Distal radius fractures

An illlustrated presentation on distal radius fractures

1. DISTAL RADIUS FRACTURES DR BASSEY, A E

2. Outline Introduction Applied anatomy Mechanism of injury Associated injuries Classification Clinical features Management Rehabilitation/prognosis Complications Current trends Conclusion

3. Introduction Distal radius fractures are the commonest fractures presenting to Orthopaedic trauma surgeons As populations continue to age, and their activity levels increase, the incidence of distal radius fractures is expected to rise. Sound understanding of mechanisms of injury as well as treatment options is necessary for optimal outcome

4. Introduction - epidemiology Comprises 17.5% of all fractures in adults Age - 57-66yrs. Affects males in 40s and females in 60s Sex - M:F = 1:2-3 Majority due to low energy impact. (66-77% due to fall from standing height) Extra-articular 57-66%, Partial articular 9-16%, complete articular 25-35% 39.4% are unstable

5. Applied surgical & radiological anatomy Distal radius is broad, rectangular in cross-section, concave and smooth volarly , convex and irregular dorsally Volar has attachment of pronator quadratus Dorsal has compartments for extensor tendons

6. Applied surgical & radiological anatomy Distal radius has 2 articulations – Radiocarpal & Distal radioulnar joints Radiocarpal J. is formed by distal radius and scaphoid and lunate

7. Applied surgical & radiological anatomy DRUJ – formed by ulna head and sigmoid notch on ulnar side of distal radius Movement – pronation-supination Stabilizer - TFCC

8. Applied surgical & radiological anatomy Several radiologic indices have been described which serve as guides to the normal anatomy of the distal radius These include: On PA xrays - radial height, radial inclination, ulnar variance On lateral xrays – Dorsal/volar tilt, carpal alignment

9. Mechanism of injury Most are low energy injuries, few are high energy Risk factors Age >50 years Female Low bone mineral density Elderly with increased physical activity FOOH with wrist dorsiflexed 40 o – 90 o will cause dorsally-displaced DRF Sequence Force transmitted thru carpus to dorsal part of DR Volar cortex fails due to tension, dorsal cortex comminutes due to compression, fragment is displaced dorsally Reverse occurs in FOOH with wrist in volar flexion

10. Mechanism of injury FOOH + Ulnar deviation = radial styloid fracture FOOH + radial deviation = ulnar styloid fracture Low BMD is associated with Increased # severity Increased risk of instability Increased malunion rates

11. Associated injuries TFCC injury It’s the commonest associated injury Ulnar styloid fracture increases risk 5-fold Operative vs conservative mgt appear to have similar outcomes, except for a slight reduction in grip strength in those conservatively mgxed Interosseous ligament injury Most frequently injured are scapholunate and lunatotriquetral ligs Positive ulnar variance of >2mm increases risk No consensus on which is superior, conservative or operative mgt Chondral injuries No certainty on long term effect of these. Thought to contribute to future joint degeneration

12. Classification Gartland – based on comminution, displacement and articular involvement Older - based on comminution & displacement Frykman – Based on extent of articular and/or ulnar involvement Fernandez classification – based on mechanism of injury AO/OTA classification – most widely used

13. Clinical features History Pain and swelling around wrist Deformity Ask about numbness/ paraesthesia Pain in other parts of same limb Hx of FOOH Examination Swelling ‘Dinner fork’, ‘garden spade’ deformities Radial deviation Prominent distal ulna due to shortening of the radius Check skin for wounds Tenderness Neurologic hand exam

14. Management - investigations Xrays – PA For extra-articular fractures assess the following: Radial length/ulnar variance Extent of metaphyseal comminution Ulnar styloid fracture location (tip/waist/base) In addition, for intra-articular fractures assess the following: Presence and orientation of articular fractures Depression of the lunate facet Gap between scaphoid and lunate facet Central impaction fragments Carpal bone assessment — Gilula’s lines Lateral Dorsal/palmar tilt Extent of metaphyseal comminution Carpal alignment Displacement of the volar cortex

15. Management - investigations CT scan – Useful in articular fractures when surgery is being planned Measures intra-articular displacement more accurately than xray Also, has superior demonstration sigmoid notch fractures

16. Treatment Principal factor influencing treatment choice is the magnitude of demand placed on the wrist. Aims of treatment Maximise wrist and hand function Optimise grip strength Preserve mobility Primary objective is to restore the anatomy Treatment is Non-operative or operative

17. Treatment – non-operative 70% of DRFs are still managed non-operatively (USA 60-96%) Indications Stable, undisplaced Displaced, stable on reduction Involves closed reduction and immobilization with a cast or splint

18. Treatment – non-operative Manipulative reduction is done If the fracture displaced is beyond acceptable radiologic limits Where early reduction is needed to avert complications (e.g. median nerve compression), even if subsequent treatment is planned RADIOLOGICAL INDEX RECOMMENDED LIMITS Positive ulnar variance (mm) 2 Carpal malalignment none Dorsal tilt (degrees) <10 if carpus is aligned Palmar tilt (degrees) No limit if carpus is aligned Gap or step in joint (mm) 2

19. Treatment – non-operative Reduction technique Done under haematoma block, regional anaesthesia , general anaesthesia or procedural sedation and analgesia Traction-countertraction Manipulation of distal fragment Immobilization Below elbow vs above elbow Position of immobilization Outcome: Pt satisfaction rates: 59-92% No benefit of surgery in this group

20. Treatment – operative Indication Failed non-operative treatment Actual/predicted instability Predictors of instability Advanced age (>80yrs have highest risk) Increased degree of displacement Metaphyseal comminution Redisplacement ffl conservative Rx Low BMD

21. Treatment – operative Options – CR and perc pinning, CREF, ORIF For decision-making purposes, they are divided into Metaphyseal unstable, extra- or minimal articular fractures Displaced intra-articular fractures Partial articular

22. Metaphyseal unstable extra-articular fracture

23. Treatment – operative Currently many still attempt conservative mgt Treatment should be operative. Use of cast has been shown to be ineffective

24. Complete articular fracture

25. Treatment – operative Treatment should always be operative A RCT found that CR and perc fixation had better functional outcome than ORIF. Some authorities therefore recommend attempting the former first, if unsuccessful then ORIF be done. The only exception being elderly, frail patients who are not fit for surgery where cast immobilization would have to suffice

26. Treatment – operative Partial articular Volar shear fracture – inherently unstable. Treat by ORIF with volar plate. Rarely, undisplaced fractures may be treated conservatively Dorsal shear fracture – usually a high energy injury occurring in young people. Treatment is ORIF with dorsal plate, volar or combined Radial styloid fracture – if undisplaced immobilize in cast. If significantly displaced, treat operatively with percutaneous pinning or screw. If CR not successful the OR and radial buttress plating may be necessary

27. Rehabilitation/prognosis Following non-operative treatment Monitor by xrays at 1 week, 2 weeks and 3 weeks MacKenney – Cast is left for 5-6 weeks Active mobilization starts as soon as cast comes off Following operative treatment Active mobilization begins as pain permits. No loading however Minimally displaced Initially displaced <2 weeks 10% 43% >2 weeks 22% 47%

28. Rehabilitation/prognosis Predictors of functional outcome Patient factors Post-reduction anatomy correlates linearly with functional outcome Activity levels correlate inversely with functional outcome Low socioeconomic status = poorer outcome Workplace injury more likely to have poor outcome Low BMD Fracture factors Radial height is has strongest correlation with outcome compared to other indices. It is recommended that operative fixation should of all, aim to restore RH Positive ulnar variance >2mm = poor outcome. Predicts DRUJ dysfunction

29. Complications Carpal tunnel syndrome Nerve injury Median nerve commonest (3-17%) Ulnar nerve (0.5-4.2%) Tendon injury EPL tendon injury commonest Wrist compartment syndrome Malunion Nonunion Complex Regional Pain Syndrome

30. Current trends Role of arthroscopy Minimally-invasive Visualise joint surface Confirm reduction r/o screw penetration Visualise associated injuries Downside – costly, long learning curve, difficult, risk of compartment syndrome from fluid extravasation, improved pt outcome not firmly established

31. Conclusion Distal radius fractures will continue to be a problem as life expectancy increases Today’s Orthopaedic trauma surgeon must be adept in its management

32. References Rockwood and Green’s Fractures in Adults 8 th EDITION Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88:1944–1951 Chung KC, Shauver MJ, Yin H, et al. Variations in the use of internal fixation for distal radial fracture in the United States medicare population. J Bone Joint Surg Am. 2011;93:2154–2162 Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37:691–697 Nguyen TV, Center JR, Sambrook PN, et al. Risk factors for proximal humerus, forearm, and wrist fractures in elderly men and women: the Dubbo Osteoporosis Epidemiology Study. Am J Epidemiol. 2001;153:587–595 Nordvall H, Glanberg -Persson G, Lysholm J. Are distal radius fractures due to fragility or to falls? A consecutive case-control study of bone mineral density, tendency to fall, risk factors for osteoporosis, and health-related quality of life. Acta Orthop . 2007;78:271–277 Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue management of distal radius. Hand Surg. 2001;6:127-35 Ogunlade SO,  Omololu AB,  Alonge TO,  Salawu SA,  Bamgboye EA. Haematoma block in reduction of distal radial fractures. West Afr J Med. 2002;21(4):282-5 Onuoha K.M, Orimolade E.A, Onuoha C.E.O, Adegbehingbe O.O, Ikem I.C. Comparing the effects of haematoma block and conscious sedation in adults with distal radius fractures. Nig J Med. 2017;26(4):311-315