Malunited distal radius fracture

MALUNITED DISTAL RADIUS FRACTURE FEATURES AND MANAGMENT

1. MALUNITED DISTAL RADIUS FRACTURE BY DR NISCHAY KAUSHIK JR2 ORTHOPAEDICS IGIMS,PATNA

2. ANATOMY The distal radius is biconcave , triangular &covered with Hyaline cartilage . The articular surface has two facets for articulation with the scaphoid & the lunate. The medial surface forms a semi-circular notch which articulates with the ulnar head. The triangular fibrocartilage(TFC) is a KEY stabilizer of distal radioulnar joint.

3. COMMON CLASSIFICATION GARTLAND AND WERLEY. FRYKMAN (radiocarpal and radioulnar) AO CLASSIFICATION MELONE CLASSIFICATION(impaction of lunate) FERNANDEZ(mechanism)

4. FRYKMAN CLASSIFICATION

5. Fernandez classification

6. COLLE’S FRACTURE It is an EXTRAARTICULAR fracture that occurs at CORTICOCANCELLOUS JUNCTION of distal end of radius within 2cm from the articular surface It may extend into DRUJ with six displacements, Impaction Lateral displacement Lateral rotation (angulation) Dorsal displacement Dorsal rotation (angulation) Supination. It may often accompany fracture of the ulnar styloid which signify avulsion of the TFCC and ulnar collateral ligaments

7. Colle’s fracture

8. SMITH’S FRACTURE (REVERSE COLLE’S FRACTURE) Occurs at the same level on the distal radius as a colle’s fracture . Distal fragment displaced in Palmar (volar) direction with a “ Garden spade " deformity. Modified Thomas Classification of Smith's Fracture: Type I: Extra-articular Type II: Crosses into the dorsal articular surface Type III: Enters the radio-carpal joint(equivalent to volar barton fracture dislocation)

9. MECHANISM OF INJURY

10. BARTON’S FRACTURE It is an INTRARTICULAR fracture dislocation or subluxation in which the rim of the distal radius is displaced dorsally or volarly with the hand and carpus. Extends from the articular surface of the radius to either its anterior/posterior cortices

11. BARTON’S FRACTURE There are 2 types: 1. Dorsal barton 2. Volar barton Dorsal Barton: Dorsal rim fracture of distal radius Mechanism : Fall with dorsiflexion and pronation of the distal forearm on a flexed wrist. Volar Barton: Palmar rim fracture of distal radius Mechanism : It is due to palmar tensile stress and dorsal shear stress and is usually combined with radial styloid fracture.

12. CHAUFFEUR’S FRACTURE It is an Intraarticular fracture involving the radial styloid,the radius is cleaved in a sagittal plane and the fragment is displaced proximally. Isolated fracture of the radial styloid are fairly common from backfiring of starting handle of car.

13. Complications Mal-union ( may needs augmentation with additional casting) Pin track infection Finger stiffness Loss of reduction more common than plating Tendon rupture nerve injury

14. RADIOGRAPHIC PARAMETERS View Measurement Normal Acceptable criteria AP Radial height 13 mm <5 mm shortening Radial inclination 23 degrees change <5 ° Articular step off congruous <2 mm step off LAT Volar tilt 11 degrees dorsal angulation <5 ° or within 20 ° of contralateral distal radius

15.  Radial inclination = 23°  Radial length = 12mm  Volar tilt = 10°  Scapholunate angle = 60° +/- 15° NORMAL PARAMETER

16. MALUNION A malunion occurs when a fractured bone heals with improper alignment, incorrect length ,articular incongruity or combination of these factors Malunion of distal radius may be intra articular or extra articular, symptomatic or asymptomatic.

17. BASIC CRETERIA TO DEFINE MALUNION RADIAL INCLINATION <10 DEGREE VOLAR TILT>20 DEGREE, DORSAL TILT>15 DEGREE RADIAL HEIGHT<10 mm ULNAR VARIANCE>2+ INTRA ARTICULAR STEP OR GAP >2 mm

18. Clinical features Decrease in Radial length- druj pathology, pain at druj Decrease in radial inclination – impaired ulnar deviation Loss of normal volar tilt Dorsal tilt- deformity, decreased wrist flexion, carpal instabiliy pattern Excessive Volar tilt – deformity, decreased extension, mid carpal instability Articular step- -- radiocarpal arthritis pain at wrist D ruj instability- -- pain at dista radio ulnar joint

19. Clinical features Excessive dorsal angulat ion ≥15-20 for long time can alter the wrist biomecanics and can cause DISI pattern instabiliy pattern Excessive volar angulation ≥20 can leas to VISI pattern.

20. Predictors of poor outcomes fernandez et al Distal radius articular step of >2 mm DRUJ step of 1-2mm Doral tilt more than 15-20 degree Volar tilt of more than 20 degree Radial length of less than 6 mm Radial inclination of less than 10 degree

21. Radiographic evaluation Ap/ lateral views in neutral rotation Cotralateral wrist also for measurement and comparision Ct san- for articular step Mri- itegrity of TFCC & Intercarpal ligaments

22. Operative treatment Not all patients of distal radius malunion requires surgery Not indicated in patients with Minimally symptomatic Not interfering daily activities Malunion in acceptable range Very old age Asymptomatic patient with even gross deformity in old age--- not indicated

23. GRAHAMS CRITERIA FOR RADIOLOGICAL ACCEPTABLE DISTAL RADIUS MALUNION Radial length- --- shortening of < 5mm Radial inclination- >15 degree Radial tilt – dorsal < 15 degree Volar < 20 degree Articular incongruency – step of < 2mm at radiocarpal joint

24. INDICATIONS All symptomatic malunions . Decreased grip strength and mobility. Signifigantly interfere with daily activities Asymptomatic young patient but with deformity that can cause problems in future Symptomatic old with high functional demand with good bone stock . Carpal tunnel syndrome

25. C ontraindications active complex regional pain syndrome osteopenia advanced radiocarpal arthrits poor soft tissue coverage acceptable function despite deformity

26. STRATEGIES OF TREATMENT PROCEEDURES TO CORRECT DEFORMITY OF DISTAL RADIUS…. DRO PROCEEDURES THAT TREAT PATHOLOGY AT DRUJ …ULNAR SHORTENING, SAUVE KAPANDJI,DURRACH’S SALVAGE PROCEEDURES– WRIST ARTHRODESIS, PROXIMAL ROW CARPECTOMY

27. TREATMENT OF EXTRAARTICULAR MALUNION 1 . FERNANADEZ OSTEOTOMY … for dorsal angulation open wedge metaphyseal osteotomy with bone grafting and internal fixation with plate. 2. SHEA OSTEOTOMY for volar angulation open wedge metaphyseal osteotomy with bone grafting and internal fixation with plate 3.INTRAMEDULLARY FIXATION WITH micronail 4. EXTERNAL FIXATION

28. Fernandez osteotomy Dorsal approach Preclinical evaluation radial parameters , bone graft size Mark osteotomy 2.5 cm proximal to joint Perform osteotomy transverse in coronal plane and oblique in sagittal plane Osteotomy must be parallel to joint surface Distract at osteotomy site, Bone graft from iliac ctrest, trim it Fixed across the osteotomy site by holding reduction Plate and screws( t plate)

29. Fernandez osteotomy

30. Shea osteotomy Volar henry approach Preclinical evaluation radial parameters , bone graft size Mark osteotomy 2.5 cm proximal to joint Perform osteotomy transverse in coronal plane and oblique in sagittal plane Osteotomy must be parallel to joint surface Distract at osteotomy site, Bone graft from iliac ctrest, trim it Fixed across the osteotomy site by holding reduction Plate and screws( t plate)

31. Shea osteotomy

32. INTRA MEDULLARY NAILING

33. INDICATION FOR IM NAILING Distal radial deformity of >15 degree. 4 mm loss of radial length. 4 mm Ulnar variance. 15 degree dorsal or 20 degree volar lateral tilt.

34. EXTERNAL FIXATOR MINIMALLY INVASIVE TECHNIQUE EASY CONTROL AND CORRECTION OF THE DISTAL FRAGMENT THE USE OF NONSTRUCTURALCANCELLOUS BONE GRAFT EASE OF REMOVAL OF THE IMPLANT

35. OSTEOTOMY MADE AND SMALL EXTERNAL FIXATOR FRAME USED TO MAINTAIN CORRECTED ALIGNMENT BEFORE PLACEMENT OF BONE GRAFT, PLATE AND

36. OPEN WEDGE OSTEOTOMY WITH A SMALL LAMINA SPREADER CLAMP, PRESERVING THE DORSAL PERIOSTEUM

37. Proceedures to correct DRUJ incongruency These proceedures may require either single or in combination with distal radius osteotomy based on maintainance of DRUJ congruency after DRO DRUJ that maintained with DRO alone can be left with DRO alone. DRUJ not maintained with DRO alone may require these proceedures.

38. Proceedures to correct DRUJ incongruency DRUJ preservation surgeries ; Ulnar shortening osteotomy DRUJ ablation sugeries ; Darrach’s p ro cedure Bowers arthroplasty- partial resection of distal ulna Sauve- kapandji Proceedure - druj fusion + prox ulnar pseudoar t hosis

39. ULNAR SHORTENING INDICATED IN SYMPTOMATIC ULNOCARPAL IMPINGEMENT ISOLATED US E IN CASE RADIUS HAS SHORTENED WITH NO ANGULAR DEFORMITY TRANSVERSE OSTEOTOMY FOLLOWED BY COMPRESSION PLATING.

40. DARRACH’S PROCEDURE COMPLETE ABLATION OF DISTAL ULNA REMOVES THE DISTAL ARTICULAR SURFACE OF ULNA USEFUL IN ELDERLY AND IN PATIENT WITH LIMITED ACTIVITY FCU OR ECU TENDON SLINGS ARE ATTACHED TO THE DISTAL ULNA TO ADDRESS THE ULNAR INSTABILITY

41. BOWER’S PROCEDURE / HEMI RESECTION ARTHROPLASTY PARTIAL RESECTION OF THE ARTICULAR SURFACE OF ULNA INTERPOSING A CAPSULAR FLAP ULNOCARPAL IMPACTION IS A RELATIVE CONTRAINDICATION PREFERRED FOR DRUJ ARTHROSIS WITH MILD DEGREE OF POSITIVE ULNAR VARIANCE

42. SAUVE- KAPANDJI PROCEDURE DRUJ FUSION WITH PROXIMAL ULNAR P S EUDOA R TH R OSI S . SEGMENTAL EXCISION OF ULNA AT THE LEVEL OF ULNAR NECK UPTO 10- 15 MM ULNAR HEAD IS RETAINED AND FUSED VIA SCREWS TO THE SIGMOID NOTCH

43. SALVAGE PROCEDURES SYMPTOMATIC COMMINUTED I/A FRACTURES AND DISTAL RADIAL MALUNIONS THAT DEVELOP POST TRAUMATIC ARTHRITIS TOTAL WRIST ARTHRODESIS TREATMENT OF CHOICE IN YOUNG PATIENTS STABLE PAINLESS WRIST ACHIEVED; THOUGH MOTION IS SACRIFICED DISTAL ULNA USUALLY RESECTED ALONG WITH ARTHRODESIS PARTIAL WRIST ARTHRODESIS ARTHRITIS LIMITED TO RADIOCARPEL JOINT ONLY RADIOSCAPHOLUNATE ARTHRODESIS IF ENTIRE RADIOCARPEL JOINT IS INVOLVED RADIOLUNATE ARTHRODESIS DIE- PUNCH INJURY OF LUNATE FACET A/W ARTHRITIS

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