5/9/2017. Distal Radius Fractures: What s New? What s New? Or Maybe New to you. Single Pak Sterile distal radius kits

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1 Distal Radius Fractures: What s New? What s New? Or Maybe New to you. Single Pak Sterile distal radius kits Extension of FCR split to release tendon for retraction Pronator Quadratus elevation with BR tendon prolongation Midline incision for exposure of lunate facet Radial column approach Dorsal lunate facet approach Liftoff technique of plate reduction TFCC repair with suture anchor 1

2 Considerations for Operative versus NonOperative Tx Patient age General health status Bone quality Functional requirements and living accommodations Concomitant injuries Intercarpal ligament injury Carpal translation DRUJ instability or incongruence Columns: Coronal Plane Don t forget about the sagittal plane as well Radial Column Lateral side of radius including the radial styloid and scaphoid fossa Intermediate Column Ulnar side of radius, including the lunate fossa and sigmoid notch Ulnar Column Ulnar head, including the triangular fibrocartilage complex (TFCC) and the ulnar part of the distal radioulnar joint (DRUJ) Lunate facet reduction critical for carpal stability and supination 2

3 DRUJ Congruence and Stability Not determined by size of ulnar styloid fragment Reduce Facets to Control Carpal Alignment This is related to outcome Lunate facet reduction critical Get CT axial view to assess congruence Carpus will follow articular facets Instability of facet fragments following closed reduction indicates ORIF Chauffeur s Die-punch 3

4 Clinical evaluation Low energy falls more likely reducible and stable Awareness of fxs associated with SLIL injury Check for sensory changes and document preexisting CTS as well as thumb arthritis Carpal tunnel compression symptoms in 13-23% CTR rarely required emergently Tips and Tricks Get traction views of wrist to assess pattern and comminution Instability criteria of La Fontaine: age, comminution mitigate against stable closed reduction Carpal translation must be controlled with lunate facet capture either volar or dorsal Surgical approach must allow ideal positioning of implant on lunate facet to prevent displacement Screws must be placed directly beneath subchondral bone to prevent subsidence and late collapse My Opinions - DRF Closed reduction should always be performed Adequate anesthesia required Assess the pattern of the fx both before and after reduction Recognition of instability of fx reduction is an essential skill Treat the patient and their expectations- not the x-ray Malunion loosely defined can be acceptable to many patients 4

5 Case /9/ y/o RHD female dentist FOOSH L hand while dancing Sarmiento used to say the Injury films predicted the final position in Rx of closed tibia fxs. What about DRF? Post-Reduction - Is it good enough? 1 Week Later - Is it good enough? 5

6 Vote with your hands 46 y.o. F dentist (needs both hands) with comminuted, intra-articular fracture of her non-dominant wrist Concerns: continued settling radial shortening, DRUJ incongruence, loss of supination Options- always the big 3 Volar plate External fixator Continue closed reduction At 2 Weeks There is still time for anything Standard X-ray Indices May Not Be Enough to make the call on going all the way with closed RX Radial length Radial inclination DRUJ congruence Articular step-off Articular tilt When I need to ensure no loss of supination, I get a CT in axial plane Assess articular surface and stability, make sure no rotatory deformity X-ray not sensitive to 30 deg rotation on AP- Tornetta et al 6

7 CT at 2 weeks - Now what? At 2 Months At Last OT F/U- 3 Months Pronation: Left 0/70 Right 0/80. Supination: Left 0/60 Right 0/80. Flexion: Left 0/40 Right 0/60. Extension: Left 0/60 Right 0/65. Radial Deviation: Left 0/15 Right 0/20. Ulnar Deviation: Left 0/25 Right 0/30. Back to work as a dentist no complaints Flex/ Ext continues to improve up to 1 year- our study 7

8 Supination = Happy Patients Assess the sigmoid notch of the distal radius and make certain there is no rotational deformity of the medial column fragments Clue: diastasis or loss of congruence arc on either AP or Lat of the medial facets of the radius Look for carpal translation on radius not reversal of volar tilt as most important indicator Metaphyseal fxs with less than 4-5 mm of shortening can be accommodated by the oversized sigmoid concavity So how do they do? Firstly think about the angle of the articular face If you correct the gross dorsal displacement (< 20 ) you will restore the ability of the wrist to assume a flexed posture which is important for prehension Shortening cannot be prevented and is tolerable to a point without adversely affecting supination It will look different: thicker, wider, prominent ulna The patients need to be told this over and over at the beginning as well as their significant others Case y/o RHD university maintenance worker and former major league baseball pitcher fell down 6 stairs at home 8

9 Post-Reduction - Is this acceptable? 1 Week Later- Is this acceptable? You Vote 38 y/o maintenence worker and former MLB pitcher with intra-articular fracture with dorsal impaction of his non-dominant wrist Volar plate External fixator Continue closed reduction Let s see a show of hands 9

10 CT at 2 weeks - Is this acceptable? 6 weeks- Outcome? At 2.5 Months- nearly full motion, no pain, full function 10

11 Case /9/2017 Outcomes Data on 4000 DRFx s prospectively recorded Pt age, metaphyseal comminution, ulnar varience were most consistent predictors of outcome Dorsal angulation not significant Maintain supination and patient usually satisfied JBJS y/o woman s/p fall on dominant wrist Management? 81 y/o woman with comminuted, impacted fracture of her dominant wrist Volar plate External fixator Continue closed reduction Let s see a show of hands 11

12 At 1 Month Acceptable? Nascent malunion At 1.5 Years Secondary articular congruence Remodeling Carpal alignment maintained At 1.5 Years Stiff but no pain and excellent function - supination 12

13 So I know what you are going to say Older ( more mature folks ) can tolerate these malunions JOT 2009 Methods Cross sectional study, 60yo with distal radius Fx were evaluated at least 1yr s/p injury Physical Activity Scale of the Elderly scores stratified participants into high- and low-activity groups Malunion defined radiographically Outcome measure: DASH, ROM, and pain Conclusions Even among highly active older adults, distal radius malunion does not affect functional outcomes Judicious use of operative management is warranted provided heightened complication rates. 13

14 Are you noticing a pattern? The point is that not all distal radius fractures require plating, even unstable fracture patterns It s not the number or direction of FX lines - it s the displacement Frykman Classification So what determines patient outcome? Carpal alignment, as controlled by the lunate facet DRUJ congruence and stability 56 y.o. F S/P fall Is this Intra or Extra articular fx?ttc# y.o. Articular surface distal radius looks congruent? RX closed vs open 14

15 If carpus translated lunate facet involved This will affect return of flexion and more importantly DRUJ and supination Medialize plate to capture lunate facet What about approach? The good old Henry FCR-radial artery interval and extensile to prox forearm Extended FCR approach Is there anything else? 15

16 Casettc#474: Volar Barton s Fx 54 y.o. Physician fell while rollerblading Volar approach- FCR Is Lunate Facet Captured? Despite casting Fx displacement with stable plate Lunate Facet Escape 16

17 FCR approach is not sacred Optimization of reduction and plate positioning is rationale for selection of app Avoid median nerve retraction during exposure can lead to a dense neurapraxia Self retainer stretching the median nerve in ulnar direction This excessive traction facilitates screw placement 17

18 Pearl Take down of pronator quadratus should be performed with 1/3 of the adjacent and contiguous brachioradialis tendon This will make a secure repair over the plate achievable Result of the struggle for medial plate placement failure to capture Consider a more medial approach utilizing 2 intervals: FCR-FDS, FDS-FCU 18

19 Enables medial facet capture and subchondral support CT scan with screws in ideal position CT scan demonstrating subchondral support preventing dorsal collapse 19

20 Axial CT medial screw capture of sigmoid notch My preferred approach for lunate facet displacement Distal Radius Dissection - Carpal Tunnel.wmv video Case: 63 yo RHD F, fall- volar Barton s What about ulnar styloid? 20

21 Always Test DRUJ stability after radius ORIF ttc479 DRUJ test.wmv (VIDEO) ORIF then DRUJ stress testing If unstable, repair TFCC attachment suture anchor looped around TFCC Don t Forget the Dorsal Lunate Facet Mostly it can be captured by a well placed volar locking plate However you cannot achieve bicortical purchase for fear of tendon irritation/ rupture In thin osteopenic cortices it may be necessary to make a dorsal incision between 4 th and 5 th DC and place small buttress plate Also in the dorsal die punch injury the volar radial cortex is unbroken and so primary dorsal approach is indicated after elevation of articular fragment 21

22 Case479: 50 y/o F s/p fall Dorsal displacement with intact volar cortex Approach? My Preferred Approach to the Dorsal Lunate Fascet (VIDEO) 22

23 FCR vs Midline Case: 63 yo RHD F, fell at US Open Intra-op stress testing of DRUJ very unstable ORIF, suture fixation of ulnar styloid 23

24 Alternative: Lift-off Technique 6 month follow up: DASH=5.0 Other options Pin DRUJ Long arm cast 24

25 Reduction must be obtained for plate to sit properly and thus avoid encroachment of tendons Dorsal Tendons: Medial facet screws masked by Lister s Make screws short to avoid tendon injury However facet capture may be inadequate Lister s tubercle projects above on x-ray lateral 25

26 Don t Forget the Dorsal Lunate Facet Mostly it can be captured by a well placed volar locking plate However you cannot achieve bicortical purchase for fear of tendon irritation/ rupture In thin osteopenic cortices it may be necessary to make a dorsal incision between 4 th and 5 th DC and place small buttress plate Also in the dorsal die punch injury the volar radial cortex is unbroken and so primary dorsal approach is indicated after elevation of articular fragment Conclusions Closed Reduction We live in an era when every DRFx gets a volar locking plate Remember CR is still a viable options for the well selected and informed patient and can yield predictable patient outcomes Remember to ensure that the lunate is aligned with the medial column articular facets or supination will be lost Thank You 26