Distal radius fractures

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2 Distal radius fractures One of the most common fractures seen by orthopaedic surgeons Incidence 195.2/100,000 persons per year Significant financial burden

3 Distal radius fractures Improved implants ORIF reproducible Older patients benefit from surgery Volar locking plates

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7 Standard Radiographs Fail to depict important injury characteristics Bradway, JBJS, 1989 Pruitt, JHS, 1994

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9 JBJS, D CT can improve the reliability of observations by individual raters The use of 2D and 3D CT together results in significant changes in treatment planning More extensive, open approaches

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11 Classification Fernandez Mechanism/patter n Bending Shearing Compression Avulsion Combination 1-4

12 Fernandez 2 Shearing Fractures Volar (Barton s) Dorsal (what exactly is this?) Radial styloid (chauffeur's fracture) Lunate facet (e.g. die-punch)

13 Volar Shearing Barton s Fracture -- AO B.3 Volar buttress plate

14 Pitfall Beware of separate scaphoid and lunate facet fragments

15 Volar Fragmentation

16 Volar Fragmentation

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19 Beware of the Volar Lunate Facet! Volar shearing fracture 7 patients treated with volar plate Loss of fixation of volar lunate facet w/ carpal subluxation

20 Lunate facet projects out 3 mm The projection is 5 mm thick

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22 JHS, February 2008

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25 Volar Locking Plate Implant Prominence and Flexor Tendon Rupture Soong et al, JBJS 2011

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29 JHS, April patients (52 fractures) AO B3 No failures in B B3.3 7/25 (28%) Loss of fixation and volar subluxation

30 Lunate facet B3.3 high risk of lunate facet subluxation Length < 15 mm Lunate subsidence distance > 5 mm Increased risk of loss of fixation even with properly placed volar plate

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32 Fixation Options Suture or wire figure of 8 Spring wire construct with volar plate Fragment specific implants Screws K wires Hook plate extension to volar plate

33 Case Example 75 y.o. male Fall from standing height Volar shearing fracture of distal radius AO B3.3

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38 Case Example 42 y.o. male Biking accident Volar shearing fracture of distal radius

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41 Case example 33 y.o. female Low energy fall C3 fracture

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43 Extended FCR approach

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47 Dorsal Shearing

48 Dorsal Shearing What is it?

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53 Radial Shearing

54 Radial Shearing

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56 Radial column plates Don t be afraid to add a radial column plate AAHS, 2016 Galle, Peterson, Harness A prospective, observational review There were no cases of tendon rupture or neuritis, however 28% (17/55) of the patients elected for hardware removal.

57 Fernandez 3 Compression Articular Fractures Basic articular fragments Central impaction Comminution Metaphyseal comminution

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59 Column specific fixation for more complex fracture patterns

60 When a volar plate won t work Putting it all together 49 y.o. RHD woman Fall Right wrist fracture

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62 When a volar plate won t work AO C3.2 Radial styloid and separate dorsal and volar lunate facet fragments Additional imaging?

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64 Central approach

65 Volar ulnar approach

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67 Lunate Facet fragment < 15 mm

68 Dorsal view

69 3 month follow up

70 3 month follow up

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74 Fernandez 4 Radiocarpal Fracture-Dislocation

75 High energy fracture dislocations 54 year old, RHD, male Fall 8 feet off roof Gross deformity left wrist 1cm volar laceration Decreased sensation median nerve dist.

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77 Who Would get a CT Scan?

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79 Volar Radial

80 Dorsal

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83 3 month follow up: S/p HWR

84 Fernandez 5 High-Energy Combined

85 BRIDGE PLATE Severe articular comminution Internal ex fix Span Zone of injury until fracture consolidation Requires second procedure Courtesy Ali Ghiassi, MD

86 Increased risk of tendon entrapment with 3 rd MC

87 Distal marginal fracture with severe osteoporosis 63 y.o. female Fall from standing height Distal radius fracture Ipsilateral tibial plateau fx

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92 Meta-diaphyseal fractures Combination of Galezzi and Dr fracture Usually more comminuted than radiographic appearance Need M-D plate Longer Recovery than simple DR fracture Courtesy Ali Ghiassi, MD

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95 Review Severe metaphyseal comminution Meta-diaphyseal plate or bridge plate Very distal marginal fractures with or without radiocarpal dislocation Fragment specific fixation and bridge plate

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