09.20-09.35_dr.dr.Heri Suroto_when to Operate

WHEN TO OPERATE AND HOW ON AN EXTRA ARTICULAR DISTAL RADIAL FRACTURE

Heri Suroto. MD.PhD.Orthopaedic & Traumatologic surgeon

Consultant of Hand & MicrosurgeryDr. Soetomo Hospital/ School of Medicine – Airlangga University

a 78-year-old woman showing a distal radius fracture with extension, radial shortening, dorsal comminution.Initial postreduction x-ray of the fracture showing correction of radial shortening, extension, and articular step-off deformities

Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg 2004;29A:1128–1138

Four-week x-ray of the patient showing loss of reduction for an unacceptable radiographic result

• At 4 weeks after reduction 46% of these unstable distal radius fractures maintained an adequate reduction.

• Of the 54% of fractures that failed to maintain an adequate reduction.

• Age was the only statistically significant predictor of secondary displacement.

Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg 2004;29A:1128–1138

Mr. Y. 35 y o man with Distal Radius Fracture

Initial X-ray 8 w post reduction 3 m post reductionInitial Postreduction

Despite the frequency of distal radius fractures, the optimal treatment remains without consensus opinion.

What should we do with this kind of distal radial fracture?

( Operative vs Nonoperative )



( Operative vs Nonoperative )

There is no Level-I clinical evidence suggesting a superior modality for treatment of distal radial fractures

Neal C. Chen and Jesse B. Jupiter. J Bone Joint Surg Am. 2007;89:2051-62



If we do surgery, what kind of fixation?

- Percutaneous pinning- External Fixation- Plating- Locking Plate

Closed reduction and external fixation

Presentation outline

1. Anatomic and biomechanic of distal radius

2. Diagnostic establishment of distal radial fracture

3. Nonoperative treatment of distal radial fracture

4. Operative treatment of distal radial fracture






Osseous Anatomy

• Distal radius – 80% of axial load– Scaphoid fossa– Lunate fossa– Sigmoid notch – DRUJ

• Distal ulna

Anatomic and biomechanic of distal radius

Three Collumn Concept

The functions of radial collumn as an osseous buttress for the carpus radially and serves as the origin of important intracarpal stabilizing ligaments.

The intermediate column is the important area for load transmission from the lunate to the radius through the lunate fossa.

The ulnar column serves as an axis for forearm and wrist rotation as well as for secondary load transmission.

Anatomy • scaphoid and lunate

fossa– Ridge normally exists

between these two• sigmoid notch: second

important articular surface

• triangular fibrocartilage complex(TFCC): distal edge of radius to base of ulnar styloid

The Volar extension of the lunate facet.

• The arrow delineates the length of the lunate facet on this lateral view of the distal part of the radius.

• The lunate facet has a considerable volar extension at the distal extent of the pronator quadratus and subsequently has an important role in fracture pathomechanics and stability.

Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg [Am]. 2006;31:892-5.)

• Orbay and Touhami (2006) defined the Watershed line as a transverse ridge bordering the pronator fossa distally.

- The watershed line is a useful surgical landmark for positioning a volar plate.- Implant placed on or distal to it can impinge on flexor tendon and cause injury

• TFCC major stabiliser of ulnar carpus & radioulnar joint

• normal wrist movement -150 degree of motion (flex/ext)

• -50 deg radial/ulnar deviation-150 deg pron/sup

• axial load-80% radius -20% TFCC

Mechanism Of Injury

Low energy trauma: In young adult, injury usually is as result of high

energy trauma & results in comminuted, intraarticular injuries

Tension on the volar cortex, comminution of the dorsal cortex, and ligamentous injury

A greater understanding of the patterns of injury is leading to treatment based on the specifics of each individual injury.

Computed tomography scans demonstrating hyperextension injury to the distal part of the radius.

Pechlaner S, et al. Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism. Handchir Mikrochir Plast Chir. 2002;34:150-7.






Diagnosis: History and Physical Findings

• History of a fall on the outstretched hand or an episode of trauma

• A visible deformity of the wrist is usually noted, with the hand most commonly displaced in the dorsal direction.

• Movement of the hand and wrist are painful.

• Adequate and accurate assessment of the neurovascular status of the hand is imperative, before any treatment is carried out.

Diagnosis• History• Physical exam, look for other injury

injury should be evaluated for:-• open/closed• degree of soft tissue injury• neurovascular injury- median nerve injury common

• Imaging Wrist PA, Lat, and oblique AP and lat. Of the contralateral wrist Ct scan

DISTAL RADIAL FRACTURE

• Distal radius fractures occur through the distal metaphysis of the radius

• May involve articular surface

• frequently involving the ulnar styloid

• Most often result from a fall on the outstretched hand. – forced extension of the

carpus, – impact loading of the

distal radius. • Associated injuries may

accompany distal radius fractures.

Diagnosis: Diagnostic Tests and Examination

• General physical exam of the patient, including an evaluation of the injured joint, and a joint above and below

• Radiographs of the injured wrist• Radiographs of other areas, if

symptoms warrant.• CT scan of the distal radius in

selected instances.

Radiographic Assessment

• radial inclination • volar tilt• radial length• Any intra-articular gap or step

Radial length• radial length was measured on

the posteroanterior view as the distance between 2 lines drawn perpendicular to the long axis to the radius: one line was drawn at the level of the radial styloid tip and the other line was drawn at the ulnar border of the radius articular surface.

Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792–800

Radial Inclination

Radial inclination was measured on the posteroanterior view by determining the angle between a line tangential to the distal radial articular surface and a line perpendicular to the shaft of the radius


Volar tilt/Palmar tilt• Palmar tilt was measured by

the angle between the plane of the distal articular surface as seen on the lateral x-ray and the plane perpendicular to the longitudinal axis of the radius


Ulnar varianceVertical distance between • a) a line drawn parallel to the

proximal surface of the lunate facet of the distal radius and

• b) a line parallel to the articular surface of the ulnar head.

• Usually negative variance (e.g. -1 mm) or neutral variance

Computed TomographyIndications:

• Intra-articular fxs with multiple fragments

• centrally impacted fragments• DRUJ incongruity

• 19 consecutive fx, CT had better sensitivity for intraarticular frag

• management change in 5 ptsCole et al: J Hand Surg, 1997

DISTAL RADIAL FRACTURE

• Classified by:– presence or absence

of intra-articular involvement,

– degree of comminution,

– dorsal vs. volar displacement,

– involvement of the distal radioulnar joint.

Classification of Distal Radius Fractures

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

Common Classifications

• Gartland/Werley• Frykman• Weber (AO/ASIF)• Melone• Column theory• Fernandez

(mechanism)

Frykman ClassificationExtra-articular

Radio-carpal joint

Radio-ulnar joint

Both joints

{Same pattern as odd numbers, except ulnar styloid also fractured

The AO/ASIF classification as proposed by MÜLLER






The treatment of fractures at the distal Radius

The treatment of fractures at the distal end of the radius has certainly evolved since Abraham Colles provided the first description to the English speaking com-munity in 1814

Determination of the best treatment option

• The fracture pattern, • The degree of displacement, • The stability of the fracture, • The age and physical

demands of the patient.

• Those patients with low demand activities may be best served with nonoperative techniques.

• High demand patients, however, may require surgical fixation to allow early range of motion and to prevent stiff-ness, which could be detrimental for certain activities.

Treatment Goals

• Preserve hand and wrist function• Realign normal osseous anatomy • promote bony healing• Avoid complications• Allow early finger and elbow ROM

A stable fracture is one that is acceptably aligned after reduction effort and where the likelihood of displacement is small

Cumulative risk factors for the loss of reduc-tion have been identified as

• age over 60, • greater than 20° dorsal

angulation, • 5 mm radial shortening, • dorsal comminution, • ulna fracture, and• intra-articular radiocarpal

involvement

Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review. J Hand Surg 2008;33A:421–429

Unstable Distal Radius Fracture• Instability is defined as the

inability of a fracture to resist displacement after it has been manipulated into an anatomic position

Lafontaine et al suggested 5 factors that indicated instability:1. initial dorsal angulation greater

than 20°, 2. dorsal comminution, 3. radiocarpal intraarticular

involvement, 4. associated ulna fractures,5. age greater than 60 years.

Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20:208 –210.

Important radiographic parameter

• Anatomic studies have determined average values for these important radiographic parameters:

• radial inclination (23°), • palmar tilt (11°), • radial length (12 mm)

Friberg S, Lundström B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol Diagn 1976; 17:249 –256.

The standard of treatmentfor fractures of the distal radius

• The standard of treatment for most fractures of the distal radius remains closed reduction and immobilization.

• Surgical intervention should be considered when an acceptable reduction cannot be achieved or maintained by closed means.

CLOSED REDUCTION AND CAST IMMOBILIZATION

Closed reduction and immobilization in a plaster cast remains an accepted method of treatment for most sta-ble distal radius fractures and for all non–displaced fractures

CLOSED REDUCTION AND PINNING

Closed reduction and percutaneous pin fixation are best suited for

• fractures without articular involvement and

• also without substantial metaphyseal comminution.

CLOSED REDUCTION AND PINNING

A variety of pinning methods have been described;

• The most popular is oblique radial styloid to proximal ulnar cortex,

• as well as placement of the pins through the fracture site.

A prospective, randomized trial encountered markedly inferior clinical and radiological results

• for percutaneous pinning compared with • locked volar plating, even for extra-articular distal radius frac-tures.

McFadyen I, Field J, McCann P, Ward J, Nicol S, Curwen C. Should unstable extra-articular distal radial fractures be treated with fixed-angle volar-locked plates or percutaneous Kirschner wires? A

pro-spective randomised controlled trial. Injury 2010;42:162–166.

EXTERNAL FIXATION

It employs ligamentotaxis to improve the length and alignment of the fracture.

Bridging external fracture fixation refers to a surgical effort that bridges the radius fracture and gains purchase distal to the radiocarpal joint.

Nonbridging external fixation uses pins in the distal radial fragment and pins proximal to the fracture with-out bridging the radiocarpal joint.

External fixation:

The treatment of choice for distal radius fractures in the

1980’s

Types of External Fixation

• Spanning– Dynamic

• Clyburne• Agee• Pennig

– Static• AO• Ace

• Non-spanning– Hoffman 2– Cobra– Zimmer– AO

Bridging external fixation• A spanning fixator is one which fixes

distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals

Nonbridging external fixation• A non-spanning fixator is one

which fixes distal radius fracture by securing pins in the radius alone, proximal to and distal to the fracture site.

• In this instance, frag-ments are reduced by direct manipulation. The non-bridging method requires a sizeable extra-articular distal fracture fragment

DORSAL PLATESRadius fractures with metaphyseal comminution typi-cally collapse in a dorsal direction and a

dorsal ap-proach will provide excellent articular surface visual-ization and allow for buttressing of these fragments.

Disadvantages are that the plate is placed under the extensor tendons, which may lead to extensor tendon irritation and rupture.

Synovitis was noted to occur where the extensor tendon glide directly over the plate and screws.

After plate removal, the tendon has visible attritional changes.

Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106

VOLAR FIXED-ANGLE PLATES

A more traditional approach involves proximal plate fixation before the fracture is reduced, and the distal screws are subse-quently placed to maintain the reduction effort

The lift-off method places the distal screws first and then uses the plate to correct the dorsal mal-alignment of the fracture.

Johannes Schneppendahl, MD, JoachimWindolf, MD, Robert A. Kaufmann, MD. J Hand Surg 2012;37A:1718–1725.

The Surgical Technique

The fracture surgery perform with the patient under regional anesthesia.

Image intensification is crucial during surgery and is accomplished with a surgeon-operated mini-C-arm fluoroscopy unit.

Parenteral antibiotics are given at least thirty minutes before the commencement of surgery.

Pneumatic tourniquet control is used.

Anterior approach

Kevin C. Chung and Elizabeth A. PetruskaJ Bone Joint Surg Am. 2007;89:256-266.

Incision line over the flexor carpi radialis tendon.

The flexor carpi radialis tendon sheath is opened (arrow).

Anterior approachThe incision is made along the radial border of the flexor carpi radialis tendon to ensure that the palmar cutaneous branch of the median nerve (displayed over a dark blue background) is protected.

The index finger of the surgeon is swept under the flexor pollicis longus tendon in an ulnar direction.

Anterior approach

Retractors are placed gently to expose the pronator quadratus

(arrow).

An L-shaped incision (dark lines) is made to elevate the pronator

quadratus.


It is useful to place a needle into the radiocarpal joint to identify the most distal rim of the radius.

Manipulative reduction is performed to realign the volar cortical fracture lines.



A smooth Kirschner wire is placed from the radial styloid across the fracture line to achieve provisional fixation of the fracture.



Retractors are placed to provide full exposure prior to plate application.

The distal row of locking screws is placed near the subchondral bone of the distal fragment.



The position of the plate and distal screws is confirmed with use of fluoroscopy.

The proximal limb of the plate purposely lies off the diaphysis by 10° to facilitate further reduction of the distal fragment when the proximal limb is secured to the bone.

Volar tilt of the distal fragment is achieved by tightening the proximal screws. The provisional Kirschner wire is removed before the screws are fully tightened.


The final anatomic reduction and plate and screw placement are confirmed with use of intraoperative fluoroscopy.


Insert plate and screwThe first consideration, insert the first screw in subchondral bone.

It is strongly recomended to use Image Intensifier

All screw had been inserted

Pronator Quadratus sutured back to its place

Complications of Volar Plate Fixation for Managing Distal Radius Fracture

Postoperative lateral radiograph (A) and intraoperative photograph (B) of a patient who presented with extensor pollicis longus rupture 2 months after volar plate fixation of a distal radius fracture. In panel B, the screw tip can be seen in the third extensor compartment (arrow).

The exposure to the dorsal aspect of the radius. The retinaculumis opened over the third extensor compartment, elevating the extensor pollicis longus.


Case Presentation

Summary

• The standard of treatment for most fractures of the distal radius remains closed reduction and immobilization.

• Surgical intervention should be considered when an acceptable reduction cannot be achieved or maintained by closed means.

Thank you

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09.20-09.35_dr.dr.Heri Suroto_when to Operate