distal radius fractures: science and · distal radius fractures: science and art thomas trumble,...

Distal Radius Fractures: Science and Art

Thomas Trumble, M.D.

Greetings from the Seattle

Comparing ORIF vs Closed Treatment

Intra-articular vs Extra-articular

Paradigm of Intra- versusExtra-articular Fractures

> 20 years with deformity from extra-articular fracture

without symptoms

Pain and degeneration only 14 months after unrecognized

intra-articular fracture

• Plain radiographs< 1.0 mm

Plains X-rays can Dx Fx Displacement

Accurate Diagnostic Imaging

Distal Radius Fractures

CT > radiograph accuracy: Cole JHS 1997

What is the most reliable fracture

classification

• Universal (Mayo)

• Frykman

• Melone

• A.O.

Classification B4 (Die Punch):

Die Punch fractures are added to the type B patterns

Classification B4 (Die Punch):

Results

Function Decreases if Incongruity > 1.0mm:



Classification C (Complex)

Disruption of articular surface

Plus disruption of metaphysis

Anatomy

22 mm

Indications for Surgery

Step or Gap > 1.0 mm

1.0 mm

1.0 mm K-wire

2.0 mm

JHS 1986

Biomechanical Effect of Congruity



> 1.0 step produces major load shift

What Type of Remodeling Occurs?

Intra-articular Fractures

The Effect of 1.0 mm Step OffTrumble et al, J Ortho Trauma 2002

Unloaded Area

Cartilage Remodeling

Unloaded side Hypertrophies

Loaded side Compresses


Remodeling the architecture of the Cartilage

100 micrometers

Overlapping Cartilage

Fracture Plane

Reduction in Extra-Articular Fractures?

• one cortex = pin

• two cortex = pin + Ext Fix

Can You Use Percutaneous Pinning for Intra-articular Fractures?

•> 6 mths Pain score not different

Are Plates Stronger Than Pins?

Are Plates Stronger Than Pins?

36 52 68 84 100

Force (N)

0

1

2

3

4

Ave

rage

Mov

emen

t (m

m)

FixationPins

Plate

Are Locking Screws Better than Pegs

Fracture Displacement with Extra-articular Fractures?

• one cortex = pin

• two cortex = pin + Ext Fix

Fracture Displacement with Extra-articular Fractures?

• 5 mm ulnar translate

• 10 mm radial shorten

What Causes Pain after Distal Radius Fractures?

• dorsal angulation ≥ 20°

• ulnar shortening ≥ 2.0 mm

Science and Art: Summary


• X-rays are sensitive but CT gives more detail

• Fracture Classification = KISS

• ORIF = ≤ 1.0 mm displace

• Plates > pins

• Locking screws > pegs

Science and Art: Summary

Extra-articular Fractures

• Pins are OK if only one cortex with comminution

• Ulnar translation (5 mm( and radial shortening (10 mm) cause loss of motion

• Ulnar wrist pain if ≥ 2 mm shorten or 20 °angulation

Results: Function

Author F/U Age Flex/Ext Rad/Ulnar

Grip

Catalano(21 Pts)

7.1 30 126°(86%)

33 (89%)

88%

Trumble

(43 Pts)

2.5 37 120°(80%)

40 (88%)

69%

Results: Radiographic/Subjective

Author OA % > 2mm Step/Gap

Satisfaction

Catalano(21 Pts)

76% 13/21 (62%) All good/

excellent

Trumble

(43 Pts)

12% 1/43 (2%) (85%) no pain

Kotsu for Distal Radius Fractures

Rigid Fixation

• Locking plates

• Anatomic plates

• Fracture nails


Rigid Fixation

• Locking plates

• Anatomic plates

• Fracture nails

Fixed angle of insertion


Rigid Fixation

• Locking plates

• Anatomic plates

• Fracture nails

15° Variable angle of insertion


Rigid Fixation

• Locking plates

• Anatomic plates

• Fracture nails

Locking bearings = completely variable angle of insertion

Locking Plates

Locking Plates

Locking Plates

Locking Plates

Dorsal Anatomic

Dorsal anatomic


Rigid Fixation

• Locking plates

• Anatomic plates

• Fracture nails

Micronail: Wright Medical

Arthroscopic Reduction and Internal Fixation (ARIF)

Set up

Arthroscopic Reduction and Internal Fixation (ARIF)

1. Stabilize Radial styloid

2. Reduce Lunate facet

Radial Styloid Fx

ARIF 3-Part Distal Radius Fracture

• Comminution Ext Fix + bone graft


Avoid External Fixation

Distal pin placement in Distal Radius Fractures

Retract 1st DI

• Protect RSN branches

•Retract 1st dorsal interosseous (DI)

External Fixation for Type C Fractures

• Use interval between ECRB and ECRL to protect RSN




Avoid External Fixation Problems



Shiubumi for Distal Radius Fractures


Shiubumi for Distal Radius Fractures



Avoid Painful Bone Graft Donor Sites

Bone Graft Substitutes

Goals?

• Provides mechanical filler

• Function as a grout to aid fixation

• Sets in 1-2 minutes not 15-20

• Absorbed as the fracture heals

• Inexpensive

• Injectable for minimally invasive procedures

Synthetic Grafts: CaPO4

•Nonresorbable

• Injectable

• Slow setting

• Expensive

Synthetic Grafts•CaPO4 ± K-wire

Synthetic Grafts• Extrusion into the Joint

Medical and Legal concerns

Grafts and Growth Factors

Thank you!

Kotsu = critical step for success or victory

Synthetic Grafts• CaPO4

CaPO4

Synthetic GraftsMore to read?

Complex Radius Malunion

• Stage I: debride osteomyelitis + IV antibiotics

• Stage I: ulnar shortening to relieve ulnar wrist pain

• Stage II: corrective osteotomy of radius if the patient still has clinical deformity and symptoms after osteomyelitis has resolved

Ulnar Shortening

Sequestrum

After Ulnar Shortening

6.0 mm shortening

After Ulnar Shortening

6.0 mm shortening

After Radius Osteotomy


6.0 mm Lengthening


Paradigm

Radius osteotomy provides more complete correction that ulnar shortening.

Volar Radius Malunions

• > clinical deformity per degree of malrotation

• Length is more difficult to assess because the dorsal rim is the landmark of AP x-rays

• A volar approach is required for corrections.


Dorsal Rim




A.O. C3 Radius Fracture



Thank you!

Cartilage Remodeling

Diagnostic Imaging

When to Order CT Scans?

• Complex fractures

• Volar rim fractures (die punch)

• Radial styloid (dorsal vs. volar)

Value of CT Imaging

Significant depression??


Perfection of anatomic reduction

• Knirk and Jupiter : > 1.0 mm = 90% DJD

• Fernandez and Geissler: ≤ 1.0 = 95% G&E results

• Trumble et al: ≤ 1.0 mm = increased grip strength and ROM

Thank You!

distal radius fractures: science and · distal radius fractures: science and art thomas trumble,...

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