A brief review of distal radius fractures
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This document provides an overview of distal radius fractures, including: - Classifications including Frykman, Fernandez, Melone, AO which describe fracture type, severity and treatment. - Common fracture types like Colles, Smith's and Barton's are described. - Radiographic parameters to assess fracture reduction are outlined. - Management approaches including closed reduction and casting, percutaneous pinning, external fixation and open reduction internal fixation are discussed. Complications of different treatment methods are also reviewed.
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A brief review of distal radius fractures
- 1. A BRIEF REVIEW OF DISTAL RADIUS FRACTURES DR. HARIS BELA
- 2. AIMS INTRO CLASSIFICATIONS RADIOGRAPHIC PARAMETERS MANAGEMENT • Non-operative and Operative COMPLICATIONS
- 3. INTRO Most common orthopaedic injury with a bimodal distribution o younger patients - high energy, intra-articular o older patients - low energy / falls, extra-articular, metaphyseal 50% intra-articular Associated injuries o DRUJ injuries must be evaluated o radial styloid fx - indication of higher energy Osteoporosis o high incidence of distal radius fractures in women >50 o distal radius fractures are a predictor of subsequent fractures
- 4. 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
- 7. CLASSIFICATION Ideal system should describe: Type of injury Severity & Mechanism Treatment Prognosis
- 8. CLASSIFICATIONS Universal (treatment algorithm) Frykman (joint involvement pattern) Fernandez (mechanism) Melone (lunate impaction injury- intraarticular) Column theory (anatomical) AO (severity)
- 9. FRYKMAN (joint involvement pattern) Extra- articular Radio-carpal joint Radio-ulnar joint Both joints { Same pattern as odd numbers, except ulnar styloid also fractured
- 10. FERNANDEZ ( mechanism) BENDING-metaphysis fails under tensile stress (Colles, Smith), Includes DRUJ injury SHEARING-fractures of articular surface (Barton, radial styloid)
- 11. FERNANDEZ (cont) COMPRESSION- intraarticular fracture with impaction of subchondral and metaphyseal bone (die- punch) AVULSION-fractures of ligament attachments (ulna, radial styloid), radiocarpal dislocation COMBINED/COMPLEX- high velocity injuries
- 12. MELONE (lunate impaction injury- intraarticular) Type I: Stable, without commination Type II: Unstable “die punch” dorsal or volar Type IIA: Reducible Type IIB: Irreducible (central impaction fracture) Type III: “Spike” fracture. Unstable. Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation of the distal and palmar fragments Type V: Explosion injury
- 14. Group A Extraarticular Group B Partially intraarticular Group C Completely intrarticular AO Association for Osteosynthesis CLASSIFICATION (severity)
- 15. Universal classification A)Extraarticular farcture Type 1-undispced and stable Type2-dispalced a)Reducible and stable b)reducible and unstable c)irreducible B)Intraarticular fracture Type1-undisplaced and stable Type 2-Displaced a)Reducible and stable b)Reducible and unstable c)irreducible d)complex
- 16. TYPES OF FRACTURES -EPONYMS Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius Barton's fx Fx dislocation of radiocarpal joint with intra- articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx) Chauffer's fx Radial styloid fx Colles' fx Low energy, dorsally displaced, extra-articular fx Smith's fx Low energy, volar displaced, extra-articular fx
- 17. COLLE’S FRACTURE Most frequently encountered injury to the distal forearm. Fall on the outstretched hand with forearm pronated,wrist in dorsiflexion/extension injury aka Dinner fork deformity Age usually above 50y; F>M. Extraarticular 2-3 cm away from articular surface of radius. Associated # of ulnar styloid
- 19. SMITH’S FRACTURE –REVERSE COLLE’S Fracture of the distal radius with volar displacement and angulation of the distal fragment Flexion injury or a direct blow to the dorsum of the hand. Garden-spade deformity Modified Thomas Classification of Smith's Fracture: Type I: Extraarticular Type II: Crosses into the dorsal articular surface Type III: Enters the radiocarpal joint (equivalent to volar barton fracture dislocation)
- 20. BARTON’S FRACTURE Fracture dislocation of radiocarpal joint with intra-articular fracures involving the volar or dorsal lip Dorsal Barton fracture Volar Bartons fracture
- 21. Chauffeur’s fracture • Involves the lateral margin of the distal radius, extending through the radial styloid process into the radiocarpal articulation . • Best seen in PA view
- 22. 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
- 23. Normal parameters Radial inclination = 23° Radial length = 12mm Volar tilt = 10° Scapholunate angle = 60° +/- 15°
- 25. CT SCAN: Intra-articular fractures with multiple fragments Occult fractures DRUJ incongruity Post op; fracture healing MRI: Soft tissue injury Nerve, tendons, ligaments Scaphoid , lunate necrosis
- 26. MANAGEMENT AIMS Efficient and functional wrist Accuracy of articular reduction (to reduce degeneration) Restoration of anatomy Radial alignment and length ( joints stability) Early motion of wrist and fingers Promote bone healing Avoid complications
- 27. MANAGEMENT OPTIONS Closed reduction and immobilization with cast Operative: Closed reduction and Percutaneous pinning (CRPP) External fixation (EF) , spanning/nonspanning ORIF with plate fixation dorsal /volar Arthroscopically assisted reduction and Ex. Fixation of intraarticular fracture. Bone grafting In malunion, corrective bone osteotomy Rehab and follow up Subjective assessment tools ,PRWE, DASH.
- 29. Closed Reduction and cast Low-energy fracture Low-demand patient Medical co-morbidities Minimal displacement- acceptable alignment most extra-articular fxs repeat closed reductions have 50% less than satisfactory results
- 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; Release required Follow-up x-rays needed in 1-2 weeks to evaluate reduction. Short-arm cast after 2-3 weeks, continue until fracture healing. Redisplacement: Repeat reduction and casting – high rate of failure Repeat reduction and percutaneous pinning, External Fixation Or ORIF
- 31. OPERATIVE INDICATIONS Surgical fixation (CRPP, External Fixation, ORIF) radiographic findings indicating instability (pre-reduction radiographs best predictor of stability) displaced intra-articular fx, Step-off volar or dorsal comminution DRUJ Incongruity Open and high energy fractures Associated neurovascular injury/tendon injury severe osteoporosis dorsal angulation >5° or >20° of contralateral distal radius >5mm radial shortening Failed closed reduction and casting associated ulnar styloid fractures do not require fixation
- 32. CRPP (CLOSED RED & PER CUT PINNING) Indications can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex cannot maintain length/alignment when unstable or comminuted volar cortex Techniques Kapandji intrafocal technique In conjunction with external fixation (Augmented external fixation) Rayhack technique with arthroscopically assisted reduction Outcomes 82-90% good results if used appropriately
- 34. Complications Mal-union ( may needs augmentation with additional casting) Pin track infection RSD Finger stiffness Loss of reduction more common than plating Tendon rupture nerve injury
- 35. External Fixation (EF) 1. Spanning, 2. Nonspanning Indications alone cannot reliably restore 10 degree palmar tilt therefore usually combined with percutaneous pinning technique or plate fixation Technical considerations relies on ligamentotaxis to maintain reduction place radial shaft pins under direct visualization to avoid injury to superficial radial nerve nonspanning ex-fix can be useful if large articular fragment avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation limit duration to 8 weeks and perform aggressive OT to maintain digital ROM Outcomes important adjunct with 80-90% good/excellent results Complications stiffness and decreased grip strength pin complications (infections, fx through pin site, skin difficulties) neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
- 36. Spanning ( Ligamentotaxis) A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals
- 37. Non-spanning
- 38. ORIF Indications significant articular displacement (>2mm) dorsal and volar Barton fxs volar comminution metaphyseal-diaphyseal extension associated distal ulnar shaft fxs die-punch fxs preference of early mobilization (ref: Bone and Joint; distal radius fracture, current concepts & Mx)
- 39. Surgical approaches Volar approach Dorsal approach
- 40. volar plating volar plating preferred over dorsal plating volar plating associated with irritation of both flexor and extensor tendons rupture of FPL is most common with volar plates associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons new volar locking plates offer improved support to subchondral bone
- 41. dorsal plating dorsal plating historically associated with extensor tendon irritation and rupture dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal comminution can combine with external fixation and PCP bone grafting if complex and comminuted studies showed improved results with arthroscopically assisted reduction volar lunate facet fragments may require fragment specific fixation to prevent early post-operative failure
- 42. Universal classification based Options TYPE TREATMENT 1)Non articular undisplaced Cast/splint 2)Non articular displaced Close reduction and cast application Percutaneous pin fixation/external fixation 3)Articular undisplaced Cast/percutaneous pin fixation 4)Articular displaced A)Reducible,stable Cast/percutaneous fixation/external fixation B)Reducible,unstable External fixation/ex fix with percutaneous pin fixation C)Irreducible ORIF with plate External fixation Combined external and internal fixation
- 43. Complications Unsightly scar Tendon rupture (flexor or extensor) Some patients may require implant removal Implant cost Technically more difficult Median nerve neuropathy (CTS) most frequent neurologic complication 1-12% in low energy fxs and 30% in high energy fxs prevent by avoiding immobilization in excessive wrist flexion treat with acute carpal tunnel release for: progressive paresthesias paresthesias do not respond to reduction and last > 24-48 hours
- 44. Ulnar nerve neuropathy seen with DRUJ injuries EPL rupture nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon. treat with transfer of extensor indicis proprius to EPL Radiocarpal arthrosis (2-30%) 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm may be nonsymptomatic
- 45. Malunion and Nonunion Intra-articular malunion treat with revision at > 6 weeks Extra-articular angulation malunion treat with opening wedge osteotomy with ORIF and bone grafting Radial shortening malunion radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs treat with ulnar shortening ECU or EDM entrapment entrapment in DRUJ injury Compartment syndrome RSD/CRPS AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperativ
- 46. BMC Musculoskelet Disord. 2013; 14: 170. Published online 2013 May 22. doi: 10.1186/1471-2474-14-170 PMCID: PMC3665633 Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs Annechien Beumer, Tommy R Lindau, and Catharina Adlercreutz CONCLUSION: The present study showed that post-traumatic ulna + is the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too.
- 47. J Hand Surg Am. 2013 Aug;38(8):1469-76. doi: 10.1016/j.jhsa.2013.04.039. Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study. Williksen JH1, Frihagen F, Hellund JC, Kvernmo HD, Husby T. CONCLUSIONS: Although we did not find a significant difference between the groups for the QuickDASH score, we believe that our results support the use of VLPs for the treatment of unstable distal radius fractures. A serious concern is that some patients will have to have their plates removed; therefore, improving the surgical technique is important.