &4 th extensor compartment EPL freed except distal part of tendon which was kept inside the distal ER Elevate the 4 th compartment subperiosteally  visualize fracture. Elevating 2 nd compartment to expose dorsal aspect of scahoid fossa PIN is lying in the floor of 4 th compartment should be secured.

20. Dorsal Approach

21. Dorsal approach Double orthogonal plating technique for radial column, passing the plate superficially to 2 nd compartment and open the 1 st compartment . Safeguarding the superficial radial nerve which is in skin flap is important. For closure EPL tendon transposed over ER to avoid tendon irritation by plate.

22. Dorsal plating Complication: Less soft tissues available for coverage. So tendon irritation. Transient radial neuropraxia MC Complication. EPL rupture Carpal tunnel syndrome.

23. Fragment specific fixation Fragment specific fixation is variable depending upon fragment to be fixe. RC #  Incise over 1 st dorsal extensor compartment. (Radial sensory nerve which is in skin flap should be protected). Release BR from radial styloid for better exposure and reduction. Dorsal fragment #  open 4 th compartment and buttress with plating / pin applied. Ulnar fragments Volar approach ulnar to PL

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