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fractures of distal end of radius

1. DISTAL RADIAL FRACTURES Dr. F aisal Younis Shah PG2Y OU 1 BAJSH

2. 20 % of all fractures Distribution: 5-40 years: Men…High energy… intraarti …stable…operative Rx…. O ver 40: females…. Low energy… extraarti …tolerate conservative….

3. ANATOMY OF DISTAL RADIUS The distal radius consists of the metaphysis, (2) scaphoid facet, (3) lunate facet, and (4) sigmoid notch. The metaphysis has thinner cortical bone lying dorsally and radially. The extrinsic ligaments of the wrist play a major role in the use of indirect reduction techniques. P almar ligaments are Thicker as compared to dorsal ligaments. Distraction will result in the palmar ligaments becoming taut before the dorsal ligaments. It is for this reason that it is difficult to achieve reduction of the normal 12 degrees of palmar tilt using distraction alone

4. wrist consists of three distinct columns, each of which is subjected to different forces. radial column; intermediate column; ulnar column

5. Signs and Symp . and EXAMINATION: Pain, swell, tender, inability to use the limb, deformity Radial shortening Communicating wounds. Scaphoid Involvement Associated Ipsilateral Limb injuries. Contralateral limb injury. Other body injuries. Median nerve involvement (treat like compartment) (monitor by 2 pt disc)

6. XR PA View For extra-articular fractures: (a) radial length (b) ulnar variance, (c) metaphyseal comminution , and (d) ulnar styloid fracture location. For intra-articular fractures: (a) depression of the lunate facet, (b) gap b/w scaphoid and lunate facet, (c) central impaction fragments, and (d) interruption of proximal carpal row.

7. Lateral View: For extra-articular fractures: (a) dorsal/palmar tilt, (b) metaphyseal comminution , (c) carpal alignment, (d) displacement of the volar cortex, and (e) position of the DRUJ. For intra-articular fractures: (a) depression of palmar lunate facet, (b) depression of the central fragment, (c) gap bw palmar and dorsal fragments.

8. Other views: Oblique View Tilted Lateral View Traction Views (AP and Lateral) Contralateral Wrist (AP and Lateral) CT Scan

9. Stability: LaFontaine et al. initial dorsal angulation of more than 20 degrees dorsal metaphyseal comminution , ( 3) intraarticular involvement, (4) Associated ulnar fracture , and ( 5) Age 60 years or above . Other suggested indicators of instability include volar tilt, dorsal angulation, comminution , and initial shortening.

10. Frykman’s

11. CLASSIFICATION: FERNANDEZ

12. Rx

13. it is becoming increasingly apparent that operative intervention needs to be customized to the patient and the fracture as well as the expertise of the surgeon. Current data confirm that patients over the age of 65 with extra-articular fractures are more likely to be satisfied with closed treatment than younger patients, but that there are still some geriatric patients who will not accept shortening and angulation. external fixation versus internal fixation, more recent studies are concluding that the restoration of normal anatomy is more important than the technique that is used. the outcomes may be more related to fracture severity, with superiority of internal fixation being seen in the lower energy fractures.

14. Nonoperative Management: Type 1 fernandez stable fractures low demand elderly patients. intact palmar buttress (less than 2/3 to 3/4 dorsal comminution )(to resist collapse) Patient factors: Non-dominant hand, physical demands, health status, independent lifestyle, vocation, avocation, and comorbidities.

15. Operative treatment: Instability D isplaced intra-articular fracture Open fractures Associated carpal fractures Associated neurovascular injury/tendon injury Bilateral fractures Impaired contralateral extremity

16. Percutaneous Pinning (1.5 and 1mm) + SAC: extra-articular and simple articular fractures with less comminution in younger patients . Not used i f the reduction is not anatomical of if there is severe comminution , The radial styloid is pinned to the proximal shaft in a reduced position. Once the lateral cortex is reconstituted, then the intermediate column (lunate facet) is pinned from dorsal ulnar to proximal radial. Finally, any central impaction fragments can be supported using subchondral transverse wires. Complications: superficial radial nerve injury. (open or go dorsal)

17. Ext . Fixators: Bridging and non-bridging + Augmentation with BG or BC + Augmentation with PCP + Augmentation with Volar plate Arthroscopically Assisted Reduction and External Fixation. Limitations: external fixation in isolation does not typically restore the physiologic 12 degrees of palmar tilt. palmar lunate facet may not reduce with distraction alone. Overdistraction : there is a gap across the midcarpal joint on fluoroscopy, and confirmed when full passive digital motion is difficult to achieve.

18. Volar Plating: the screw position in the distal fragment directly buttresses collapse. The addition of locking fixation of the screws in the distal fragment further prevents dorsal displacement of the distal fragment.

19. TYPE 1: Colles , Smiths Stable: CRSAC in low function, elderly . Weekly Chk XR x 3 CR PCP SAC in young Unstable fractures: two long term problems: ( i ) shortening of the radius (ii) loss of palmar tilt. shortening of the radius relative to the intact ulna of more than 5 mm must by definition disrupt the TFCC or cause avulsion of the ulnar styloid . nonbridging external fixation, DRLP

20. TYPE II: Volar barton , dorsal barton , chauffers Non countoured palmar buttress plate (never to be used in complete articular fractures)

21. EF (1) longitudinal traction is applied to achieve radial length and the fracture is assessed for the presence of a metaphyseal defect, (2) palmar translation (not palmar flexion) of the carpus, and finally (3) ulnar deviation. If there is evidence of significant radioulnar instability, the fracture is reduced in supination to avoid displacing the radial metaphysis palmar to the distal ulna as ulnar deviation is applied. The most critical element P.863 to this technique is to align the palmar cortex anatomically on the lateral view. It is especially useful to incline the radius 15 degrees to 20 degrees to the fluoroscopy beam to check the alignment. In order to prevent collapse during healing and permit early removal of the external fixator, the metaphyseal void may be filled with a bone graft or a bone graft substitute at this time

22. TYPE III: Compression Fractures of the Articular Surface Augmented EF Internal fixation 3 part # Radial column: CR + 2 (1, 1.5mm) Kw The lunate fossa should then be assessed on a tilted lateral view. Towel clip may be used between the dorsal ulnar corner and the newly fixed radial column . Then Kw from DU to PR or transverse Kw can be introduced 4 part fracture + some comminution : Volar locked plating is preffered .

23. TYPE IV: Smaller fragments may be neutralized by placing a wire through the fragment and through a drill hole in the radius. The fragments are then sutured to the radius. Larger fragments may be fixed with a plate screw construct. External fixation may be required to stabilize the radiocarpal joint . Dorsal lip injuries are associated with Volar lip injuries, impaction of joint, scaphoid injuries. CT should be done. EF should be used to stabilize the radiocarpal joint and percutaneous pinning may be used to fix the intercarpal instability.

24. TYPE V: Combination of Rx

25. Ulnar Styloid Fractures Fractures of the ulnar styloid occur in approximately 60% to 70% of distal radius fractures The indications for treatment of ulnar styloid fractures is evolving . If the ulnar styloid is fractured and displaced, making the distal radioulnar joint unstable, fix the styloid with one or two percutaneous Kirschner wires . A volar approach may be helpful to obtain ulnar styloid reduction. in patients with obvious DRUJ instability and no large ulnar styloid fracture, the patient should be immobilized in supination to reduce the DRUJ for 4 weeks before permitting forearm rotation . Triangular Fibrocartilage (TFCC) Injuries occur in roughly 40% to 70% of intraarticular fractures of the distal radius in young patients and should be fixed to uln . Styloid by non absorbable sutures..

26. Thank you