Distal Radius Fractures

Outline
Epidemiology Anatomy Classification Imaging Treatment Complications Conclusions

Epidemiology
Distal radius fractures
1/6th of all #s treated in ED 450,000 annually in US in elderly 2nd only to hip # Lifetime risk = 15% women; 2% men Bimodal distribution (ages 6-10 & 60-69)
Older population = women, postmenopausal osteoporosis, caucasian, family history

Mechanism of Injury
Elderly
FOOSH in osteoporotic bone (insufficiency #)

Young
High-energy with marked comminution and wide displacement E.g. MVC, fall from height, sports

Anatomy
Distal radius consists of
Metaphysis Scaphoid facet Lunate facet Sigmoid notch

TFCC from distal edge of radius to base of ulnar styloid

Stabilizes DRUJ

80% of axial load supported by DR, and 20% by ulna/TFCC

Anatomy
Metaphysis
Primarily cancellous bone Flared distally with thinner cortical bone lying dorsally + radially
#s typically collapse dorsoradially

Cross-Sectional Anatomy
Radial styloid angles volarly Extensor tendons in direct contact with bone Layer of fat between flexor tendons and bone
VOLAR

DORSAL

Clinical Evaluation
Physical Exam
Wrist typically swollen, with ecchymosis, tenderness and painful ROM Deformity of the wrist/Displacement of the hand in relation to the wrist
E.g. dorsal displacement, radial shortening

Open injury
Soft tissue injury typically palmarly + ulnarly (result of distal ulna)

Associated injuries
Examine ipsilateral shoulder & elbow E.g. # radial head Carpal #s

Neurovascular status
Carpal tunnel compression symptoms in 13% to 23% Result of displacement of median N, direct trauma from # fragments, or hematoma in carpal tunnel Symptoms should improve with reduction of #

Imaging
X-rays
Standard View (PA, lateral, oblique views) Contralateral wrist views
May assess pts normal ulnar variance + SL angle

CT Scan
Demonstrate extent of intra-articular involvement

Normal Radiographic Parameters

Radial Inclination
avg = 23 (range 13-30)

Radial Length
Avg = 11 mm (range, 818mm)

Ulnar variance
Avg = 1 mm ulnar negative

Normal Radiographic Parameters

Volar Tilt
Avg = 11-12 (range 0-28)

Classification
Extra-articular vs intra-articular Degree of comminution Dorsal vs volar displacement Open vs Closed

Classification Systems
Multiple
Frykman Jupiter & Fernandez Melone AO classification

None frequently used

Frykman Classifcation
8 categories based on
Intra-articular extension (radiocarpal or DRUJ) # of ulnar styloid process

Does not consider displacement nor comminution

Jupiter & Fernandez

Based on mechanism
I) Metaphyseal bending # II) Shearing # III) Compression # of articular surface IV) Avulsion # or radiocarpal #-dislocation V) High-energy, combined mechanism

Melone Classfication
Based on number of parts
1 = radial shaft 2 = radial styloid fragment 3 = volar lunate fossa 4 = dorsal lunate fossa

Medial lunate complex (3+4) are important for radiocarpal + DRUJ function

AO classification

Management
Non-operative
Reduction + Casting

Operative
Percutaneous Pinning Ex-fix ORIF

Factors affecting treatment

Fracture pattern Fracture stability Patient factors

Factors affecting treatment

Fracture pattern
ACCEPTABLE RADIOGRAPHIC CRITERIA Radial Length = < 5 mm radial shortening Volar tilt = neutral (0 deg) Intra-articular step-off/gap < 2mm Radial Inclination > 10 deg

Fracture stability Patient factors

Radial Shortening
Accept < 5 mm radial shortening Palmer & Werner (Clin Orthop 1984)
Increase of 18% to 42% in force borne by distal ulna, with a relative radial shortening of 2.5 mm

TFCC becomes tighter, and DRUJ is disrupted, leading to pain & loss of forearm rotation Shortening of 6-8 mm causes ulnocarpal impingement

Dorsal Angulation
Accept neutral tilt (young) or <10 dorsal tilt (elderly) As DA increases, load distribution shifts from volar-radial to dorsal-ulnar Load thru ulna increased to 50% at 30 dorsal tilt (Short et al.) Loss of normal tilt affects grip strength

Radial Inclination
Affects grip strength, ROM in radial/ulnar deviation, distribution of load in wrist Pogue et al (JHS 1990)- increased load borne by lunate facet

Articular congruency
Knirk & Jupiter (JBJS 1986)
> 2 mm of intra-articular step-off increased rate of symptomatic post-traumatic OA in young adults

Some other studies quote > 1 mm step-off or > 2 mm gap at risk for arthrosis In elderly, radiographic arthrosis may not be symptomatic

Factors affecting treatment

Fracture pattern Fracture stability
Initial dorsal angulation >20 *** Comminution (especially dorsal) *** Intra-articular involvement Associated ulna # Age > 60 yrs *** Radial shortening > 5 mm 3+ RF = high likelihood of collapse

Patient factors

Factors affecting treatment

Fracture pattern Fracture stability Patient factors
Physiologic patient age Lifestyle Occupation Hand dominance Associated medical conditions Associated injuries

FRACTURE TYPES: Extra-articular

75%-80% of stable fractures treated closed Signs of instability:
Dorsal comminution Significant displacement Volar displacement

Colles #
Described by Abraham Colles in 1813 Classic definition
Transverse # 2.5 cm proximal to radio-carpal joint Dorsally displaced & dorsally angulated

Dinner-fork deformity From FOOSH onto a dorsiflexed wrist with forearem pronated

FRACTURE TYPES:
Colles Type: Dorsally displaced
Treatment algorithm:
Hematoma block/ conscious sedation Closed reduction
In-line traction relying on ligamentotaxis Exaggerate deformity (increase dorsal angulation to unlock volar cortex) Direct pressure on distal fragment to correct angulation

3 point casting

FRACTURE TYPES:
Colles Type: Dorsally displaced

FRACTURE TYPES:
Colles Type: Dorsally displaced
Use finger traps OR assistant for counter traction Traction Traction Traction When you think you have enough.more traction

FRACTURE TYPES:
Colles Type: Dorsally displaced

FRACTURE TYPES:
Colles Type: Dorsally displaced

FRACTURE TYPES: Extra-articular Stable

Post reduction xrays Careful evaluation of anatomy Careful patient instructions
Tight cast necessary

Close follow-up
Xrays and evaluation weekly for three weeks Argument about length of immobilization 4-6 weeks

FRACTURE TYPES: Extra-articular Unstable

Smiths #
reverse Colles # volar angulation/displacement of distal fragment FOOSH onto hyperflexed or supinated wrist Very unstable # Rxed with ORIF (volar plating)

FRACTURE TYPES: Extra-articular Unstable

Surgical Treatment Options
CR
Percutaneous k-wire fixation (+/- Kanpandji technique) Casting

External fixator
+/- k-wire fixation Careful attention to soft tissue/overdistraction

ORIF
Dorsal plating Volar fixed angle plating

Percutaneous Pinning
Good results in lower energy injuries At least 0.062 size Technique:
1 radial styloid pin (avoid first ext compartment) directed ulnarly 1 pin from dorsal-ulnar corner (b/w 4th and 5th ext compartments) directed volarly + radially Advance to penetrate cortex of radial shaft proximal to zone of metaphyseal comminution Augment prn

Apply plaster or fibreglass cast Remove pins at 4-6 weeks

Kapandji technique
intra-focal pinning Traps distal fragment by buttressing it from displacing Pin is placed thru the # site and maneuvered to elevate the fragment Once adequate reduction achieve, pin is driven thru opposite cortex to achieve stability Can restore radial inclination + volar tilt

External-Fixation
Can restore radial length and radial inclination, or if soft tissue problems Provides traction
Excessive traction associated with CRPS (look for increased intercarpal distance on fluorscopy)

Some loss of volar tilt

Supplement with percutaneous pinning

Associated with loss of ROM vs. ORIF Risk of pin site infections

External Fixation
Pin placement
2 pins on bare area of radius just proximal to 1st dorsal compartment outcroppers, b/w ECRB + ECRL Watch for superficial radial N 2 pins in second MC

ORIF
Dorsal vs Volar plating Locking vs non-locking plates

DORSAL PLATING
Excellent exposure to articular surface Avoids neurovascular structures Fixation on compression side of #, acts a buttress against collapse Early plate designs bulky Increased wrist stiffness and extensor tendon problems Smaller implants in evolution

DORSAL APPROACH
Between 3rd + 4th dorsal extensor compartments Do not violate ECRB subsheath Repair retinaculum

VOLAR PLATING
Early return of function Improved ROM No extensor tendon problems Easier reduction: less comminution volarly Fixed angle implants (locking)
Not reliant on distal screw purchase Supports subchondral plate Able to maintain # reduction in presence of dorsal comminution

VOLAR APPROACH
Interval b/w FCR + radial artery Palmar cutaneous branch of median N. at risk (b/w FCR and PL) Elevate pronator quadratus with intent to repair! Release of BR for exposure, partial or full

VOLAR PLATING
Early return of function Improved ROM No extensor tendon problems Easier reduction: less comminution volarly Fixed angle implants
Not reliant on distal screw purchase Supports subchondral plate

FRACTURE TYPES: Intra-articular fracture

CHAUFFEURS FRACTURE:
Avulsion # with extrinsic ligaments remaining attached to radial styloid Associated with backfiring of automobile crank starters Direct axial compression of scaphoid into radial styloid with wrist in dorsiflexion + ulnar deviation Associated injries
Scapholunate dissociation Perilunate dislocation

ORIF often necessary

FRACTURE TYPES: Intra-articular fracture

BARTONS FRACTURE:
shear # of dorsal or volar rim of distal radius, with associated subluxation of carpus Volar (reverse) type more common Principles of intraarticular fractures apply ORIF on side of fracture

FRACTURE TYPES: Bartons Fracture

Buttress plate, does not need to have fixation in fragment Indirect reduction of articular surface via volar approach Dorsal approach allows visualization of articular surface

FRACTURE TYPES: Intra-articular

Two part:
Die-punch Impaction from lunate, causes depression of lunate facet

Three part:
Scaphoid facet, lunate facet, sigmoid knotch

Four part:
Split in lunate facet

FRACTURE TYPES: Intra-articular

Can be very complex fracture patterns. Articular surface WILL NOT be visible via volar side Pre-op CT helps with planning

FRACTURE TYPES: Intra-articular

ORIF is standard of tx Maximum of 1-2 mm of gap, 1 mm of step Indirect reduction in volar approach Post-traumatic OA in inadequate reduction.

GOALS OF ORIF
Young, active
Articular step/ gap < 1mm Radial shortening < 2mm Neutral volar tilt Radial inclination >10

Elderly, sedentary
<10 dorsal tilt 2mm shortening Reduced RIA <2mm step

Arthroscopically-guided reduction
Arthroscope placed in dorsal 3,4 portal Probe inserted in dorsal 4,5 portal Radial styloid fragment stabilized with percutaneous K-wires

ULNAR STYLOID
Injured in 50-70% of cases Review papers have shown that presence/non-union does not affect long term outcome BASE OF STYLOID:
Associated with detachment of TFCC DRUJ instability Tension band wire/small fragment screw

COMPLICATIONS: Nerve Injuries

Median Nerve:
Initial sensory loss can be observed if not progressive Any progressive changes/unremitting pain
Immediate carpal tunnel release If concern about forearm compartments, fasciotomy

Nerve can be explored/released at time of OR if any concern Late median nerve symptoms associated with CRPS

COMPLICATIONS:
Tendon Adhesions/Ruptures
Casting must leave MCPs free for ROM Tenosynovitis can involve any dorsal compartment
Most common in first

EPL rupture
First 8 weeks Ischemic/mechanical mechanism EIP to EPL rupture unless discovered acutely

COMPLICATIONS: Malunions
Treatment depends on:
Patient demands Location of symptoms Nature of malunion

>15 degrees of dorsal angulation in young person:

Opening wedge dorsal osteotomy Requires significant planning to address multiplanar deformity (RIA, Tilt, Length)

COMPLICATIONS: Malunions
Ulnar sided impingment/pain:
Most common complaint from malunion Multiple options dependent on nayure of problem:
Ulnar shortening osteotomy Hemiresection arthroplasty for DRUJ malunion Many procedures described

Do we have evidence to justify our current practice?

Review of case lists of applicants of American Board of Orthopaedic Surgery from 1999-2000
Proportion of DR#s treated with Open treatment vs Closed percutaneous fixation increased from 42% in 1999 to 81% in 2007

Koval, JBJS 2008

Do we have evidence to justify our current practice?

Biomechanical
Dorsal plating (locked and not locked) stronger than volar in cadaveric study Clinical implications?

Trease, J of Hand Surg, 2005

Do we have evidence to justify our current practice?

RECENT PUBLICATIONS: Do we have evidence to justify our current practice?

New dorsal plates:
Universally good functional outcomes 23 % had plate removal for extensor tenosynovitis +/limitation in flexion Authors recommended plate removal

Khandjula, Acta Orthopeadica Scan, 2005

RECENT PUBLICATIONS: Do we have evidence to justify our current practice?

Volar locked plating:
Universally good functional outcomes All dorsally displaced fractures in the elderly 12 month follow-up No comparison arm

Wong, JOT, Aug 2005

THE END