CURRENT MANAGEMENT OF FRACTURES OF THE DISTAL RADIUS

Presenter : Dr. Sreenivas .T Moderators : Dr. Vikas Gupta : Dr. Shamshery

CONTENTS
Introduction Anatomy Diagnosis Classification Treatment Goals and Considerations Complications Associated injuries Current management

INTRODUCTION
-Fractures of the distal radius -1/6 of all fractures -Bimodal age distribution- one peak in early adolescence, distributionsecond in the older age -Controversy and confusion exists in medical literature -Fundamental principle -restoration of anatomy with the hope of producing full ,painless motion of wrist. -Employment of a single technique -prone to variable and often disappointing results

ANATOMY
Distal radius articulates with ulnar head and carpus. This articulation enable the radius to guide forearm rotation and wrist movements. The cortical bone in the area of distal radial metaphysis is thin.

Contd
Normal palmar angulation 11 in the lateral plane. Normal radial angulationangulation23 in the AP plane Average radial length is around 12mm with negative ulnar variance.

DIAGNOSIS
History
Age of the patient Mechanism of injury
-FOOSH -wrist 40-60 40dorsiflexion

Clinical examination
-Examination of joints above and below the wrist -Deformity ;dinner fork -Swelling ,degree of radial and ulnar tilt ,DRUJ -Associated scaphoid fracture -Neurovascular assessment - Median nerve compression

Radiological evaluation
X-ray
PA/Lateral

Check for
Loss of radial height (>5mm) Loss of radial inclination (Normal 20-25) 20Dorsal tilt (Normal 10 volar) Comminution Ulnar fracture Axial or rotational malalignment can produce DRUJ problems

CT
For intra-articular intrafractures

Wrist arthroscopy
As a diagnostic aid- eg-to R/O associated TFCC tears aid- eg-

CLASSIFICATIONS
15 different Classification systems exist!

Fracture Classification
-SHOULD be practical and useful in treatment decision -SHOULD NOT BE cumbersome and impractical -Recognizing that the major forces resulting in fracture propagation -Some basic principles can be developed to separate out potentially unstable from stable fractures

1. Frykman (1967)
Descriptive only and does not include variables, such as direction and degree of displacement or Comminution

2 .McMurtry and Jupiter

2 parts: Barton #, Chauffeur #,Die-punch #,Die# 3 parts: lunate and scaphoid fossae separate from distal radius 4 parts :lunate fossa fractured into dorsal and volar fragments 5 parts or more

3 Melone Classification(1984)
SubSub-types of 4-part intra-articular fractures 4intraGives indication to treatment

Types
1 Minimal comminution stable 2 Comminuted stable 3 Displacement of medial complex as a unit + anterior spike 4 Wide separation or rotation of the dorsal fragment + palmar fragment rotation

4 .Universal Classification
Based on the concept and principle of EA vs IA fractures and stable vs unstable

5.AO Classification

Comprehensive but has poor inter and intra observer agreement

TREATMENT GOALS AND CONSIDERATIONS

Principles
1. 2. 3. 4.
restoration of articular congruity and axial alignment maintenance of reduction achievement of bony union restoration of hand and wrist function Principles needs to be tailored to the needs of the patient

CONTD
Other factors
Low functional demand Significant medical illness Inability to comply with postoperative instructions Previous fracture and deformity
-These may justify acceptance of less than anatomic results. -Chronological age does not correlate with functional age and many of these fractures, even in older patients, will benefit from aggressive treatment

Anatomical aims
To restore radial length, inclination and tilt Acceptance criteria 1. 10 loss of normal volar angulation (i.e. No more than 0 or 20 volar angulation) 2. < 5 loss of radial inclination 3. < 2mm shortening 4. Accurate restoration of the articular surface < 2mm step

Characteristics of instability
Dorsal +/or volar cortical comminution Fragmentary displacement >5 mm Angulation >10 Shortening (impaction) > 5 mm Articular comminution Diastasis DRUJ Fracture ulnar head/neck Concomitant scaphoid fracture or scapholunate dissociation These principles -basis for practical classification system which guide treatment

Displaced + stable
Closed reduction + Cast immobilization

Plaster/brace
Advantages
Easy to apply Operation not required

Disadvantages
Movement of the hand may result in loss of position of the fracture especially as swelling goes down Plaster needs to be kept on for six weeks and so wrist and hand stiffness may result Plaster cannot control dorsal comminution

Displaced Intraarticular Fractures

Specific subset of distal radius fractures High energy injury resulting in comminuted fracture pattern Usually occurs in younger age population Inherent tendency for shortening and collapse Associated with carpal and distal radioulnar instability Less amenable to closed manipulation and casting

ASSOCIATED INJURIES
Distal Radioulnar Joint
- Ulnar styloid fracture - frequent - rarely unstable - partial TFCC tear - rarely needs treatment (50%)
Disruption
Diastasis - Complete TFCC tear Bony constraints cannot control Requires soft tissue stabilization Repair with sutures/suture anchors ORIF larger fragments

Ulnar Head/Neck Fracture - Comminuted - very

unstable
Difficult to securely fix Treat with excision/soft tissue reconstruction Bone can be used for grafting radius

Median Nerve Injury (13-23%) (13Contusion Hematoma/Compression Traction / Neuropraxia Reduction frequently increases intracompartmental pressure in carpal canal Early surgical decompression - if significant symptoms Late decompression - less successful

Intercarpal Ligament Injury

Total/Partial
Scapholunate (30%) Lunotriquetral(15%) Can see diastasis in traction x-ray xTreated early with percutaneous pin fixation - usually adequate

Scaphoid Fracture
If nondisplaced - percutaneous pin fixation If displaced - ORIF

COMPLICATIONS
Early
Difficult reduction, loss of reduction, unstable reduction Associated carpal injury: fracture or ligamentous tear TFCC tear - 50% DRUJ subluxation or dislocation Acute Carpal Tunnel Syndrome Acute post reduction swelling / Compartment syndrome Nerve - median most common - 13-23% 13Vessel - rare - radial artery commonest Tendon - rare

Contd..
Intermediate and Late
Loss of reduction and 2 deformity 2 Malunion, NonNon-union - rare Symptomatic Radiocarpal OA - 7% ( Stiff Hand) Median Nerve compression (23%), carpal tunnel syndrome, ulnar or radial nerve compression EPL rupture in 1.5% (Treatment EIP to EPL transfer) transfer) RSD 25% DRUJ OA (Treatment = Darrach's / SuaveSuaveKapandji procedure)

ADVANCES IN DISTAL RADIUS FRACTURE MANAGEMENT

Pearls and Pitfalls of External Fixation William H. Seitz, Jr, MD, Cleveland, OH Internal Fixation and Early Motion Jesse B. Jupiter, MD, Boston, MA The Role of Arthroscopic-Assisted Fixation ArthroscopicWilliam Geissler, MD, Jackson, MS The Roles of the DRUJ and Rehabilitation in Outcome of Distal Radius Fractures Matthew D. Putnam, MD, Minneapolis, MN Augmentation of Fracture Fixation: Bone Graft and Alternatives Scott W. Wolfe, MD, New Haven, CT

1.External Fixation
NOT applicable to all fractures DOES provide a useful tool for many fractures Provides LIMITED, GROSS CONTROL of major fragments It does so by controlling length, alignment and rotational orientation of the hand on the forearm DOES NOT provide precise fragment realignment nor restoration of articular congruence

BIOMECHANICAL PRINCIPLES FOR APPLICATION

LIGAMENTOTAXIS

Tension across intact soft tissue structures Spanning a joint will help to mold major fragments back into alignment & hold these there using physiological tension

PEARLS
Physiologic tension - maintains "healthy" capsular stretch
R-C joint 1 mm > mid carpal joint Avoid over distraction (back off) Watch for scapholunate displacement (pin/suture) Watch for scaphoid fracture displacement Don't try to gain full alignment restoration by over distraction

PITFALLS
Over distraction -disaster Median neuropraxia RSD Finger stiffness

FIXATOR APPLICATION/FRACTURE REDUCTION

With pins in place - assemble and apply fixator to pins with fixation in unassembled mode Apply gentle - but firm - traction to hand and gently manually compress fracture fragments into alignment between thumb and palm Secure fastener lock-ups and check overall alignment for locklength, angle and rotation of fragments by image intensifier Adjust traction as needed Re-adjust/reRe-adjust/re-reduce if needed Proceed with fine fragment reduction/augmentation Ensure NO over distraction Following internal fixation - return to neutral position

Augmentation
Limited internal fixation with percutaneous KKwires providesprovidesInterfragmentary realignment & precise articular restoration In complex irreducible fractures (usually high energy)energy)ORIF+External fixation

Percutaneous K-wires KExtra focal

-Classical styloid + Lister's tubercle wire placement -Trans-ulnar pin placement Intra-focal - Kapandji technique (Kapandji A. Ann. Chir. Main. Memb. Super. 6:57-63. 1987)

Contd

Arum pinning

Contd
Subchondral Support
When there is > 5 mm shortening i.e. impaction with very osteopenic bone - or after reduction a large void is noted radiographically Metaphyseal bone replacement prevent late collapse and affords relatively early fixator removal

Postoperative Care
Bulky soft dressing - Compress gently - controls edema - fingers free - allows hand use 4 days only REHABILITATION
Begins Pre-operatively PrePatient instructed in what to expect and what his/her responsibility will be

2.Internal Fixation and Early Motion

Hypothesis - Anatomy does correlate with function! Distal radius. Foundation of two joints.
RadiocarpalRadiocarpal- radial alignment. Important for normal carpal kinematics.

Critical capsular ligaments originate from radius Intercarpal ligament injuries shown to be commonplace Axial scaphoid shift sign - scaphoid more distal than lunate with traction suggests S-L ligament injury. SCarpal instability post-fracture more commonplace postthan previously thought

ANATOMIC ISSUES

Dorsal Fixation
Great obstacle to stable internal fixation -soft tissue problems by application of large metallic implants on the dorsum Complications -pain, tendon irritation, and tendon rupture Dorsal fixation devices can be applied free from extensor tendon irritation only if they lie within narrow space along the dorsal ridge and between the wrist extensor and the digital extensor tendons

Volar Fixation
Not associated with tendon problems as there is much more space on the volar aspect The volar radius is concave in the sagittal plane and the flexor tendons lie well above the floor of the concavity; the pronator quadratus fills this space Volar implants can be much larger than dorsal and can therefore withstand the loads imposed by functional use of the hand.

FIXATION ISSUES
To provide stable internal fixation - conventional screws were unable to gain purchase in the distal fragment, except in favorable circumstances. Fixation plates used in the pure buttress mode, when there was no cortical comminution of the opposite cortex. Introduction of fixed angle fixation solved the distal fixation problem and had been utilized in orthopedics for many decades; (Matthew D. Putnam,
MD, and then further developed by Jesse Jupiter, MD, and Robert J. Medoff, MD).

Contd
A fixed angle device provides distal fixation by functioning as a nail plate; It supports the distal fragment by interference effect created by rigid extensions referred to as tines, pegs, or locking screws.
Fixed angle fixation works best if the pegs are placed immediately underneath the subchondral bone, as this frequently is the only substantial bone left in the distal fragment of osteoporotic patients. Pegs must support primarily the dorsal aspect of the joint surface, as majority of these fractures are unstable in a dorsal direction

VOLAR APPROACH TO DORSAL FRACTURES

Introduction of volar fixed angle implants for dorsally unstable fractures challenged old surgical paradigms Benefits of volar fixed angle fixation- mainly less fixationsoft tissue disturbance and hence faster recovery, soon convinced many and this has now become an accepted treatment method.

Advantages
Minimizes dissection and surgical insult to the delicate extensor tendon sheaths. Alignment of the articular surface with the shaft fragment is the goal of reduction and comminuted metaphyseal fragments can be ignored. Periosteal attachments of the comminuted dorsal fragments are preserved, fracture healing is hastened. Volar scar is more cosmetic and better tolerated Finally the volar exposure is extensile and allows the management of concomitant scaphoid fractures.

Contd
Extended form of the flexor carpi radialis (FCR) approach to manage the more complex articular fractures Volar access to the dorsal aspect of the fracture gained Addresses each specific articular fragment which extends the reach of volar fixed angle fixation

Figure 1. A 48-year-old womans fall from a ladder resulted in a dorsally displaced intra-articular fracture of 48-yearintrathe distal radius. She was treated with a volar fixed angle plate applied through the extended FCR volar approach.

DESIGN OF VOLAR FIXED ANGLE PLATES

Volar fixed angle implants should be available in different lengths and sizes to best fit each clinical situation. The design is optimized by the accurate positioning of the pegs in space. Pegs should fan out and cover as much area of subchondral bone as possible to provide broad support in case of articular comminution. The volar plate should have a volar buttress extension distal to the origin of the pegs for stabilization of volar marginal fragments; this is especially important for the stabilization of the comminuted lunate fossa. The volar marginal fragment from the lunate fossa is a rare but very serious problem that requires careful attention.

Contd.. Contd..
- It should come in different sizes -It should be strong enough to tolerate the forces of rehabilitation -Should be designed with a large margin of safety to prevent fatigue failure -The pegs, the plate, and proximal fixation should be equal in strength -Proximal fixation is into strong cortical bone, therefore standard screw fixation is adequate

Dorsal locking nail plate

In patients with multiple medical problems and poor anesthetic candidatescandidates-minimally invasive method is often desirable. A fixed angle implant -rapidly applied with minimal dissection and under local anesthesia has been developed Unique unicortical screws and a distal portion consisting of a very narrow fixed angle plate.

Contd
Inserted through the fracture & dorsal approach is particularly suited as the dorsal ridge of the radius is immediately subcutaneous Consists of a proximal intramedullary portion that is locked using site; the plate portion avoids tendon irritation Allows early functional use of the hand and extends the benefits of fixed angle fixation to the debilitated patients.
(Jorge L. Orbay, MD, is a specialist in hand and microsurgery, and is the founder and director of Florida s Miami Hand Center.)

Bioabsorbable Plates
Strong enough to fix the fracture to allow immediate mobilization Broken down by the body after about three months and so hopefully will help to avoid the problems with the tendons. These plates are combined with bone substitutes. Early results are encouraging but have not been in use for long enough to show that they are better in a scientific sense than other methods

Hybrid fixation by limited incision approach

By use of k wires,low profile plates for fixing different fragments,percutaneous screw fixation of ulnar styloid fracture.

Contd

Fracture Classifications Relative to Operative Indications Bending fractures (AO Type A) - When associated with neurologic deficit or seen late. Shearing fractures (AO Type B) - definite indication Compression fractures (AO Type C) - 4 part fracture with displaced volar lunate facet. Radiocarpal fracture-dislocation - frequent. fractureComminuted complex fracture - common

Algorithm
Shearing Fracture (AO Type B)
(AO Group B3). Vast majority will be split into two or more fragments (Jupiter et al, Journal of Bone and Joint Surg, 78A: Surg, 1996.)
Operative Approaches - Simple Operative Tactics - buttress plate PostPost-operative Management -Splint for two weeks, then active assisted range of motion Results favorable: 31 excellent 10 good, 8 fair (Jupiter et al., JBJS, 78A: 1996.) JBJS,

Volar

Dorsal (AO Group B2)

Uncommon More often combination with styloid
 

Operative approach Operative tactics: Plate fixation; p plate very effective.

Volar neutralization plate fixation for dorsally displaced fractures

Radial Styloid (AO Group B1)

(Chauffeur's fracture)
Association with scapholunate ligament injury Styloid often in 2 or more fragments


Fixation with cannulated screws PostPostoperative managment dependent upon ligaments

Compression Fractures
4-part frature may need volar exposure (Melone Type IV) Many 3-part fractures can be treated with 3percutaneous pins and external fixation. Operative tactics Reduce and percutaneously fix volar lunate facet with plate or K-wire KVolar ulnar approach and reduce and fix volar lunate facet with plate or K-wire KManipulate and fix dorsal lunate facet with KKwire. External fixation is usually necessary.

Radiocarpal FractureFractureDislocation
  

Open high energy trauma May have intracarpal ligament injury Ulnar styloid fracture often needs fixation

Complex Combined Fractures

Ipsilateral skeletal and ligament injury Associated complex carpal trauma Proximal skeletal and articular injury Fractures with bone loss Fractures with neurovascular injury Compartment syndrome

Contd


 

Failure of Prior Treatment -Malunion Operative treatment may limit overall disability Applicable, even in an elderly patient

3.The Role of ArthroscopicArthroscopicAssisted Fixation

Advantages
Ideal view of joint surface with minimal surgical trauma Joint surface viewed under magnification and ample light Osteochondral flaps, loose bodies may be excised Associated soft tissue injuries detected and managed Evaluate ulnar styloid fragment

Disadvantages
Technical procedure Expertise needed Special equipment helpful

Surgical Technique
Arthroscope --- 3-4 portal Working portal --- 4-5 portal or 6-R portal 6Inflow --- 6-R portal Usually easier to triangulate from 4-5 4portal if fibrin clot/debris obscures vision
Easier to elevate fragment with instruments from 4-5 portal 4Compressive elastic wrap around forearm retard fluid extravasation

Contd

Instrumentation
Small joint arthroscope (2.7 mm) Traction tower Motorized shaver Fluoroscopy unit Traction tower allows manipulation of wrist to help reduce fragments while maintaining traction

Arthroscopic fixation
Landmarks
Wrist are very swollen, unable to palpate usual soft tissue landmarks Know bony landmarks; metacarpal bases, dorsal lip of radius, ulnar head usually palpable Radial side of long finger, mid axis of ring finger used to determine radioulnar location of 3-4 and 4-5 portals 34-

Timing of Reduction
Between 3 to 7 days Earlier attempts may have troublesome bleeding, obscure vision, fluid extravasation? Later attempts harder to disengage and mobilize fragments

INDICATIONS
Displaced intraarticular fracture with articular cartilage step-off of 2 mm stepor more after closed manipulation Intraarticular or extraarticular fracture with suspected carpal ligamentous injury or distal radioulnar instability

CONTRAINDICATIONS
Compartment syndrome Open joint with massive soft tissue injury

1.RADIAL STYLOID FRACTURES

Can almost always be reduced anatomically In complex fracture patterns provides anatomic landmark to reduce remaining fragments Radial styloid fragment may be manipulated and pinned under fluoroscopy and reduction "fined tuned" as viewed arthroscopically Alternatively, 2 Kirschner wires may be placed and used and joysticks to manipulate and reduce the fragment as seen arthroscopically

KIRSCHNER WIRE PLACEMENT

Stay dorsal in snuffbox so as not to injure radial artery Protect cutaneous nerves Place 0.045 Kirschner wires through 1414-gauge needle TIP: Place needle cap over exposed wires

2.THREE PART FRACTURES

Reduce radial styloid as before Medial fragment can be manipulated up with joysticks Place needle intraarticularly over displaced fragment to be elevated Helps determine location of the fragment to be reduced Drop down 1-2 cm proximally in line with needle and 1place Steinmann joystick into fragment to elevate it Pin transversely just beneath subchondral bone, aiming dorsal ulnar to catch "die- punch" fragment "dieTIP: Pronate/supinate wrist to make sure transverse pins do not violate radioulnar

3.FOUR PART FRACTURES

Reduce redial styloid fragment as before Limited open reduction, approach volar medial fragment between ulnar neurovascular bundle and flexor tendons and buttress plate Volar fragment now used as fulcrum to arthroscopically reduce remaining dorsal fragments like a "die punch" fracture

4.VOLAR AND DORSAL BARTON'S FRACTURE

Plate as classically described Percutaneous pinning does not provide sufficient stability Do not sacrifice stability for an arthroscopic procedure Arthroscopically evaluate joint through standard portals after plating Alternatively place scope ulnar to long radiolunate ligament after plating of volar Barton's fracture as described by Levy and Glickel

5.ULNAR STYLOID FRAGMENT

Arthroscopic evaluation provides rationale for management Palpate the TFCC, should be taut Taut TFCC, majority of TFCC fibers still attached to proximal ulna Lax TFCC, look for peripheral TFCC tear, repair if present, consider ORIF ulnar styloid fragment if peripheral tear is not present

EXTERNAL FIXATION

Consider when metaphyseal comminution is present May be placed before or after arthroscopic reduction Bone graft added through small incision between fourth and fifth dorsal compartments TIP: Medial fragments may be further stabilized with treaded half pin through free clamp and attached to frame

4.THE ROLES OF THE DRUJ AND REHABILITATION IN OUTCOME

The DRUJ/Ulnar Head
Point of attachment TFCC Direct longitudinal load transmission Resist transverse compressive forces Requires relaxation of PQ to supinate

Points of Attachment and Function TFCC

 

Displacement of dorsal band increases with pronation Displacement of dorsal palmar band increases with supination (Acosta)

Contd
Importance of the DRUJ and rehabilitation related to distal radius fracture management deserves greater empahsis. Stabilize the DRUJ for all cases. Develop patient/fracture specific rehabilitation plans

5.Augmentation of Fracture Fixation: Bone Graft and Alternatives

BONE GRAFTING
Clinical series show improved outcomes with earlier motion Biomechanical work demonstrates sufficient stability to allow early motion after partial healing Clinical experience; high energy injuries - trend towards bone graft (50 - 85%) Results demonstrate 80% and higher restoration grip and motion in these high energy injuries

Indications
Articular incongruency High energy injuries, dorsal or metaphyseal commination Late collapse, unstable extra-articular extrafracture

Bone graft - The "Gold Standard"

Autogenous Graft
Advantages
Highest biological activity Rapid integration Can be vascularized

Disadvantages
Limited quantity Donor site morbidity (6 - 30%) Increased operative time/blood loss Increased cost/overnight stay

Contd
Allograft
Advantages
Unlimited supply Strong, osteoinductive

Disadvantages
Finite risk of disease transmission Immunogenicity highly variable
FreshFresh-frozen: osteoprogenitor cells killed FreezeFreeze-dried: lacks structural support

Bone Graft "Substitutes

Prerequisite for bone graft substitute
Osteoconduction Osteoinduction Osteogenic cells Structural support

Bone graft alternatives

Structural bone substitutes Osteogenic agents Cancellous bone substitutes

Contd
Structural bone substitutes (cements)
-PMMA
high rates of thermal necrosis; infection; brittle

- Norian SRS
Injectable ceramic, hardens to 50% strength in one hour Multicenter trial results encouraging for extraarticular fractures

- Bone Source
can be mixed with blood or marrow

-TrueBond
PeriPeri-odontal applications; modular biodegradability

Contd
Osteogenic agents
Demineralized bone matrix (Grafton, Dynagraft)
available in gel, strips, powder variable osteoinductivity no structural integrity may be mixed with marrow

Bone Morphogenetic Proteins

rhBMPrhBMP-2; Encouraging in vivo results - canine Osteogenic Protein 1 (OP-1, BMP-7) (OP- BMPPotent bone induction agent Laboratory and human defect/nonunion trials promising

Others
NeNe-osteon Platelet concentrate

Cancellous bone substitutes

Collagraft (Collagen-HA-TCP composite) (Collagen-HAmixed with marrow to add osteoinductivity, Osteogenic cells

Calcium Phosphate Ceramics

TCP; variable biodegradation Synthetic HA; high affinity for bone in growth; non-resorbable non-

Coralline Hydroxyapatite
Hydrothermal exchange reaction Porosity identical to cancellous bone; high affinity for growth factors Brittle, anisotropic

Calcium Sulfate (Plaster of paris)

Unpredictable biodegradation Void filler

Bone grafts and alternatives

Customized treatment for high energy distal radius fractures Bone graft accelerates healing time, reduces dependency on ligamentotaxis Bone graft alternatives backed by clinical and basic laboratory studies Rapid osseointegration; cost-effective costPromising future for bone graft alternatives, bone regeneration

Prognosis
Position of the fracture at union than the position at time of presentation has the greatest correlation with long-term longfunctional results Malunion associated with -poor function, pain, decreased range of motion, decreased grip strength, and poor patient function/satisfaction leads to poor anatomic results after fracture (McQueen M, Caspers J: Colles' fracture: J Bone Joint Surg 1988;70B:649-651.) 1988;70B:649-

SUMMARY
Fractures of distal radius are not simple injuries The concept of fragment specific fixation emphasizes the need to fix individual fragment Dorsal bone grafting is an important adjunct in c/o of dorsal comminution External fixator should be used as a neutralization device Every patient is unique,treatment plan should be unique,treatment based on individual needs and expectations.

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