Fractures of distal radius

By Dr. UPENDER SATELLI

PG IN MS (ORTHO)GANDHI MEDICAL COLLEGE

Anatomy

3 concave articular facets-scaphoid fossa-lunate fossa-sigmoid notch

• axial load-80% radius -20% TFCC

LIGAMENTOUS ANATOMY

BONY ANATOMY

BONY ANATOMY

epidemiology

• Incidence; most common upper extremity # account for 17% in emergency room

• Age– Bimodal age– Peaks at ages 5-14 years and at ages 60-69 years.– Elderly patients extra-articular, metaphyseal– Young patients intra-articular fractures with joint surface

displacement.

• Gender– older postmenopausal women, female-to-male ratio 4:1

adolescent boys and girls, the ratio is 3:1

Fracture patterns and age

• Salter harris type 1&2 more common

Mechanism of injury

Low energy trauma: fall on outstretched handIn young adult, high energy trauma

comminuted, intraarticular injuries

Diagnosis

• History of trauma • Clinical examination look for other injury injury should be evaluated for:-• open/closed• degree of soft tissue injury• neurovascular injury- median nerve injury

common• Tendon injury• Imaging Wrist PA, Lat, and oblique CTscan-intrarticular

PA view

lateralview

ANCILLARY IMAGING TECNIQUES• ARTHROGRAPHY

• ARTERIOGRAPHY

• Radionuclide imaging bonescan,scintigraphy

• CT

• MRI

• Radiocarpal articulation• Tear of TFCC

• Vascular injuries

• Subtle fractures

• Fracture healing and complications

• Tear of TFCC• Tendon ligament injuries• Subtle fractures• Injury to interosseous membrane

Ulnar/hulten variance

• PA view - anatomic variations in the length of the radius and the ulna, known as

• As a rule, the radial styloid process exceeds the length of the articular end of the ulna by 9 to 12 mm

• At the site of articulation with the lunate, the articular surfaces of the radius and the ulna are on the same level, yielding neutral ulnarvarince

• ulna projects more proximally—negative ulnar variance (or ulna minus variant); or more distally—positive ulnar variance (or ulna plus variant)

Positive ulnar variance

• Negative ulnar variance

• used for measuring radial inclination, radial• height, and ulnar variance to reduce variation caused by• excess dorsal or volar angulation of the distal fragment

SIGNIFICANCE

1.direction of carpal instability2.Altered in axial loading injuries articular incongruity3.depression in the teardrop angle representssignificant residual dorsiflexion of the volarrim fragment and frequently is the only evidencethat reduction is incomplete and articular incongruity

TEAR DROP Represents the volar ulnar cornerangle between a line along the shaft of Radius and a line drawn along the apex of the tear drop

Normal parameters

• Radial inclination = 23°• Radial length = 12mm• Palmar tilt = 10°• Scapholunate angle = 60° +/- 15°

ASSESSMENT OF X RAYS• Assess involvement of dorsal or volar rim• Look for “die-punch” lesions of the scaphoid

or lunate fossa.• Assess amount of shortening• Look for DRUJ involvement

Distal radius fracture characteristics

• Location 1.extraarticular 2.intraarticular a)radiocarpal b)distalradioulnar c)combined

configuration

• Simple Transverse oblique • Comminuted Dorsal cortex Palmar cortex Dorsal and palmar cortices Intraarticular Number of major pieces

displacements

• Undisplaced• Displaced (direction)• Axial shortening • Radial inclination• Radial/ulnar displacement • Dorsal inclincation• Dorsal/palmar displacement• Rotation Pronation Supination,

ULNAR STYLOID

Intact Fractured Level Tip Middle Base Displacement Undisplaced Displaced

DISTAL RADIOULNAR JOINT

Stable Unstable Dorsal Palmar Dislocated Dorsal Palmar

four reliable radiographic signs of injury to the DRUJ

1. Fracture of the base of the ulnar styloid. 2. AP view: Widening of the distal radial ulnar joint space. 3. Lateral view: Dislocation of the distal radius relative to the ulna. 4. Shortening of the radius by >5 mm.2

2

Bone mineralisation

• Normal• Osteoporotic• other

INDICATORS OF INSTABILITY

• GREATER THAN 1mm articular stepoff

• >10 degrees of dorsal tilt <15 degrees of radial inclination• Loss of radial height > 5mm• Communition of one cortex

across midaxial line of lateral xray

• Communition of both dorsal palmar cortices

• Irreducible fracture• Loss of reduction

Associated injuries

• Tissue Laceration• Crush or Loss Skin • Muscle • Tendon• Nerve • Artery • Ligament, TFCC Dislocation& Fracture ofCarpalbones

classification

• Ideal system should describe:–Type of injury–Severity–Evaluation–Treatment–Prognosis

Eponyms

Colles

Classification of Fernandez,

• Type 1 One cortex of the metaphysis fails due to tensile stress (Colles and Smith fractures) an the opposite undergoes a certain degree of comminution Shearing:

• Type 2 Fracture of the joint surface - Barton's, reversed Barton's, styloid process fractures, simple articular fracture Compression:

• Type 3 Fracture of the surface of the joint with impaction of subchondral and metaphyseal bone (die-punch fracture), intraarticular comminuted fracture Avulsion:

• Type 4 Fracture of the ligament attachments ulnar and radial styloid process, radiocarpal fracture dislocation Combinations

• : Type 5 Combination of types, high velocity injuries

FERNANDEZ

Classification of Cooney, Universal Classification of Distal Radius

• Type 1 Articular Un-displaced,• Type 2 Non articular* Reducible ** Reducible

* Irreducible DisplacedStableUnstable,• Type 3 Articular Non-displaced• , Type 4 Non articular* Reducible ** Reducible

* Irreducible Displaced StableUnstable * (by ligamentotaxis only)

Gartland & Werley

• Group I: Simple Colles' fracture with no involvement of the radial articular surfaces

• Group II: Comminuted Colles' fractures with intra-articular extension without displacement

• Group III: Comminuted Colles' fractures with intra-articular extension with displacement

• Group IV: Extra-articular, undisplaced

frykman

• Extraarti cularRadiocarpalJointRadioulnar jointBoth joints

Same pattern as right, except ulnar styloid also fractured

melone

melone• Type I: Stable fracture without displacement. This pattern has

characteristic fragments of the radial styloid and a palmar and dorsal lunate facet.

• Type II: Unstable “die punch” with displacement of the characteristic fragments and comminution of the anterior and posterior cortices– Type IIA: Reducible– Type IIB: Irreducible (central impaction fracture)

• Type III: “Spike” fracture. Unstable. Displacement of the articular surface and also of the proximal spike of the radius

• Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation of the distal and palmar fragments

• Type V: Explosion injury

AO

• Group A Extraarticular

• Group BPartially intraarticular

• Group C Completely

intrarticular

MEDOFF/FRAGMENT SPECIFIC

RAYHACK

Chauffeur”s /Hutchinson #shear,torsion injury

•Involves the lateral margin of the distal radius, extending through the radial styloid process into the radiocarpal articulation .•Best seen in PA view

Colles fracture

• Most frequently encountered injury to the distal forearm.

• Fall on the outstretched hand with forearm pronated in dorsiflexion.

• Age usually above 50y; F>M.• Extraarticular 2-3 cm away

from articular surface of radius.

• Associated # of ulnar styloid process

Smith #

• Fracture of the distal radius with volar displacement and angulation of the distal fragment

• Results from a fall on the back of the hand or a direct blow to the dorsum of the hand.

• Often referred to as a reverse Colles fracture.

Bartons #

• The fracture line is intra-articular and runs obliquely as compared to the transverse fracture seen in Smith’s type.

• • Originally described as two types: dorsal and volar Barton’s,

• Today the label of ‘Barton’s fracture’ tends to be reserved for a fracture i nvolving the volar distal radius with subluxation of the wrist and distalradio-ulnar joint.

• high-velocity impact injuries.• AP and lateral views . • Carpal displacement best seen on lateral view

bartons • when it involves the volar aspect of

distal radius

• Fractureof dorsal margin of the distal radius extending into the radiocarpal articulation.

Reverse Barton”s

Neurovascular injury carpaltunnelsyndrome, compartmentsyndrome, complex regional pain syndrome, infectionMalunionDelayed union & non unionStiffnessoftheshoulderSuddeck’s atrophyTendon rupture

COMPLICATIONS

COMPLICATIONS Neurovascular injury

carpaltunnelsyndrome, compartmentsyndrome, complex regional pain syndrome,

• infection• Malunion• Delayed union & • non union• Stiffnessoftheshoulder• Suddeck’s atrophy• Tendon rupture

Complications treatment related

• Hardware –tendon &joint• Dorsal plate-rupture of extensors EPL

adhesions,irritation attrition,wrist stiffness • to avoid subcutaniousEPL Transposition to

radial side of the wrist is done • Volarplate-flexor tendons rare• SCREWS- tendon, joint injury• External fixation – pin tract infection

Treatment Goals

pain free, mobile and stable wrist. Anatomical reduction should be the goal Howard,1989. Avoid complications

Treatment options

• Closed reduction and immobilization with cast• Closed reduction and Percutaneous pinning• External fixation spanning/nonspanning• Arthroscopically assisted reduction and Ex.

Fixation of intraarticular fracture.• ORIF with plate fixation dorsal /volar• Bone grafting

Indications for closed treatment

• Low-energy fracture

• Low-demand patient

• Non-dominant hand

• Medical co-morbidities

Closed treatment

• Depends on obtaining and then maintaining an acceptable reduction.

• Usually achieved with a short-arm cast• Frequent follow-up necessary in order to diagnose

redisplacement.• The aim of conservative treatment are to obtain and

maintain anatomic realignment of the fracture for a period of 4 weeks, the time at which bony union is well advanced, so that the risk for secondary displacement at that stage ispractically nonexistent.

Technique of Closed Reduction• Anesthesia

– Hematoma block– Intravenous sedation– Bier block

• Reduction Maneuver (dorsally angulated fracture): – hyperextension of the distal

fragment, – apply traction and reduce the

distal to the proximal fragment with pressure applied to the distal radius.

• Apply well-molded “sugar-tong” splint /shortarm cast, with wrist in neutral to slight flexion.

• Avoid Extreme Positions!

a/e cast dorsiflexion mid supination

The Kapandji Technique:

A pin is inserted into the fracture site, manipulated to elevate the fragment distally (B), and then driven into the opposite cortex (C). The fragments are thus trapped and prevented from dorsal displacement.

After-treatment

• Watch for median nerve symptoms (may need carpal tunnel release if symptoms are not relieved by removal of splint).stiffness of digits, elbow, shoulder

• Follow-up x-rays needed in 1-2 weeks to evaluate reduction.

• Change to short-arm cast after 2-3 weeks, continue until fracture healing.

INDICATIONS for SURGERY

• Comminuted displaced intra-articular fracture

• Open fractures

• Associated carpal fractures

• Associated neurovascular injury/tendon injury• Failed conservative treatment

• Bilateral fractures

• Impaired contralateral extremity

Selection of Approach

• Based on location of comminution.• Dorsal approach for dorsally angulated

fractures.• Volar approach for volar rim fractures.• Combined approaches needed for high-energy

fractures with significant axial impaction.

Surgical approaches

Volar approach Dorsal approach

BARTONS

• Ellis technique

ALGORITHM

• -cast immobilisation

• -cast immobilisation-percutaneous pins-ORIF/ex fix

• -cast immobilisation/ percutaneous pins

• I. Nonarticular/ undisplaced

• II Nonarticular/ displaced A.reducible/stable B.reducible/unstable C.Irreducible/stable

• IIIArticular/ undisplaced

• IV Articular,displacedA.reducible,stable

B.reducible,unstable

C.irreducible

D.complex

• -closed reduction & K wires-A/A +/- ex fix

-ORIF or ex fix & K wires-ORIF/ex fix & wires+ bone graft

Factors affecting the functional outcome

• Accurate reduction of the articular surface was the most critical factor

• Intracarpal lesions like TFCC tear,interosseous ligament tear

• Incongruity of DRUJ• Unstable fractures

Suave-Kapandji reconstruction of the distal radioulnar joint.

WEDGE STEOTOMY OF DISTAL RADIUS IN MALUNION

SO MANY OPTIONS BUT CONTROVERSY LACK OF EVIDENCE

Take home message

• operative intervention needs to be customized to the patient and the fracture as well as the expertise of the surgeon

• the restoration of normal anatomy is more important than the technique that is used

• The perception that internal fixation allows immediate range of motion, and therefore an improved functional arc of motion at the end of treatment, has been questioned. Immediate motion may not change the outcome as much as the other factors associated with patient demographics and fracture reduction

Thank u