VolarVolar fixedfixed--angle plating angle plating for distal radius fracturesfor distal radius fractures

刀圭会協立病院刀圭会協立病院

津村津村 敬敬

NNormal ormal didistal stal rradius adius aanatomynatomy

dorsal viewdorsal view ulnarulnar viewview radial viewradial view

endend--onon viewview

palmarpalmar viewview

Sigmoid notchSigmoid notch

ScaphoidScaphoid fossafossa LunateLunate fossafossa

ListerLister’’s tubercles tubercle

Radial Radial styloidstyloid processprocessVolarVolar liplip

ulnarulnar styloidstyloid processprocess

Radial Radial styloidstyloid processprocessEPLEPL

ECUECU

ListerLister’’s tubercles tubercle

Radiographic parameters of distal radiusRadiographic parameters of distal radius

Radial lengthfrom medial cortex of radius 1mmfrom tip of radial styloid process 12mm

Radial inclination ２３°

Volar tilt １１°

AO classificationAO classificationA extraA extra--articulararticular

B partial B partial articulararticular

C complete C complete articulararticular

A1 ulna fracture , radius intactA1 ulna fracture , radius intactA2 radius fracture , ulna intactA2 radius fracture , ulna intactA3 A3 multifragmentarymultifragmentary radius fracture radius fracture

B1 B1 sagittalsagittalB2 dorsal rimB2 dorsal rimB3 B3 volarvolar rimrim

C1 simple C1 simple articulararticular and and metaphysismetaphysisC2 simple C2 simple articulararticular , ,

metaphysealmetaphyseal multifragmentarymultifragmentaryC3 C3 multifragmentarymultifragmentary

J J OrthopOrthop Trauma , Vol.10 , Trauma , Vol.10 , SupplSuppl. 1.1996. 1.1996

FernandezFernandez’’ classificationclassificationconservative percutaneous pinningexternal fixation

Shearing ORIF

conservativepercutaneous pinningexternal fixationORIFarthoroscopic assisted

Avulsion pin or screw fixation(fracture dislocation) tension wiring

Combined combined method(high velocity injury)

CompressionCompression

BendingBending

Comparative Classification for Fractures of the Distal End of the Radius

Jesse B. Jupiter etc. The journal of Hand Surgery / vol 22A 1997

Prediction of instabilityPrediction of instability

Radial shorteningRadial shortening ≧≧5mm5mmDorsal tiltDorsal tilt ≧≧2020°°ComminutionComminution of of

the the metaphysealmetaphyseal regionregion ≧≧50%50%BicorticalBicortical comminutioncomminutionExtensive intraExtensive intra--articulararticular involvementinvolvementAssociated fracture of the ulnaAssociated fracture of the ulnaPoorPoor--bone qualitybone quality

(AO Principles of Fracture Management)(AO Principles of Fracture Management)

RadiologicRadiologic MeasurementsMeasurementsPredicting Poor Functional OutcomePredicting Poor Functional Outcome ArticularArticular step off or gap step off or gap >2>2ｍｍｍｍ Positive Positive ulnarulnar variance variance >3mm>3mm Dorsal tiltDorsal tilt >10>10°° VolarVolar tilttilt >15>15°° Carpal Carpal malalignmentmalalignment

（Orthopedic surgery essentials TRAUMA）

Limits of acceptable displacement Limits of acceptable displacement of fractured distal radiusof fractured distal radius

ArticularArticular step offstep off <2<2ｍｍｍｍRadial shorteningRadial shortening <<４４mmmmDorsal tiltDorsal tilt <<１５１５°° VolarVolar tilttilt <<２０２０°°Loss of normal radial inclinationLoss of normal radial inclination <<１０１０°°

（OKU Trauma 2）

External fixation and supplemental KExternal fixation and supplemental K--wireswiresDorsal platingDorsal platingVolarVolar fixedfixed--angle platingangle platingDouble plating Double plating (fragment(fragment--specific fixation)specific fixation)

Treatment of Treatment of unstable distal radius fracturesunstable distal radius fractures

VolarVolar fixedfixed--angle plating angle plating means....means....

Not depending on the buttress effect.Not depending on the buttress effect. Reducing dorsal fragments indirectly.Reducing dorsal fragments indirectly. Using a locking plate to support the Using a locking plate to support the subchondralsubchondral bone.bone.

fracture voidfracture void

fixedfixed--angle constructangle construct

volarvolar plating for distal radius fractures using locking platesplating for distal radius fractures using locking plates

dorsaldorsal

Advantages of Advantages of volarvolar fixedfixed--angle platingangle plating

Preserving the vascular supply Preserving the vascular supply of dorsally comminuted fragments.of dorsally comminuted fragments.

Reducing the need of bone grafting.Reducing the need of bone grafting.Fewer soft tissue and tendon problem.Fewer soft tissue and tendon problem.Providing rigid fixation Providing rigid fixation

that permit early rehabilitation program.that permit early rehabilitation program.Having an advantage Having an advantage

with fractures in with fractures in osteoporoticosteoporotic bone.bone.

Distal Radius Plate (Synthes)

Locking Distal Radius System 2.4 Locking Distal Radius System 2.4 ((SynthesSynthes))

ACUACU--LOC DISTAL RADIUS PLATE SYSTEMLOC DISTAL RADIUS PLATE SYSTEM(ACUMED)(ACUMED)

Indications for Indications for volarvolar fixedfixed--angle platingangle plating

palmarpalmar

Fractures involving displaced and rotated Fractures involving displaced and rotated volarvolar lunatelunate--facetfacetDefinitive indicationDefinitive indication

Dorsally displaced fractures with depressed dorsal Dorsally displaced fractures with depressed dorsal lunatelunate--facetfacetRelative indicationRelative indication

dorsaldorsal

Unstable extraUnstable extra--articulararticular fractures including fractures including osteoporoticosteoporotic boneboneVolarVolar Barton fracturesBarton fractures

Points of surgical technique Points of surgical technique in in volarvolar fixedfixed--angle platingangle plating

Subchondral support.Epiphyseal fixation first ,

Reduction second.(Lift maneuver)

清重 佳郎 ：橈骨遠位端骨折に対する掌側アプローチのよるcondylar stabilizing法

Surgical techniquesSurgical techniquesof of

volarvolar fixedfixed--angle plating angle plating

Henry ApproachHenry Approach

Expose fracture through Expose fracture through Henry approachHenry approachto diminish flexor adhesion.to diminish flexor adhesion.

Make surgical incisionMake surgical incisionbetweenbetween FCR and radial arteryFCR and radial artery..

Retract the Retract the flexor tendon flexor tendon ulnaryulnary.. Retract the Retract the radial artery radial artery radialyradialy.. Detach the Detach the pronatorpronator quadratusquadratus.. Open the carpal tunnelOpen the carpal tunnel

through the 2nd incision, if necessary.through the 2nd incision, if necessary.

Radial arteryFPL

incisionincision

Fracture model in the distal radius Fracture model in the distal radius

palmarpalmar viewview

ulnarulnar viewviewdorsaldorsal

palmarpalmar

ulnarulnarradialradial

EndEnd--on viewon view

Sigmoid notchSigmoid notch

styloidstyloid processprocess

Rotated Rotated volarvolar lunatelunate--facetfacet

FernaFernandez typendez typeⅢⅢ（（compression type)compression type)

AO 23AO 23--C3C3

Rotated Rotated volarvolar lunatelunate--facetfacet

Provisional reduction of Provisional reduction of intraintra--articulararticular fragmentsfragments

Reduce fracture with intrafocal manipulation. Provide temporary fracture fixation with K-wires

inserted through fracture line.

palmarpalmar viewview ulnarulnar viewview

KirschnerKirschner wireswires KirschnerKirschner wireswires

IntrafocalIntrafocal manipulation manipulation （（ⅠⅠ））

palmarpalmar

articulararticular incongruityincongruity

1.5 1.5 KirschnerKirschner wirewire

Fractures involving displaced and Fractures involving displaced and rotated rotated volarvolar lunatelunate--facetfacet

dorsaldorsal1.5 1.5 KirschnerKirschner wirewire

compressioncompression

articulararticular incongruityincongruity

Dorsally displaced fractures Dorsally displaced fractures with depressed dorsal with depressed dorsal lunatelunate--facetfacet

IntrafocalIntrafocal manipulation manipulation （（ⅡⅡ））

Reduction maneuverReduction maneuver of of intraintra--articulararticular fragmentsfragments（（ⅢⅢ））

The The extenedextened form of the FCR approachform of the FCR approach

Initial plate placement Initial plate placement

Apply plate to the Apply plate to the volarvolar aspect aspect of of articulararticular fragments. fragments.

Determine ideal plate position with fluoroscopy.Determine ideal plate position with fluoroscopy.The proximal portion of plate is lifted off the radiusThe proximal portion of plate is lifted off the radius

during initial plate placement.during initial plate placement.

lift off

temporary plate fixationtemporary plate fixation

deformity to be correcteddeformity to be corrected

the angle of the platethe angle of the platein relation to the long axis of the radius in relation to the long axis of the radius

To restore To restore volarvolar tilt to normal.....tilt to normal.....

AA

BB

A=BA=B

DrillingDrilling

Use facet lateral fluoroscopic view to control drilling.Use facet lateral fluoroscopic view to control drilling.Make holes in the Make holes in the subchondralsubchondral position.position.Lift Lift articulararticular fragments using drill bit fragments using drill bit

to reduce residual stepto reduce residual step--off deformity ,if necessary.off deformity ,if necessary.Avoid penetrating the dorsal cortex.Avoid penetrating the dorsal cortex.

Residual step offResidual step off

Facet lateralFacet lateralfluoroscopic viewfluoroscopic view

drill hole drill hole in in subchondralsubchondral positionposition

drilldrill

Distal pin insertionDistal pin insertion

Insert fixedInsert fixed--angle pins in angle pins in subchondralsubchondral position.position.

pins in pins in subchondralsubchondral positionposition

Final plate fixationFinal plate fixation

Advance the plate distally Advance the plate distally to correct radial shortening ,if necessary.to correct radial shortening ,if necessary.

Complete fixation of the plate to the shaft Complete fixation of the plate to the shaft with biwith bi--cortical screw , resulting in increased cortical screw , resulting in increased volarvolar tilt.tilt.

Assess the the stability of the DRUJ.Assess the the stability of the DRUJ.

palmarpalmar viewviewulnarulnar viewview

ComplicationsComplications

MalunionMalunionOsteoarthritisOsteoarthritisNonunionNonunionInfectionInfectionTendon ruptureTendon rupturePeritendinousPeritendinous adhesionsadhesionsPeripheral nerve compression and injuryPeripheral nerve compression and injuryCompartment syndromeCompartment syndromeComplex regional pain syndrome type1Complex regional pain syndrome type1

Postoperative carePostoperative careSplint the wrist in extended , postoperatively.Splint the wrist in extended , postoperatively.Instruct the patients Instruct the patients

to to begin active finger motion immediatelybegin active finger motion immediately..Begin Begin active wrist motionactive wrist motion

at 1 to 2 weeksat 1 to 2 weeks postoperatively.postoperatively.Begin Begin passive stretching of wristpassive stretching of wrist

at 3 to 4 weeksat 3 to 4 weeks postoperatively.postoperatively.Use a removable wrist splintUse a removable wrist splint

for 4 weeks postoperatively.for 4 weeks postoperatively.

Associated DRUJ lesionsAssociated DRUJ lesionsAssess the stability of the DRUJ Assess the stability of the DRUJ

, following fixation of the radius., following fixation of the radius.

Prediction of the instability of the DRUJPrediction of the instability of the DRUJshortening > 4shortening > 4ｍｍｍｍdorsal dorsal angulationangulation > 15> 15°°

Injury patternInjury patternosseous injuryosseous injury fxfx of the sigmoid notch and/or the of the sigmoid notch and/or the ulnarulnar styloidstyloid processprocess

ligamentousligamentous injuryinjury disruption of the TFCCdisruption of the TFCC

Effect of distal radius fracture malunion on wrist joint mechanics.Pogue DJ / The Journal of Hand Surgery / Vol.15A 1990

Managements of associated DRUJ lesionsManagements of associated DRUJ lesionsThe Fernandez classificationThe Fernandez classification

Type Type ⅠⅠstablestable

Type Type ⅡⅡunstableunstable

Type Type ⅢⅢpotentiallypotentiallyunstableunstable

A+BA+B early early pronationpronation--supinationsupination excercisesexcercises..

AA closed treatment.closed treatment.redusereduse subluxation,sugarsubluxation,sugar tong splinttong splintin 45in 45°°supination 4 to 6 weeks.supination 4 to 6 weeks.

A+B A+B operative treatment.operative treatment.

AA anatomic reduction. anatomic reduction. if residual if residual subluxationsubluxation tendency present tendency present immobilize as in type immobilize as in type ⅡⅡinjury.injury.

BB functional functional aftertreatmentaftertreatment to enhance to enhance remodellingremodelling of of ulnarulnar head.head.

Unstable DRUJ after fixation of radiusUnstable DRUJ after fixation of radius

Osseous injuryOsseous injury LigamentousLigamentous injuryinjury

SigmoidSigmoidnotchnotch

UlnarUlnar styloidstyloidprocessprocess

Base Base fracturefracture

Tip Tip fracturefracture

RepairRepairoror

Immobilization Immobilization in in supinationsupination for 4wfor 4w

Dose it reduce Dose it reduce in in supinationsupination??

Immobilization Immobilization in in supinationsupination for 4wfor 4w

ORIFORIF

YesYes NoNo

Current Concepts in the TreatmentCurrent Concepts in the Treatmentof Distal Radial Fracturesof Distal Radial Fractures

David S. David S. RuchRuch etc. /etc. /AAOS Instructional Course Lectures TraumaAAOS Instructional Course Lectures Trauma

67y/o female67y/o femaleRtRt distal radius distal radius fxfxFernandez typeFernandez typeⅢⅢAO 23AO 23--C3C3

ILLUSTRATIVE CASE 1ILLUSTRATIVE CASE 1RI 14°UV 2mm VT -2°

P/O P/O 17M

VT 7° VT 8°

RI 22°UV 2mm

RI 22°UV 1mm

ILLUSTRATIVE CASE 1ILLUSTRATIVE CASE 1

DF/PF DF/PF 85/8085/80

Supin/PronSupin/Pron 85/7085/70

Grip StrengthGrip Strength 20kg(18kg)20kg(18kg)

ILLUSTRATIVE CASE 2ILLUSTRATIVE CASE 2

83y/o male83y/o maleLt distal radius Lt distal radius fxfxFernandez typeFernandez typeⅠⅠAO 23AO 23--C3C3

RI 19°UV 2mm VT -24°

P/O P/O 6M

RI 20°UV 0mm

RI 20°UV 1mm

VT 1°VT 1°

DF/PF DF/PF 85/5585/55

Supin/PronSupin/Pron 90/6090/60

Grip StrengthGrip Strength 33kg(39kg)33kg(39kg)

ILLUSTRATIVE CASE 2ILLUSTRATIVE CASE 2

ILLUSTRATIVE CASE 3ILLUSTRATIVE CASE 3

67 67 y/oy/o femalefemaleRtRt distal radius distal radius fxfxFernandez type Fernandez type ⅠⅠAO 23AO 23--A3A3

2 weeks after cast 2 weeks after cast immobilizationimmobilization

RI 19°UV 2mm

RI 14°UV 3mm

VT -31° VT -29°

ILLUSTRATIVE CASE 3ILLUSTRATIVE CASE 3

RI 21°UV 0mm

VT 8°

ILLUSTRATIVE CASE ILLUSTRATIVE CASE ４４

８３８３ y/oy/o femalefemaleLt distal radius Lt distal radius fxfxFernandez typeFernandez typeⅠⅠOTA 23OTA 23--C2C2

VT 12°RI 25°UV 3mm

ILLUSTRATIVE CASE 6ILLUSTRATIVE CASE 6

RI 22°UV 0mm VT 10°

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