11/18/2009. day 1. 6 weeks

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1 11/18/2009 from Fractures of the Distal Radius : a practical approach to management DL Fernandez and JB Jupiter, Springer, New York, 1995 SGH, Biel, 2009 FRACTURES OF THE DISTAL RADIUS: do we still indicate conservative treatment and percutaneous fixation? Diego L. Fernandez M.D. Professor of Orthopaedic Surgery University of Berne Department of Orthopaedic Surgery Lindenhof Hospital Berne, Switzerland is there a place for cast treatment any more?... yes, there is Fourrier P, Bardy A, Roche G, Cisterne JP, Chambon A: Approche d une définition du cal vicieux du poignet. Int Orthop (SICOT) 4: , 1981 it is recommended and reliable for: p extraextra- and intra intra- non or minimallyy displaced articular fractures displaced fractures that remain stable after closed reduction lower limits of deformity at which symptoms are likely to be present: - radial deviation saggital tilt radial shortening 00-2 mm unstable fractures in the elderly (tolerable asymptomatic malmal-union) acceptable distal radius malunion in 64 malunions they correlated functional impairment p and residual deformity y MALUNION OF THE DISTAL RADIUS Symtomatic or Asymptomatic 1.5 mm years old lawyer..., 60 years after Colles` fracture!! do not treat the X-ray but the patient 1

2 in patients with underlying ligamentous laxity a dorsal tilt of can result in symptomatic mid-carpal instability Taleisnik J, Watson HK: Midcarpal instability caused by malunited fractures of th distal radius. J Hand Surg 11A: , 817, 1986 dorsal tilt over is a pre-arthrotic deformity and causes DRUJ dysfunction Short WH, Palmer AK et al JHS 12A: , ,1987 A biomechanical study of distal radial fractures with increasing values of dorsal tilt over 20 there is up to 67% over the distal ulna and force concentration on the dorsal aspect of the radiocarpal joint also valid for increased volar tilt CONSERVATIVE TREATMENT HOW TO MAKE A CAST WORK rule out unstable fracture patterns recognize deformity and correlate to mechanism of injury use adequate anesthesia meticulous casting technique careful early follow-up (X-rays + clinical) unstable fracture high incidence of secondary progressive displacement despite initial adequate reduction FAILURE TO RECOGNIZE RADIOGRAPHIC PARAMETERS OF INSTABILITY IN INITIAL X-RAYS day 1 6 weeks DISTAL RADIUS FRACTURE radiographic criteriae of instability 1. > than 20 of dorsal (or palmar) angulation 2. displacement (> than 2/3 width of shaft) 3. metaphyseal comminution 4. > than 5mm of initial shortening 5. intra-articular articular component 6. associated distal ulnar fracture 7. osteoporosis displaced intra-articular articular fracture 2

3 absolute contraindication for cast treatment!!! non or minimaly displaced fracture post-traumatic DJD - no reduction - forearm cast 3-4 weeks - removable wrist brace until patient confortable closed reduction and cast immobilsation displaced reducible fractures that remain stable following reduction POUTEAU-COLLES FRACTURE MANIPULATIVE REDUCTION (Colles fracture) obtained by applying the opposite force to the one responsible for the fragment displacement (mech. injury) 1. disimpact increasing initial deformity 2. apply longitudinal traction Brachioradialis: supinatory deforming force 3. flexion and pronation of the wrist 3

4 CLOSED REDUCTION WITH FINGER TRAP TRACTION (unstable and impacted fractures) CLOSED REDUCTION WITH FINGER TRAP TRACTION ALTHOUGH LENGTH AND ULNAR INCLINATION IS INVARIABLY ACHIEVED, RESTORATION OF VOLAR TILT REQUIRES PALMAR DISPLACEMENT OF THE HAND AND CARPUS ( J. Agee) palmar displacement of the capitate volarly rotates the scaphoid and lunate effectively forcing the distal fragment into flexion 3-point contact cast tension John Charnley: The closed treatment of common fractures Williams & Wilkins, Baltimore, 1961 (page 142) compression adequate contact of the volar cortex imperative cortical overlapping renders reduction unstable! SUGAR TONG SPLINT used in the first 2-3 weeks, immobilizes DRUJ, elastic wrapping adaptable to soft tissue swelling, easy to change 4

5 45 immobilise in: 15 of flexion 15 of ulnar deviation 20 of pronation 3-point contact cast post-reduction protocol - keep sugar tong splint for the first 2 weeks - follow up X-rays at 3, 7 and 12 days -detect early loss of reduction:remanipulation for stable fractures up to 3 rd week possible. pins, ex-fix or ORIF for unstable types!! -change splint for forearm cast at 2-3 weeks for another 3-4 weeks 12 days 6 weeks 1.6 yrs post-reduction SMITH-GOYRAND FRACTURE 6 weeks 3 months palmar displacement and pronation of distal fragment 5

6 86 year old patient, significant osteoporosis immobilise in: 30 of extension 40 of supination 12 weeks 6 weeks Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? Koenig KM, Davis GC, Grove MR, Tosteson ANA, Koval KJ. J Bone Joint Surg 2009;91A: Internal fixation with use of a volar plate for potentially ti 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. PERCUTANEOUS PINNING ideal minimally invasive method of fixation of unstable reducible extra and intrarticular fractures in adolescents and young adults with good bone quality and minimal amount of metaphyseal comminution 6

7 radial styloid fracture INTRA-FOCAL PINNING (Adalbert Kapandji) 5 weeks post reduction 25 dorsal tilt weeks post op conventional trans-styloid styloid percutaneous pinning 7

8 11/18/2009 combined closed and percutaneous reduction intra--articular 3 intra 3--part fracture percutaneous pinning more than often fails in osteoporotic fractures associated with significant metaphyseal comminution in elderly patients... dangerous method!!! 8

9 Most recent literature review... Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospecitve randomized trial. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS J Bone Joint Surg 2009;91A: Similar functional results but...consider volar plate fixation for patients requiring a faster functional recovery after the injury EXTERNAL FIXATION -recognition of the mechanical advantage of augmentation with K-wires -use of autologous bone graft to support the joint fragments, fill the metaphyseal defect and accelerate healing time -use of non-bridging fixators to allow early wrist motion EXTERNAL FIXATION MAIN INDICATIONS CRITICAL SOFT TISSUE CONDITIONS OPEN FRACTURES 1. COMMINUTED INTRA-ARTICULAR ARTICULAR 2. UNSTABLE EXTRA-ARTICULARARTICULAR 3. OPEN FRACTURES 4. INFECTED FRACTURES gram-negative infection, osteomyelitis distal radius débridement and insertion of Gentamycin beads, ex-fix EXTERNAL FIXATION FURTHER INDICATIONS 5. AS DISTRACTOR FOR INDIRECT REDUCTION 6. TEMPORARY STABILISATION OF COMPLEX FRACTURES 7. SUBSTITUTION OPPOSITE CORTICAL DEFECT (J. MAST) 8. FIXATION OF WRIST FRACTURES IN SEVERELY MULTIPLE TRAUMATIZED PATIENTS 9

10 Bridging external fixation of wrist fractures Bridging external fixation of wrist fractures A NUMBER OF STUDIES HAVE REPORTED HIGHLY SATISFACTORY FUNCTIONAL RESULTS flexion-extensionextension 120 forearm rotation on average Seitz et al JHS % Edwards et al JBJS % Jakim et al JBJS % Leung et al JHS % Kreder H, Hanel D JBJS (Br) 1995: ex fix + K wires (n 88) scored better than ORIF ( n 91) in 179 patients with intra-articular articular fractures followed for 2 years BRIDGING EXTERNAL FIXATOR a) Ligamentotaxis alone b) Augmentation with K-wires c) Primary bone grafting d) substitution of dorsal cortex associated with volar plate fixation 2.5 y post op 10

11 Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius. A RANDOMIZED PROSPECTIVE TRIAL unstable fracture Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N. J Bone Joint Surg 2008;90B: DVR plate GROUP EX FIX + pins GROUP 39 patients 38 patients No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group. NON-BRIDGING EXTERNAL FIXATION -direct control of distal fragment (joy sticks) -easy restoration of volar tilt -early post-operative operative wrist motion possible 3 y post-op 11

12 CONCLUSIONS CONCLUSIONS EX-FIX 20 years ago the residents did the closed reductions and put the casts on, while the seniors did the surgery... now the residents just operate and the seniors (residents 20 years ago) are the only ones around who know how to make a cast work..!! this may explain (to a certain extent) why statistics on conservative treatment have overall disapointing outcomes DON T THROW YOUR FIXATORS AWAY!! 2. THIS TREATMENT MODALITY IS STILL A VALID ALTERNATIVE IN THE MANAGEMENT OF DISTAL RADIUS FRACTURES 3. HIGHLY RECOMMENDED IN.: severe articular comminution complex trauma + soft tissue damage wrist fractures in the multiple injured patient infected cases CONCLUSIONS - definite trend towards locking plate fixation of DRFxs - better earlier functional results, but... - late functional and radiographic outcomes show no significant ifi differences with other treament t modalities - complication rates similar: loss of reduction, pin tract infection in ex fix studies extensor and flexor tendon problems in plating series THANK YOU -best option for osteoporotic fractures 12