Distal Radius Fractures

1
Distal Radius Fractures

• John T. Capo, MD
• Original Author Thomas F. Varecka, MD March
  2004
• New Author John T. Capo, MD Revised January
  2006

2
The Problem of Distal Radius Fractures

• Common injury gt450,000/yr. in USA
• High potential for functional impairment and
  frequent complications

3
Introduction

• Distal radius fractures occur through the distal
  metaphysis of the radius
• May involve articular surface
• frequently involving the ulnar styloid
• Most often result from a fall on the outstretched
  hand.
• forced extension of the carpus,
• impact loading of the distal radius.
• Associated injuries may accompany distal radius
  fractures.

4
Introduction

• Classified by
• presence or absence of intra-articular
  involvement,
• degree of comminution,
• dorsal vs. volar displacement,
• involvement of the distal radioulnar joint.

5
Diagnosis History and Physical Findings

• History of a fall on the outstretched hand or an
  episode of trauma
• A visible deformity of the wrist is usually
  noted, with the hand most commonly displaced in
  the dorsal direction.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the
  neurovascular status of the hand is imperative,
  before any treatment is carried out.

6
Diagnosis Diagnostic Tests and Examination

• General physical exam of the patient, including
  an evaluation of the injured joint, and a joint
  above and below
• Radiographs of the injured wrist
• Radiographs of other areas, if symptoms warrant.
• CT scan of the distal radius in selected
  instances.

7
Treatment Goals

• Preserve hand and wrist function
• Realign normal osseous anatomy
• promote bony healing
• Avoid complications
• Allow early finger and elbow ROM

8
Osseous Anatomy

• Distal radius 80 of axial load
• Scaphoid fossa
• Lunate fossa
• Sigmoid notch DRUJ
• Distal ulna

9
Anatomy

• scaphoid and lunate fossa
• Ridge normally exists between these two
• sigmoid notch second important articular
  surface
• triangular fibrocartilage complex(TFCC) distal
  edge of radius to base of ulnar styloid

10
Radiology

• Radial inclination 22
• Radial length 12mm
• ulnar neutral
• Palmar tilt 11-14
• Scapho-lunate angle 47 /- 15

11
Measurement of Radial Length and Inclination
Inclination 23 degrees
12
(No Transcript)
13
Scapholunate angle measured between lines 2 and
3 (normal 47 15 degrees)
1 Line connecting dorsal and volar tip of lunate
2 Line perpendicular to lunate
3 Line along axis of scaphoid
14
Computed TomographyIndications

• Intra-articular fxs with multiple fragments
• centrally impacted fragments
• DRUJ incongruity
• 19 consecutive fx, CT had better sensitivity for
  intraarticular frag
• management change in 5 pts

Cole et al J Hand Surg, 1997
15
Classification of Distal Radius Fractures

• Ideal system should describe
• Type of injury
• Severity
• Evaluation
• Treatment
• Prognosis

16
Common Classifications

• Gartland/Werley
• Frykman
• Weber (AO/ASIF)
• Melone
• Column theory
• Fernandez (mechanism)

17
Frykman Classification
Extra-articular
Radio-carpal joint

Same pattern as odd numbers, except ulnar styloid
also fractured
Radio-ulnar joint
Both joints
18
AO/ OTA Classification
Group A Extra-articular
Group B Partial Intra-articular
Group C Complete Intra-articular
19
Column Theory
3 Columns radial, intermediate, medial
Rikli Regazzoni, 1996
20
Classification Fernandez (1997)

• I. Bending-metaphysis fails under tensile stress
  (Colles, Smith)
• II. Shearing-fractures of joint surface (Barton,
  radial styloid)

21
Classification Fernandez (1997)

• III. Compression-intraarticular fracture with
  impaction of subchondral and metaphyseal bone
  (die-punch)
• IV. Avulsion-fractures of ligament attachments
  (ulna, radial styloid)
• V. Combined/complex - high velocity injuries

22
Assessment of X-rays

• Assess involvement of dorsal or volar rim
• Is comminution mainly volar or dorsal?
• is one of four cortices intact?
• Look for die-punch lesions of the scaphoid or
  lunate fossa.
• Assess amount of shortening
• Look for DRUJ involvement

23
Dorsal angulation and comminution
24
Volar subluxation of carpus with fracture fragment
25
Options for Treatment

• Casting
• Long arm vs short arm
• Sugar-tong splint
• External Fixation
• Joint-spanning
• Non bridging
• Percutaneous pinning
• Internal Fixation
• Dorsal plating
• Volar plating
• Combined dorsal/volar plating
• focal (fracture specific) plating

26
Indications for Closed Treatment

• Low-energy fracture
• Low-demand patient
• Medical co-morbidities
• Minimal displacement- acceptable alignment
• Match treatment to demands of the patient

27
Closed Treatment of Distal Radial Fractures

• Depends on obtaining and then maintaining an
  acceptable reduction.
• Immobilization
• long arm (cast or sugar-tong for high demand)
• short arm adequate for elderly patients
• Frequent follow-up necessary in order to diagnose
  redisplacement.

28
Technique of Closed Reduction

• Anesthesia
• Hematoma block
• Intravenous sedation
• Bier block
• Traction finger traps and weights
• Reduction Maneuver (dorsally angulated fracture)
  
• hyperextension of the distal fragment,
• Maintain weighted traction and reduce the distal
  to the proximal fragment with pressure applied to
  the distal radius.
• Apply well-molded sugar-tong splint or cast,
  with wrist in neutral to slight flexion.
• Avoid Extreme Positions!

29
Acceptable Reduction Criteria

• No dorsal angulation
• gt 15 degrees of inclination
• Articular step-off lt 2mm
• lt 5 mm shortening compared to opposite wrist.
• DRUJ congruent

30
After-treatment

• Watch for median nerve symptoms
• parasthesias common but should diminish over few
  hours
• If persist release pressure on cast, take wrist
  out of flexion
• Acute carpal tunnel symptoms progress CTR
  required
• Follow-up x-rays needed in 1-2 weeks to evaluate
  reduction.
• Change to short-arm cast after 2-3 weeks,
  continue until fracture healing.

31
Management of Redisplacement

• Repeat reduction and casting high rate of
  failure
• Repeat reduction and percutaneous pinning
• External Fixation
• ORIF

32
Treatment Choice

• Depends on assessment of fracture stability
• Indicators of instability are
• Shortening
• Comminution
• Reversal of normal volar angulation
• Articular involvement

33
Indications for Surgical Treatment

• High-energy injury
• Open injury
• Secondary loss of reduction
• Articular comminution, step-off, or gap
• Metaphyseal comminution or bone loss
• Loss of volar buttress with displacement
• DRUJ incongruity

34
Evidence of High-Energy Injuries

• Irreducible fracture
• Unable to maintain reduction
• Significant initial displacement
• Comminution extending from dorsal to volar
• Significant Soft tissue disruption

35
Operative Management of Distal Radius Fractures
36
External fixation The treatment of choice for
distal radius fractures in the 1980s
37
(No Transcript)
38
(No Transcript)
39
Literature Articles Discussing External Fixation
1999
1974
1980
1986
40
External Fixation Where Do We Stand Now??
41
Types of External Fixation

• Spanning
• Dynamic
• Clyburne
• Agee
• Pennig
• Static
• AO
• Ace

• Non-spanning
• Hoffman 2
• Cobra
• Zimmer
• AO

42
Spanning

• A spanning fixator is one which fixes distal
  radius fractures by spanning the carpus I.e.,
  fixation into radius and metacarpals

43
Non-spanning

• A non-spanning fixator is one which fixes distal
  radius fracture by securing pins in the radius
  alone, proximal to and distal to the fracture
  site.

44
(No Transcript)
45
(No Transcript)
46
Courtesy of Hill Hastings,MD
47
Factors Affecting Functional Outcome
Author Length Radial
Tilt Volar Tilt Gap Step-off ARO
(1988) 0 0 0 VILLAR (!987)
0 0 0 WOLFE (1994)
0 0 0 JUPITER (1986)
0 0 0
BACORN (1953) 0
0 OLDER (1966)
0 0 TRUMBLE (1994) -- --
McQUEEN (1989, 1995) --
TALIESNIK (1984) 0
0 0
48
Factors Affecting Functional Outcome

• McQueen (1996) carpal alignment after distal
  radius fractures is the main influence on final
  outcome
• malalignment has significant negative effect on
  function
• failure to restore volar tilt predisposes to
  carpal collapse and carpal malalignment

49
Fixator Type vs. Restoration of Outcome Factors
Type Length Radial Tilt
Volar Tilt Gap Step-off SPANNING
---------
-------- NONSPANNING

50
Reduction Tactics

• DePalma (1952) introduced traction / distraction
  as means of reducing distal radius fractures
• Spanning fixator relies on distraction as
  principle method of reducing fracture fragments
• Distraction (Ligamentotaxis) excellent for
  restoring length

51
Ligamentotaxis

• Bartosh, J Hand Surg 15A, 1990
• 19 cadaver hands with distal radius osteotomy
• Ligamentotaxis with 10 and 20 of traction _at_
  100, 200 and 300 of flexion
• volar tilt could not be re-established

52
Ligamentous Anatomy

• Volar ligaments
• Straight
• Stout
• Tighten readily

• Dorsal ligaments
• Zig-zag
• Elastic
• Tighten slowly

53
Dorsal ligaments more lax, zig-zag
54
Ligamentotaxis

• Adverse effect of carpal over-distraction well
  documented
• Kaempffe (1993) pain, function, grip strength
  adversely affected
• Gupta (1999) 10 of distraction can induce over
  10mm of ligament elongation
• Davenport (1999) 10mm carpal distraction
  produces gt20 increase in ligament strain

55
Non-Spanning vs. Spanning Fixator

• McQueen, JBJS-B, 1998
• Prospectively studied 30 spanning vs 30
  non-spanning fixator patients
• Non-spanning better preserved volar tilt,
  prevented carpal malalignment, gave better grip
  strength and hand function (all with plt.001)
• Complication rate 50 lower

56
(No Transcript)
57
(No Transcript)
58
Complications

• Complication rates high in almost all reported
  series
• Mal-union
• Pin track infection
• RSD / arthrofibrosis
• Finger stiffness
• Loss of reduction early vs late
• Tendon rupture

59
Complications

• Complication rates high in almost all reported
  series
• Szabo ( 1986) 61
• Cooney (1979) 33
• van Dijk (1996) 41
• McQueen (1991) 50 (spanning)
• McQueen (1998) 28 (non-spanning)
• McQueen (1999) 15 (non-spanning)

60
Percutaneous Pinning-Methods

• variety described
• most common radial styloid pinning dorsal-ulnar
  corner of radius pinning
• supplemental immobilization with cast, splint
• in conjunction with external fixation (Augmented
  external fixation)

61
Percutaneous Pins
62
Percutaneous Pins
63
Percutaneous Pinning

• 2 radial styloid pins - Mah and Atkinson, J Hand
  Surg 1992
• excellent anatomic 82
• good-excellent functional results 100
• radial styloid with dorsal - prospective study,
  30 pts (Clancey JBJS 1984)
• excellent anatomic results in 90

64
Percutaneous Pinning-Kapandji

• intrafocal pinning through fracture site
• buttress against displacement
• good results in literature
• -Greatting Bishop, OCNA 1993

65
Internal Fixation of Distal Radius Fractures

• Useful for elevation of depressed articular
  fragments and bone grafting of metaphyseal
  defects
• required if articular fragments can not be
  adequately reduced with percutaneous methods
• Dorsal and/or volar approaches both used.

66
Selection of Approach

• Based on location of comminution.
• Dorsal approach for dorsally angulated fractures.
• Volar approach for volar rim fractures
• Radial styloid approach for buttressing of
  styloid
• Combined approaches needed for high-energy
  fractures with significant axial impaction.

67
WHICH APPROACH? DORSAL
3rd DC EPL (extensile)
1-2nd DC
-
68
VOLAR
Classical Henry approach
Extended carpal tunnel approach
69
Distal Radius-volar barton

• 64 yo M, MVA, contralateral tibial shaft Fx

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
Volar Henry Approach
74
Radial to FCR
75
Elevate Pronator Quadratus
76
Dorsal Fracture
77
CT Scan
78
Dorsal Plating, PCP and Ex Fix
79
(No Transcript)
80
(No Transcript)
81
Volar Plating for Dorsal Fractures
-less tendon irritation than dorsal - Indirect
reduction -better tolerated than Ex
fix
82
Fixed angle locked screws
83
Courtesy J. Orbay, MD
84
(No Transcript)
85
Courtesy J. Orbay, MD
86
Three Column Theory

• Radial Column
• Lateral side of radius
• Intermediate Column
• Ulnar side of
• radius
• Ulnar Column
• distal ulna

87
Fragment Specific System
88
Radial and Ulnar Columns
-Pin plates -90-90 plating technique
89
Focal Plating Radial Styloid Fragment Dorsal
ulnar fragment
70 90 degrees apart
90
Dorsal Fracture
Radial Styloid and dorsal-ulnar corner
91
Dorsal Case focal plating
92
Radial shortening, comminution
Dorsal angulation
Indication for Volar and Dorsal Plating
93
Volar approach, application buttress plate
94
Dorsal approach, application of 2 L buttress
plates
95
EPL Tendon
96
Extensor retinaculum repaired beneath EPL to
prevent erosion against plate- EPL left transposed
97
(No Transcript)
98
Advanced TechniquesArthroscopic-Assisted

• reduce articular incongruities
• also diagnose associated soft tissue lesions
• minimally invasive

99
Arthroscopic-Assisted
Culp and Osterman, OCNA 26(4) 1995
100
Malunion of Distal Radius Fractures

• Changes load-bearing patterns on the distal
  radius and load sharing between the radius and
  ulna.
• Can lead to arthrosis.

101
X-ray 4 months later shows malunion
Injury X-Ray
102
Lateral X-Ray of another patient 6 months after
injury demonstrating dorsal angulation of the
distal radius
103
Normal loading patterns
104
Malunion loading patterns
105
Altered Load through Ulna with Radial Shortening
106
(No Transcript)
107
(No Transcript)
108
Conclusions

• Need to be able to use all tools for treatment of
  distal radius fractures
• Both external fixation and ORIF are useful.
• ORIF better in high-energy fractures associated
  with depression of articular surface
• ORIF gives better anatomic restoration, although
  not necessarily higher patient satisfaction.

109
Conclusions

• External fixators still have a role in the
  treatment of distal radius fractures
• Spanning ex fix does not completely correct
  fracture deformity by itself
• Should usually combined with percutaneous pins
  (augmented fixation)

110
Conclusions

• new plating techniques allow for accurate and
  rigid fixation of fragments
• Plating allows early wrist ROM
• Volar, smaller and more anatomic plates are
  better tolerated
• combination treatment is often needed

If you would like to volunteer as an author for
the Resident Slide Project or recommend updates
to any of the following slides, please send an
e-mail to ota_at_aaos.org
Return to Upper Extremity Index
E-mail OTA about Questions/Comments