2. 20% of all fractures
Distribution:
5-40 years: Men…High energy… intraarti…stable…operative Rx….
Over 40: females…. Low energy… extraarti…tolerate conservative….
3. ANATOMY OF DISTAL RADIUS
The distal radius consists of the
(1) metaphysis, (2) scaphoid facet, (3) lunate facet, and (4) sigmoid notch.
The metaphysis has thinner cortical bone lying dorsally and radially.
The extrinsic ligaments of the wrist play a major role in the use of indirect
reduction techniques.
Palmar ligaments are Thicker as compared to dorsal ligaments. Distraction will
result in the palmar ligaments becoming taut before the dorsal ligaments.
It is for this reason that it is difficult to achieve reduction of the normal 12
degrees of palmar tilt using distraction alone
4. wrist consists of three distinct columns, each of which is subjected to different
forces.
radial column; intermediate column; ulnar column
5. Signs and Symp. and EXAMINATION:
Pain, swell, tender, inability to use the limb, deformity
Radial shortening
Communicating wounds.
Scaphoid Involvement
Associated Ipsilateral Limb injuries.
Contralateral limb injury.
Other body injuries.
Median nerve involvement (treat like compartment) (monitor by 2 pt disc)
6. XR
PA View
For extra-articular fractures: (a) radial length
(b) ulnar variance,
(c) metaphyseal comminution, and
(d) ulnar styloid fracture location.
For intra-articular fractures: (a) depression of the lunate facet,
(b) gap b/w scaphoid and lunate facet,
(c) central impaction fragments, and
(d) interruption of proximal carpal row.
7. Lateral View:
For extra-articular fractures: (a) dorsal/palmar tilt,
(b) metaphyseal comminution,
(c) carpal alignment,
(d) displacement of the volar cortex, and
(e) position of the DRUJ.
For intra-articular fractures: (a) depression of palmar lunate facet,
(b) depression of the central fragment,
(c) gap bw palmar and dorsal fragments.
10. Stability:
LaFontaine et al.
(1) initial dorsal angulation of more than 20 degrees
(2) dorsal metaphyseal comminution,
(3) intraarticular involvement,
(4) Associated ulnar fracture, and
(5) Age 60 years or above.
Other suggested indicators of instability include volar tilt, dorsal angulation,
comminution, and initial shortening.
15. it is becoming increasingly apparent that operative intervention needs to be
customized to the patient and the fracture as well as the expertise of the
surgeon.
Current data confirm that patients over the age of 65 with extra-articular
fractures are more likely to be satisfied with closed treatment than younger
patients, but that there are still some geriatric patients who will not accept
shortening and angulation.
external fixation versus internal fixation, more recent studies are concluding
that the restoration of normal anatomy is more important than the technique
that is used. the outcomes may be more related to fracture severity, with
superiority of internal fixation being seen in the lower energy fractures.
16. Nonoperative Management:
(1) Type 1 fernandez
(2) stable fractures
(3) low demand elderly patients.
(4) intact palmar buttress (less than 2/3 to 3/4 dorsal comminution)(to resist
collapse)
Patient factors:
Non-dominant hand, physical demands, health status, independent lifestyle,
vocation, avocation, and comorbidities.
18. Percutaneous Pinning (1.5 and 1mm) + SAC:
• extra-articular and simple articular fractures with less comminution in
younger patients. Not used if the reduction is not anatomical of if there is
severe comminution,
The radial styloid is pinned to the proximal shaft in a reduced position.
Once the lateral cortex is reconstituted, then the intermediate column (lunate
facet) is pinned from dorsal ulnar to proximal radial.
Finally, any central impaction fragments can be supported using subchondral
transverse wires.
Complications: superficial radial nerve injury. (open or go dorsal)
19. Ext. Fixators: Bridging and non-bridging
+ Augmentation with BG or BC
+ Augmentation with PCP
+ Augmentation with Volar plate
Arthroscopically Assisted Reduction and External Fixation.
Limitations: external fixation in isolation does not typically restore the
physiologic 12 degrees of palmar tilt. palmar lunate facet may not reduce with
distraction alone.
Overdistraction: there is a gap across the midcarpal joint on fluoroscopy, and confirmed when full passive
digital motion is difficult to achieve.
20. Volar Plating:
the screw position in the distal fragment directly buttresses collapse. The
addition of locking fixation of the screws in the distal fragment further
prevents dorsal displacement of the distal fragment.
21. TYPE 1: Colles, Smiths
Stable: CRSAC in low function, elderly. Weekly ChkXR x 3
CR PCP SAC in young
Unstable fractures: two long term problems: (i) shortening of the radius (ii)
loss of palmar tilt. shortening of the radius relative to the intact ulna of more than 5
mm must by definition disrupt the TFCC or cause avulsion of the ulnar styloid.
nonbridging external fixation, DRLP
22. TYPE II: Volar barton, dorsal barton, chauffers
Non countoured palmar buttress plate (never to be used in complete articular
fractures)
23. EF
• (1) longitudinal traction is applied to achieve radial length and the fracture is
assessed for the presence of a metaphyseal defect, (2) palmar translation
(not palmar flexion) of the carpus, and finally (3) ulnar deviation. If there is
evidence of significant radioulnar instability, the fracture is reduced in
supination to avoid displacing the radial metaphysis palmar to the distal ulna
as ulnar deviation is applied. The most critical element P.863
• to this technique is to align the palmar cortex anatomically on the lateral
view. It is especially useful to incline the radius 15 degrees to 20 degrees to
the fluoroscopy beam to check the alignment. In order to prevent collapse
during healing and permit early removal of the external fixator, the
metaphyseal void may be filled with a bone graft or a bone graft substitute at
this time
24. TYPE III: Compression Fractures of the Articular
Surface
Augmented EF
Internal fixation
3 part #
Radial column: CR + 2 (1, 1.5mm) Kw
The lunate fossa should then be assessed on a tilted
lateral view.
Towel clip may be used between the dorsal ulnar
corner and the newly fixed radial column.
Then Kw from DU to PR or transverse Kw can be
introduced
4 part fracture + some comminution: Volar locked
plating is preffered.
25. TYPE IV:
Smaller fragments may be neutralized by placing a wire through the fragment
and through a drill hole in the radius. The fragments are then sutured to the
radius. Larger fragments may be fixed with a plate screw construct.
External fixation may be required to stabilize the radiocarpal joint.
Dorsal lip injuries are associated with Volar lip injuries, impaction of joint,
scaphoid injuries. CT should be done.
EF should be used to stabilize the radiocarpal joint and percutaneous pinning
may be used to fix the intercarpal instability.
27. Ulnar Styloid Fractures
Fractures of the ulnar styloid occur in approximately 60% to 70% of distal radius
fractures
The indications for treatment of ulnar styloid fractures is evolving.
If the ulnar styloid is fractured and displaced, making the distal radioulnar joint
unstable, fix the styloid with one or two percutaneous Kirschner wires . A volar
approach may be helpful to obtain ulnar styloid reduction.
in patients with obvious DRUJ instability and no large ulnar styloid fracture, the
patient should be immobilized in supination to reduce the DRUJ for 4 weeks
before permitting forearm rotation.
Triangular Fibrocartilage (TFCC) Injuries occur in roughly 40% to 70% of
intraarticular fractures of the distal radius in young patients and should be fixed
to uln. Styloid by non absorbable sutures..
Vs Dorsal plating
Make an 8-cm incision over the forearm between the radial artery and the flexor carpi radialis. V Shape
Open the FCR sheath and incise the forearm deep fascia to expose the flexor pollicis longus.
Using index finger gently sweep FPL ulnarly. Partially detach the flexor pollicis longus muscle belly from the radius if necessary to expose PQ
L-shaped incision
small osteotome into the fracture line to serve as a lever to reduce the fracture.
the brachioradialis can be transacted or detached from the distal radius.
Kirschner wire can be used to temporarily fix if needed.
Ist screw in GLIDING hole
Distal screw….20- to 22-mm screws are used. avoid having a prominent distal screw perforate the dorsal cortex;
Once the first screw is inserted, distal traction can be released
