distal radius fractures- journal club
TRANSCRIPT
JOURNAL CLUB - 081216
DISTAL RADIUS FRACTURES-TREATMENT
Presentor- Dr REJUL K RAJ
CMCH LUDHIANA
OVERVIEW
bull Introduction
bull Anatomy
bull Applied anatomy
bull Classification
bull Management options
bull Journal Review
REFERENCES
bull ROCK WOOD AND GREENS
FRACTURES IN ADULTS ndash VIII th Edition
bull Campbellrsquos Operative Orthopaedics
XII th Edition
bull Indian Journal Of Orthopaedics
bull Pub Med
bull Cochrane Library
Name Place Time Discovery
PetitPouteau
France 18th Century fractures rather than dislocations
Colles Ireland 1814 ldquoOn the fracture of the carpal extremity of the radiusrdquo
Barton Philadelphia 1938 Concept of types
Dupuytren Paris 1841 ldquoLeccedilons Oralesrdquo
Malgaigne 1847 Intra and extra articular fractures
INVENTION OF X RAYS
Carl Beck New york 1901 8 types
Fredrick Cotton Dublin Metaphyseal communition
Champonniegraver Massage and early mobilization
ANESTHESIA AND ASEPSIS
Lambotte 1907 Percutaneous pinning
Ombredanne Parisian 1929 External fixation ndash non bridging
Roger AndersonGordon OrsquoNeill
Seattle 1944 Bridging external fixation
Raoul Hoffman Geneva 1940s External fixator with universal clamps
Jacques Vidal et al Ligamentotaxis
Ellis 1965 PlatingROCKWOOD AND GREEN VIII th Edition
ANATOMYbull 2 concave articular surfaces
ndash scaphoid
ndash lunate
bull volar and ulnar inclination
bull The palmar surfacendash relatively smooth
ndash which allows easy contouring of plates
bull The dorsal surface ndash convex
ndash irregular with Listerrsquos tubercle- EPL Tendon
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
OVERVIEW
bull Introduction
bull Anatomy
bull Applied anatomy
bull Classification
bull Management options
bull Journal Review
REFERENCES
bull ROCK WOOD AND GREENS
FRACTURES IN ADULTS ndash VIII th Edition
bull Campbellrsquos Operative Orthopaedics
XII th Edition
bull Indian Journal Of Orthopaedics
bull Pub Med
bull Cochrane Library
Name Place Time Discovery
PetitPouteau
France 18th Century fractures rather than dislocations
Colles Ireland 1814 ldquoOn the fracture of the carpal extremity of the radiusrdquo
Barton Philadelphia 1938 Concept of types
Dupuytren Paris 1841 ldquoLeccedilons Oralesrdquo
Malgaigne 1847 Intra and extra articular fractures
INVENTION OF X RAYS
Carl Beck New york 1901 8 types
Fredrick Cotton Dublin Metaphyseal communition
Champonniegraver Massage and early mobilization
ANESTHESIA AND ASEPSIS
Lambotte 1907 Percutaneous pinning
Ombredanne Parisian 1929 External fixation ndash non bridging
Roger AndersonGordon OrsquoNeill
Seattle 1944 Bridging external fixation
Raoul Hoffman Geneva 1940s External fixator with universal clamps
Jacques Vidal et al Ligamentotaxis
Ellis 1965 PlatingROCKWOOD AND GREEN VIII th Edition
ANATOMYbull 2 concave articular surfaces
ndash scaphoid
ndash lunate
bull volar and ulnar inclination
bull The palmar surfacendash relatively smooth
ndash which allows easy contouring of plates
bull The dorsal surface ndash convex
ndash irregular with Listerrsquos tubercle- EPL Tendon
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
REFERENCES
bull ROCK WOOD AND GREENS
FRACTURES IN ADULTS ndash VIII th Edition
bull Campbellrsquos Operative Orthopaedics
XII th Edition
bull Indian Journal Of Orthopaedics
bull Pub Med
bull Cochrane Library
Name Place Time Discovery
PetitPouteau
France 18th Century fractures rather than dislocations
Colles Ireland 1814 ldquoOn the fracture of the carpal extremity of the radiusrdquo
Barton Philadelphia 1938 Concept of types
Dupuytren Paris 1841 ldquoLeccedilons Oralesrdquo
Malgaigne 1847 Intra and extra articular fractures
INVENTION OF X RAYS
Carl Beck New york 1901 8 types
Fredrick Cotton Dublin Metaphyseal communition
Champonniegraver Massage and early mobilization
ANESTHESIA AND ASEPSIS
Lambotte 1907 Percutaneous pinning
Ombredanne Parisian 1929 External fixation ndash non bridging
Roger AndersonGordon OrsquoNeill
Seattle 1944 Bridging external fixation
Raoul Hoffman Geneva 1940s External fixator with universal clamps
Jacques Vidal et al Ligamentotaxis
Ellis 1965 PlatingROCKWOOD AND GREEN VIII th Edition
ANATOMYbull 2 concave articular surfaces
ndash scaphoid
ndash lunate
bull volar and ulnar inclination
bull The palmar surfacendash relatively smooth
ndash which allows easy contouring of plates
bull The dorsal surface ndash convex
ndash irregular with Listerrsquos tubercle- EPL Tendon
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Name Place Time Discovery
PetitPouteau
France 18th Century fractures rather than dislocations
Colles Ireland 1814 ldquoOn the fracture of the carpal extremity of the radiusrdquo
Barton Philadelphia 1938 Concept of types
Dupuytren Paris 1841 ldquoLeccedilons Oralesrdquo
Malgaigne 1847 Intra and extra articular fractures
INVENTION OF X RAYS
Carl Beck New york 1901 8 types
Fredrick Cotton Dublin Metaphyseal communition
Champonniegraver Massage and early mobilization
ANESTHESIA AND ASEPSIS
Lambotte 1907 Percutaneous pinning
Ombredanne Parisian 1929 External fixation ndash non bridging
Roger AndersonGordon OrsquoNeill
Seattle 1944 Bridging external fixation
Raoul Hoffman Geneva 1940s External fixator with universal clamps
Jacques Vidal et al Ligamentotaxis
Ellis 1965 PlatingROCKWOOD AND GREEN VIII th Edition
ANATOMYbull 2 concave articular surfaces
ndash scaphoid
ndash lunate
bull volar and ulnar inclination
bull The palmar surfacendash relatively smooth
ndash which allows easy contouring of plates
bull The dorsal surface ndash convex
ndash irregular with Listerrsquos tubercle- EPL Tendon
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
ANATOMYbull 2 concave articular surfaces
ndash scaphoid
ndash lunate
bull volar and ulnar inclination
bull The palmar surfacendash relatively smooth
ndash which allows easy contouring of plates
bull The dorsal surface ndash convex
ndash irregular with Listerrsquos tubercle- EPL Tendon
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
3 COLUMN CONCEPT
bull Jakob et al interpreted the wrist as consisting of three distinct columns
bull subjected to different forces and thus must be addressed as discrete elements
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
INTRODUCTION
bull Most common fracture ndash 175
bull F M = 3 1
bull Age and Gender specific distribution curves
bull Males ndash 40sFemales ndash 60s
bull Extra articular ndash 57 to 66
bull Metaphyseal comminution ndash 48
bull Low energy fractures
bull BMD ndash Risk Factor
Rockwood and Greenrsquos Fractures in Adults 8th edition
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
INJURY MECHANISMS
bull Fall on an outstretched hand
bull Dorsifexion ndash 40 to 90 degrees( Frykman )
bull Tensile forces at Volar cortex
bull Compression at dorsal cortex
Rockwood and Greenrsquos Fractures in Adults 8th edition
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
ASSOCIATED INJURIES
bull Interosseous ligaments of the carpus
bull Triangular fibrocartilage complex (TFCC)
ndash Clinically significant
bull EPL injuries
Rockwood and Greenrsquos Fractures in Adults 8th edition
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
SIGNS AND SYMPTOMSbull Pain + swelling ndash Wrist
bull Visible deformity
ndash Dinner fork
ndash Garden spade
bull Exclude median and ulnar nerve injury
bull Rule out open injuries
bull Rule out compartment
syndrome
Rockwood and Greenrsquos Fractures in Adults 8th edition
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
IMAGING
bull The standard series of
ndash posteroanterior (PA)
ndash lateral
ndash Oblique
bull CT ndash 3 D reconstruction
ndash Intrarticular
Rockwood and Greenrsquos Fractures in Adults 8th edition
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
nclination
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull Mishra PK Nagar M Gaur SC Gupta A Morphometry of distal end radius in the Indian populationA radiological study Indian J Orthop 201650610-5
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
MANAGEMENT
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
TIME LINE OF TREATMENTMETHODS YEAR
Nonoperatively until 1929
Pins and plaster 1929
External skeletal fixation 1944
AO group designed plates 1970s
Agee introduced the Wrist Jack multiplanarligamentotaxis
1994
HARNESS N G MEALS R A The history of fracture fixationof the hand and wristClin Orthop 445 19ndash29 2006
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
AUTHOR YEAR RESULTS
Abraham Colles 1814 fractures tended to do well despite considerableDeformityldquo will at some remote period again enjoy perfect freedom in all of its motions and be
completely exempt from painrdquo
Cassebaum 1950 Supported Colles
McQueen andCaspers
19c8 Demonstrated Clear Correlation betweenmalunion and poor functional outcomes
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
TREATMENT OPTIONS
1 Cast Immobilization
2 Percutaneous Pin Fixation
3 External Fixation
4 Arthroscopicaly Assisted Fixation
5 Open Reduction Internal Fixation
6 Fragment Specific Internal Fixation
7 Intramedullary Fixation
8 Bioabsorbable Implants
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
ROCKWOOD AND GREENS VIII th Edition
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
ROCKWOOD AND GREENS VIIIth Edition
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
An unstable distal radius fracture
bull Distal radius fracture current concepts and management F Leung K Kwan C Fang 2013 The British Editorial Society of Bone and Joint Surgery
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
1 CAST IMMOBILIZATION
Indications
ndash Undisplaced fractures
ndash Well reduced stable fractures
ndash Old age low functional demand
Pitfalls
ndash Cumbersome
ndash Adjacent joint stiffness
ndash Loss of reduction
ndash Median nerve neuropathies
ndash Cast impingement and compartment syndrome
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
FERNANDEZ Et al
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
2 PERCUTANEOUS PIN FIXATION
bull Indications
ndash Reducible extraarticular fractures
ndash simple intraarticular fractures that are nondisplacedwith good bone quality
bull Pitfalls
ndash Additional casting or external fixator often needed
ndash Pin-tract infections
ndash Tendon and superficial radial nerve impalement
ndash Loss of reduction
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull Multiple different techniques
ndash pins placed through the radial styloid
ndash two or three crossed pins
ndash across the fracture site or
ndash intrafocal pinning within the fracture site
ndash Transfixation wires across the distal radioulnarjoint
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
KAPANDJI Double Intrafocal Pinningbull Indication
ndash Noncomminuted extraarticular injuries
bull Techniquendash Kirschner wire into the fracture site in a radialndashtondashulnar direction
ndash When the wire reaches the ulnar cortex the wire is usedto elevate the radial fragment and recreate the radial inclination
ndash This wire is then driven through the ulnar cortex for stability
ndash A second wire is introduced 90 degrees to the first in a similar manner to restore volar tilt
KAPANDJI A I Treatment of nonndasharticular distal radial fractures by intrafocal pinning with arum pins In SAFFER PCOONEY W P (eds) Fractures of the distal radius Philadelphia JB Lippincott 1995 71ndash83
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
3 EXTERNAL FIXATION
bull Indications
ndash 1 Comminuted intra-articular
ndash 2 Unstable extra-articular
ndash 3 Open fractures
ndash 4 Infected fractures
bull Ligamentotaxis
ndash Maintain fracture reduction
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
EXTERNAL FIXATION
bull Complications
ndash stiffness
ndash pin tract infections
ndash pin loosening
ndash radial sensory Loss
ndash nerve injury
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull J Bone Joint Surg [Br] 199880-B665-9
bull A randomised prospective study
bull 60 patients with unstable fractures of the distal radius
bull compare bridging with non-bridging external fixation
bull The radiological results showed significant improvement in the non-bridging group
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
4 ARTHROSCOPICALY ASSISTED FIXATION
bull Minimally invasive way of monitoring closed reduction with percutaneous pin fixation
bull Advantagesndash assessment of the articular joint surfacendash interosseous carpal ligament or TFCC injuryndash excision of osteochondral flaps and loose bodies
bull Disadvantages ndash the steep learning curvendash few studies that demonstrate improved functional
outcomes
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
DOI K HATTORI Y OTSUKA K ABE Y YAMAMOTOH Intrandasharticular fractures of the distal aspects of the radius arthroscopically
assisted reduction compared with open reduction and internal fixation J Bone Jt Surg 81ndashA 1093ndash1110 1999
bull randomized prospective study
bull 34 patients
bull 30 month average followndashup -good or excellent results
bull 82 Better ROM and grip strength improved radiographic
bull Concluded that arthroscopically assisted fixation of distal radius fractures is an effective technique in patients less than 70 years of age with intraarticular injuries
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
5 OPEN REDUCTION INTERNAL FIXATION DORSAL AND VOLAR
bull Indications
ndash Unstable fractures
ndash Intra-articular fractures
ndash Fractures irreducible by closed means
ndash Delayed fixation
ndash Preference for earlier mobilisation
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull Advantages
ndash Direct restoration of anatomy
ndash Stable internal fixation
ndash decreased period of immobilization
ndash Earlier return of wrist function
bull Pitfalls
ndash Unsightly scar
ndash Tendon rupture (flexor or extensor)
ndash Some patients may require implant removal
ndash Implant cost
ndash Technically more difficult
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Advantages of a volar plating
1 simpler to reduce because the volar cortex is usually disrupted by a simple transverse line
2 frestoration of radial length radial inclination and volar tilt
3 preserve the vascular supply to the dorsal fragments
4 Implant is separated from the flexor tendons by the pronator quadratus
5 shortening and secondary displacement
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Disadvantages of Dorsal plates
bull Need for mobilization of extensor tendons to achieve proper plate placement
bull Tendon irritation or rupture
bull Additional surgery
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Dorsal vs volar platingRUCH D S PAPADONIKOLAKIS A Volar versus dorsal platingin the management of
intrandasharticular distal radius fracturesJ Hand Surg Amer 31 9ndash16 2006
bull Retrospective review of 34 patients
bull 20 dorsal plating and 14 volar plating
bull RESULTS
ndash functional outcome was better in the volar plating group
ndash higher rate of volar collapse and late complications in the dorsal plating group
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
6 REDUCTION INTERNAL FIXATIONFRAGMENT SPECIFIC
(1) Application of small contoured plates
(2) Strong bone proximally
(3) Gliding motion of tendons
(4) The exposure cause minimal soft tissue disruption
(5) Allow early range of motion
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
DISTRACTION PLATE INTERNAL FIXATION
bull As an alternative to external fixation
bull Highly comminuted fractures of the distal radius
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
7 INTRAMEDULLARY FIXATION
bull Intramedullary devices ndash Advantages
ndash Increase fracture stability
ndash Allow load transfer across the fracture site
ndash Minimize soft tissue problems by minimizing scarring and adhesions
ndash Maintain vascular blood supply to promote fracture healing
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
INTRAMEDULLARY FIXATION
bull Two implants
1 Micronail
2 Dorsal Nail Plate
bull Both are used for metaphyseal distal radius fractures
bull Incision made over the radial styloid
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
INTRAMEDULLARY FIXATION
bull Difficulties
ndash possible soft tissue irritation of the interlocking screws
ndash possible screw penetration into the distal radioulnar joint
ndash difficulty observing sagittal alignment secondary to use of the jig
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
8 BIOABSORBABLE IMPLANTS
bull Polylactic acid or polyglycolic acid
bull at least two years to degrade completely within the body
bull contourable after placing in a hot water bath
bull The advantagesndash No need for hardware removal in the future
ndash do not incite an inflammatory response
ndash MRI compatible
bull Valid concerns ndash initial fixation strength
ndash slightly thicker than metal counterparts
ndash cannot visualize the
ndash implants on radiographs
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Late Foreign-Body Reaction After Treatment of Distal Radial Fractures with Poly-L-Lactic Acid Bioabsorbable Implants A Report of Three CasesChih-Yu Chen et alJ Bone Joint Surg Am 2010 Nov 17 92 (16) 2719 -2724
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
AUTHORS RESULTS INTERPRETATION
KNIRK J L JUPITER J B Intrandasharticular fractures of the distal end of the radius in young adultsJ Bone Jt Surg 68ndashA
647ndash659 198621
Absence of joint stepoff=arthrosis in 11
Stepoffs of 2 mm or greater=91
Articular incongruity predisposeddegenerative jointdisease
CATALANO Lresults in young adults after open reduction and internalfixation J Bone Jt Surg 79ndashA 1290ndash1302 1997
strong association betweenintraarticular stepoff and degenerative joint disease
Found that all patients presented with good or excellent outcomes an average of 7 years
GOLDFARB C A RUDZKI J R CATALANO L WHUGHES M BORRELLI J Jr Fifteenndashyear outcome of displacedintrandasharticular fractures of the distal radius J Hand SurgAmer 31 633ndash639 2006
patients continued to function at high levels that strength and range of motion measurementswere unchanged and that the joint space wasreduced an additional 67
No correlation was noted between thepresence or degree of arthrosis and upper extremityfunction as measured by DASH scores and the Gartlandand Werley criteria
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull 581 patients 133 patients were operated
bull The subjective outcome was measured by DASH
RESULTS
bull Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull There is no robust evidence at present to suggest that any treatment method is superior to any other in the Cochrane metaanalysis reports either for different types of
ndash Conservative treatment (Handoll and Madhok 2003a)
ndash or for surgical treatment (Handoll and Madhok2003b)
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
REVIEWS
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Prediction of Instability in Distal Radial Fractures
bull J Bone Joint Surg Am 2006 Sep 88 (9) 1944 -1951
bull PJ Mackenney MM McQueen
bull Level of Evidence Prognostic Level I
bull Methods
bull Data on approximately 4000 distal radial fractures were prospectively recorded over a 55-year period
bull Outcome measures consisted ndash radiographic measurements made at one week and six weeks and
ndash assessment of carpal alignment at six weeks
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Results
Most consistent predictors of radiographic outcome
1 Patient age
2 Metaphyseal comminution
3 Ulnar variance
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
A Meta-Analysis of Outcomes of External Fixation Versus Plate Osteosynthesis for
Unstable Distal Radius Fractures
bull The Journal of Hand Surgery
bull Volume 30 Issue 6 November 2005 Pages 1185e1ndash1185
bull Zvi Margaliot MD Steven C Haase MD Sandra V Kotsis MPH H Myra Kim ScD Kevin C Chung MD
bull 46 articlesndash 28 (917 patients) external fixation studies(603 patients) internal fixation
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Conclusions
bull No evidence to support the use of internal fixation over external fixation for unstable distal radius fractures
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Is Early Internal Fixation Preferred To Cast Treatment For Well-reduced Unstable Distal Radial Fractures
bull J Bone Joint Surg 200991A2086-2093
bull Koenig KM Davis GC Grove MR Tosteson ANA KovalKJ
bull Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature making early internal fixation the preferred treatment in most cases
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Safety and Efficacy of Operative Versus NonsurgicalManagement of Distal Radius Fractures in Elderly Patients
A Systematic Review and Meta-analysis
bull J Hand Surg Am 2016 Mar41(3)
bull Chen Y1 Chen X2 Li Z2 Yan H2 Zhou F2 Gao W2
bull Division of Plastic and Hand Surgery Department of Orthopedics Wenzhou Medical University Wenzhou China
bull TYPE OF STUDYLEVEL OF EVIDENCE Therapeutic III
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull 60 years and older
bull Two randomized controlled trials and 6 retrospective studies
RESULTS
bull Meta-analysis did not detect statistically significant differences in pooled data for pain level functional assessment and wrist ROM
bull Grip strength was significantly greater in the operative group
bull Radiographic outcomes -significantly better in the operated
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Factors associated with one-year outcome after distal radial fracture treatment
bull Journal of Orthopaedic Surgery 201523(1)24-8
bull Cowie J Anakwe R McQueen M
bull Edinburgh Orthopaedic Trauma Unit Edinburgh United Kingdom
bull PURPOSE To identify factors that affect functional outcome one year after distal radial fracture treatment
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
bull METHODS
bull 521 women and 121 men aged 16 to 92 (mean 59)ndash external fixation (n=123)
ndash open reduction and internal fixation (n=63)
ndash a combination of both (n=10)
ndash Distal radial osteotomy for symptomatic malunion (n=90) or
ndash Casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia
bull The indication for surgery (rather than casting) was metaphysealinstability
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
RESULTS
bull Poorer functional score was associated withndash increasing age ndash dorsal angulation after healing ndash presence of volar comminutionndash pain
bull Poorer grip strength was associated withndash non-dominant side injury ndash increasing age ndash dorsal angulation after healing ndash positive ulnar variance ndash comminution and ndash pain
bull Predicted malunion showed colinearity with ndash age ndash dorsal comminutionndash dorsal angulation
bull CONCLUSIONUnderstanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
The effect of fracture-related factors on the functional outcome at 1 year in distal radius
fracturesbull Injury
bull Volume 33 Issue 6 July 2002 Pages 499ndash502
bull Sumit Batra Ajay Gupta
bull Department of Orthopaedics Maulana Azad Medical College and Associated Lok Nayak Hospital New Delhi
bull Sixty-nine cases of distal radius fracture were studied retrospectively for various factors that might affect the functional outcome
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
RESULTS
bull The most important factor affecting the functional outcome was
ndash Radial length
ndash followed by Volar tilt
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Assessing Results After Distal Radius Fracture Treatment - A Comparison of Objective and Subjective Tools
bull Geriatr Orthop Surg Rehabil 2011 Jul 2(4) 155ndash160
bull Iris H Y Kwok Frankie Leung Grace Yuen
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
Conclusion
bull Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome
THANK YOU
THANK YOU
