Distal Radius fractures, treatment, comp

Distal Radius Fractures

1. DISTAL RADIAL
FRACTURES
KEEP OPTIONS
OPEN!
SMIT SHAH
YORK AND SCARBOROUGH TEACHING HOSPITALS NHS FOUNDATION TRUST, YORK.

2. LEARNING
OBJECTIVES
Understanding the radiograph
Classification
Imaging and consent
Approach
Surgical case based discussion
Classic volar plate
Conclusion

3. NORMAL
RADIOLOGICAL
PARAMETERS.

4. GILULA’S
LINES

5. LUNATE AND SCAPHOID FACET AND
VOLAR SIDE WITH RADIAL STYLOID

6. RADIAL AND VOLAR SIDE

7. LATERAL VS A TRUE LATERAL
- SIGMOID NOTCH

8. TRUE LATERAL

9. DORSAL

10. EXTRINSIC LIGAMENTS - DORSAL

11. EXTRINSIC LIGAMENTS - VOLAR

12. CLASSIFICATION
COLLES

13. CLASSIFICATION
SMITHS AND BARTONS

14. CLASSIFICATION
CHAUFFEUR’S AND
LUNATE DIE PUNCH

15. CLASSIFICATION
FRYKMAN’S

16. CLASSIFICATION
AO – TOO COMPLEX
FERNANDEZ –
MECHANISM
CLASSIFICATION

17. COLUMNAR
CLASSIFICATION
•DANIEL RIKLI & PIETRO
REGAZZONI
•LATERAL – LENGTH AND
ALIGNMENT
•INTERMEDIATE – WEIGHT
BEARING AND NOTCH
•MEDIAL - ROTATION

18. STANDARDS FOR PRACTICE
•THE MECHANISM OF INJURY AND CLINICAL FINDINGS, INCLUDING SKIN
INTEGRITY, ASSESSMENT OF CIRCULATION AND SENSATION, SHOULD BE
DOCUMENTED AT PRESENTATION. RADIOGRAPHIC ASSESSMENT SHOULD BE
POSTEROANTERIOR AND LATERAL VIEWS CENTRED AT THE WRIST.
•IF MANIPULATION IS INDICATED, IT SHOULD BE UNDERTAKEN USING
REGIONAL ANAESTHESIA, PERFORMED BY A SUITABLY QUALIFIED AND
TRAINED PRACTITIONER (AS OPPOSED TO LOCAL HAEMATOMA BLOCK).
•OPEN FRACTURES SHOULD UNDERGO SURGICAL DEBRIDEMENT AND
STABILISATION IN ACCORDANCE WITH THE BOAST OPEN FRACTURES.
•PATIENTS SHOULD BE REFERRED TO THE FRACTURE CLINIC SERVICE AND
ASSESSED WITHIN 72 HOURS (BOAST FOR FRACTURE CLINIC SERVICES).
•PATIENTS WITH A STABLE FRACTURE OF THE DISTAL RADIUS SHOULD BE
CONSIDERED FOR EARLY MOBILISATION FROM A REMOVABLE SUPPORT
ONCE PAIN ALLOWS.
•WHEN USING A PLASTER CAST TO TREAT A DISTAL RADIUS FRACTURE, THE
WRIST SHOULD BE IN NEUTRAL FLEXION WITH 3POINT MOULDING USED TO
HOLD THE FRACTURE AND NOT FORCED PALMAR FLEXION. CONSIDER
REMOVING THE CAST AND STARTING MOBILISATION 4 WEEKS AFTER INJURY.
•IN PATIENTS 65 YEARS OF AGE OR OLDER, NON-OPERATIVE TREATMENT CAN
BE CONSIDERED AS A PRIMARY TREATMENT FOR DORSALLY DISPLACED
DISTAL RADIUS FRACTURES UNLESS THERE IS SIGNIFICANT DEFORMITY OR
NEUROLOGICAL COMPROMISE.
•IN PATIENTS UNDER 65, CONSIDER ULNAR VARIANCE, INTRA-ARTICULAR STEP,
DORSAL TILT AND REFLECT ON THE PATIENT’S NEEDS WHEN ASSESSING
WHETHER THE PATIENT MAY BENEFIT FROM SURGICAL RECONSTRUCTION.
•VOLAR DISPLACED FRACTURES ARE UNSTABLE AND SHOULD BE
CONSIDERED FOR OPEN REDUCTION AND PLATE FIXATION.
•WHEN SURGICAL FIXATION IS INDICATED FOR DORSALLY DISPLACED DISTAL
RADIUS FRACTURES OFFER K-WIRE FIXATION IF DISPLACEMENT OF THE RADIAL
CARPAL JOINT CAN BE REDUCED BY CLOSED MANIPULATION. IF THIS IS NOT
POSSIBLE CONSIDER OPEN REDUCTION AND INTERNAL FIXATION.
•IF SURGICAL INTERVENTION IS UNDERTAKEN, THIS SHOULD BE
PERFORMED WITHIN 72 HOURS OF INJURY FOR INTRAARTICULAR
FRACTURES AND WITHIN ONE WEEK FOR EXTRA-ARTICULAR
FRACTURES. WHEN OPERATIVE MANAGEMENT IS INDICATED FOR
RE-DISPLACEMENT FOLLOWING MANIPULATION, SURGERY
SHOULD BE UNDERTAKEN WITHIN 72 HOURS OF THE DECISION TO
OPERATE.

19. HISTORY AND
EXAMINATION-
Low energy Vs High Energy
Normal Vs Osteoporotic
Dominant Vs Non – Dominant
Occupation and Functional Demands
Soft tissues (skin, nerves, tendons)
Pre-morbid conditions including MTS
Patient choice!
Fracture patterns and mechanism
Ulna fracture or carpal injury

20. CONSENT
Continued pain
Malunion
Infection
Stiffness
Chronic regional pain syndrome (500mg Vitamin C daily for
6 weeks)
Nerve/Vessel/Tendon Injury
Non-union
Instability carpus and ulna
Removal of metal work
Carpal Tunnel Syndrome

21. WHAT KIT
DO YOU
NEED?
Bring the kitchen
sink!
Volar plates, dorsal
straight plates, k-
wires, Ex-fix, hand
plating system

22. APPROACH
Volar Henry’s releasing
brachioradialis
Dorsal
Combined

23. HOW TO
FIX
Volar plate
Dorsal plate
Fragment specific
Percutaneous Wires
Bridge plating
Ex-fix
? Arthroscopic assisted
Bone graft or bone graft substitute
Bit of everything
Plan for a two stage?!

24. MODIFIED
HENRY’S
APPROACH
(FCR
APPROACH)

25. STEPS FOR
VOLAR
PLATE
Have an assistant
who knows what they
are doing
Traction the fracture
closed
Open and Reduce
+/- K wire
Put plate on shaft
and gliding hole
screw and screen
Plate can be rotated
and pushed up or
down depending on
xray
Fill ulna holes distally,
check lateral and
then put in radial
ones and complete
proximally

26. TIPS
•DON’T GO BICORTICAL DISTALLY
(CONTROVERSIAL).
•CHECK SCREW LENGTH ON X-RAY
•ANGLE SCREWS OUT OF JOINT

27. TIPS
•DON’T BE AFRAID TO PUT A K-WIRE AND A PLATE ON THE RADIAL
STYLOID
•IF IN DOUBT DO A CARPAL TUNNEL DECOMPRESSION
•ALWAYS RELEASE BRACHIORADIALIS
•IF PROBLEMS WITH DORSAL FRAGMENT REDUCTION, PUT IN
SCREWS DISTALLY FIRST AND REDUCE FRAGMENT ONTO SHAFT
•CONTINUOUS TRACTION OR EX-FIX CAN HELP WITH FIXATION
•MULTI-FRAGMENTARY FRACTURES, INTRA-ARTICULAR FRACTURES
TRY BRIDGE PLATING

28. TIPS
•LOOK AT SCAPHO-LUNATE INTERVAL ON BOTH WRISTS
•SCREEN IN RADIAL AND ULNA DEVIATION WITH SOMETIMES
COMPRESSION
•LOOK AT ULNA POSITION, STRESS VIEWS AND EXAMINE OTHER
SIDE
•HAVE NO ISSUES ABOUT IMPLANT REMOVAL
•IF IN DOUBT DO NOTHING AND SEND TO SPECIALIST

29. SURGICAL CASE

30. POST FIXATION – LOOKS ALRIGHT

31. SIX WEEKS POST FIXATION

32. LOOK AGAIN AT THE ANATOMY

33. THEATRE FILMS

34. CONCLUSION
FIX WELL OR DON’T
FIX AT ALL!