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Dr. yt reddy distal radius fractures modified
1. Dr Y Thimma Reddy
Assistant Professor & Registrar
Department of Orthopedics
OSMANIA MEDICAL COLLEGE
2. Distal Radius Fractures
Common injury
Potential for functional
impairment and frequent
complications
3. HISTORY
First surgeon to recognize these injuries was Pouteau 1783.
his work was not widely publicized.
Later Abraham Colles 1814 gave the classic description of
fracture
Dupuytren brought to the world attention that it is a fracture
rather than a dislocation as it was previously assumed.
Goyrond 1832 differntiated between dorsal and volar
displacement.
Barton 1838 described wrist subluxation consequent to
intraarticular fracture of radius which could be dorsal or volar.
Smith described fracture of distal radius with „forward‟
displacement.
Advent of X rays at the end of nineteenth century contributed
much to the understanding of different patterns of injury.
4. Incidence
One sixth of all fractures treated in the
Emergency Room
Bimodal distribution
○ less than 30 years (70% men)
○ over 50 years (85% women)
5. Introduction
Occurs through the distal metaphysis of the radius
May involve articular surface
frequently involving the ulnar styloid
FOOSH
forced extension of the carpus,
impact loading of the distal radius.
Associated injuries may accompany distal radius
fractures.
6. Diagnosis: History and Physical
Findings
History of a FOOSH
Visible deformity of the wrist, 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.
7. 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
CT scan of the distal radius in selected
instances.
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
14. Scapholunate angle measured between lines 2 and 3
(normal 47 ± 15 degrees)
2: Line perpendicular to 1: Line connecting dorsal and
lunate volar tip of lunate
3: Line along axis of scaphoid
15. Computed Tomography
Indications:
Intra-articular fxs with multiple
fragments
centrally impacted fragments
DRUJ incongruity
Cole et al: J Hand Surg, 1997
16. Classification of
Distal Radius Fractures
Ideal system should describe:
Type of injury
Severity
Evaluation
Treatment
Prognosis
17. Common Classifications
Column theory
Gartland/Werley
Frykman
Weber (AO/ASIF)
Melone
Fernandez (mechanism)
18. Frykman Classification
Extra-
articular
Radio-carpal joint
Same pattern as
Radio-ulnar joint
{ odd numbers,
except ulnar
styloid also
fractured
Both joints
19. AO/ OTA Classification
Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C:
Complete Intra-
articular
21. Three Column Theory
Radial Column
Lateral side of radius
Intermediate Column Radial column Ulnar column
Ulnar side of Intermediate column
radius
Ulnar Column
distal ulna
22. Classification – Fernandez
(1997)
I. Bending-
metaphysis fails
under tensile stress
(Colles, Smith)
II. Shearing-fractures
of joint surface
(Barton, radial styloid)
23. 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
24. 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
27. 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
28. Treatment Goals
Preserve hand and wrist function
Realign normal osseous anatomy
promote bony healing
Avoid complications
Allow early finger and elbow ROM
29. Indications for Closed
Treatment
Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement-
acceptable alignment
30. Closed Treatment of Distal
Radial Fractures
Obtaining and then maintaining an
acceptable reduction.
Immobilization:
long arm
short arm adequate for elderly patients
Frequent follow-up necessary in order to
diagnose redisplacement.
31. 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!
32. Acceptable Reduction
Criteria
No dorsal angulation
> 15 degrees of inclination
Articular step-off < 2mm
< 5 mm shortening compared to opposite wrist.
DRUJ congruent
33.
34. 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.
35. Management of
Redisplacement
Repeat reduction and casting – high rate of failure
Repeat reduction and percutaneous pinning
External Fixation
ORIF
36. Indications for Immediate
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
43. Spanning ( Ligamentotaxis)
A spanning fixator is
one which fixes
distal radius
fractures by
spanning the
carpus; I.e., fixation
into radius and
metacarpals
44. 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.
49. 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 >20% increase in ligament strain
50.
51.
52. 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
55. 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)
56. 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%
58. 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
59. 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.
89. 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.
90. 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)
91. 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
92.
93. Relationship
of Anatomy to Function
Colles; “The wrist will regain perfect freedom
in all of its motions and be completely
exempt from pain” (1814)
Generally true for low demand individuals
Direct relation between residual deformity
and disability
Quality of reduction more important than
method of immobilisation