Volar fixed-angle plating for distal radius fractures 刀圭会協立病院 津村敬

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1 Volar fixed-angle plating for distal radius fractures 刀圭会協立病院 津村敬

2 Normal distal radius anatomy Radial styloid process EPL Volar lip Lister s s tubercle Radial styloid process Sigmoid notch palmar view Lister s s tubercle dorsal view ulnar view ECU radial view ulnar styloid process Scaphoid fossa Lunate fossa end-on view

3 Radiographic parameters of distal radius Radial length from medial cortex of radius 1mm from tip of radial styloid process 12mm Radial inclination 23 Volar tilt 11

4 AO classification A extra-articular articular A1 ulna fracture, radius intact A2 radius fracture, ulna intact A3 multifragmentary radius fracture B partial articular B1 sagittal B2 dorsal rim B3 volar rim C complete articular C1 simple articular and metaphysis C2 simple articular, metaphyseal multifragmentary C3 multifragmentary J Orthop Trauma, Vol.10, Suppl

5 Fernandez classification Bending Shearing Compression Avulsion (fracture dislocation) conservative percutaneous pinning external fixation ORIF conservative percutaneous pinning external fixation ORIF arthoroscopic assisted pin or screw fixation tension wiring Combined (high velocity injury) combined method Comparative Classification for Fractures of the Distal End of the Radius Jesse B. Jupiter etc. The journal of Hand Surgery / vol 22A 1997

6 Prediction of instability Radial shortening 5mm Dorsal Dorsal tilt 20 Comminution of the metaphyseal region 50% BicorticalBicortical comminution Extensive intra-articular articular involvement Associated fracture of the ulna Poor-bone quality (AO Principles of Fracture Management)

7 Limits of acceptable displacement of fractured distal radius Articular step off <2mm Radial shortening <4mm Dorsal tilt <15 15 Volar tilt <20 20 Loss of normal radial inclination <10 10 (OKU Trauma 2) Radiologic Measurements Predicting Poor Functional Outcome Articular step off or gap >2mm Positive ulnar variance >3mm Dorsal tilt >10 Volar tilt >15 Carpal malalignment (Orthopedic surgery essentials TRAUMA)

8 Treatment of unstable distal radius fractures External External fixation and supplemental K-wiresK Dorsal Dorsal plating VolarVolar fixed-angle plating Double Double plating (fragment-specific fixation)

9 Volar fixed-angle plating means... volar plating for distal radius fractures using locking plates dorsal fixed-angle construct fracture void Not depending on the buttress effect. Reducing dorsal fragments indirectly. Using a locking plate to support the subchondral bone.

10 Advantages of volar fixed-angle plating Preserving the vascular supply of dorsally comminuted fragments. Reducing Reducing the need of bone grafting. Fewer Fewer soft tissue and tendon problem. Providing Providing rigid fixation that permit early rehabilitation program. Having Having an advantage with fractures in osteoporotic bone.

11 Distal Radius Plate (Synthes)

12 Locking Distal Radius System 2.4 (Synthes)

13 ACU-LOC DISTAL RADIUS PLATE SYSTEM (ACUMED)

14 Indications for volar fixed-angle plating Definitive indication Fractures involving displaced and rotated volar lunate-facet palmar Relative indication Dorsally displaced fractures with depressed dorsal lunate-facet dorsal Unstable extra-articular articular fractures including osteoporotic bone Volar Barton fractures

15 Points of surgical technique in volar fixed-angle 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

16 Surgical techniques of volar fixed-angle plating

17 Henry Approach FPL Radial artery incision Expose fracture through Henry approach to diminish flexor adhesion. Make surgical incision between FCR and radial artery. Retract the flexor tendon ulnary. Retract the radial artery radialy. Detach the pronator quadratus. Open the carpal tunnel through the 2nd incision, if necessary.

18 Fracture model in the distal radius Fernandez ndez typeⅢ (compression type) AO 23-C3 Rotated volar lunate-facet Sigmoid notch Rotated volar lunate-facet ulnar view dorsal radial ulnar styloid process palmar view palmar End-on view

19 Provisional reduction of intra-articular articular fragments palmar view ulnar view Kirschner wires Kirschner wires Reduce fracture with intrafocal manipulation. Provide temporary fracture fixation with K-wires inserted through fracture line.

20 Intrafocal manipulation (Ⅰ) Fractures involving displaced and rotated volar lunate-facet articular incongruity palmar 1.5 Kirschner wire

21 Intrafocal manipulation (Ⅱ) Dorsally displaced fractures with depressed dorsal lunate-facet articular incongruity compression dorsal 1.5 Kirschner wire

22 Reduction maneuver of intra-articular articular fragments(Ⅲ) The extened form of the FCR approach

23 Initial plate placement temporary plate fixation lift off Apply plate to the volar aspect of articular fragments. Determine ideal plate position with fluoroscopy. The proximal portion of plate is lifted off the radius during initial plate placement.

24 To restore volar tilt to normal... the angle of the plate in relation to the long axis of the radius B A A=B deformity to be corrected

25 Drilling drill Facet lateral fluoroscopic view drill hole in subchondral position Residual step off Use facet lateral fluoroscopic view to control drilling. Make holes in the subchondral position. Lift articular fragments using drill bit to reduce residual step-off deformity,if necessary. Avoid penetrating the dorsal cortex.

26 Distal pin insertion pins in subchondral position Insert fixed-angle pins in subchondral position.

27 Final plate fixation ulnar view palmar view Advance the plate distally to correct radial shortening,if necessary. Complete fixation of the plate to the shaft with bi-cortical screw, resulting in increased volar tilt. Assess the the stability of the DRUJ.

28 Complications Malunion Osteoarthritis Nonunion InfectionInfection Tendon Tendon rupture Peritendinous adhesions Peripheral nerve compression and injury Compartment syndrome Complex Complex regional pain syndrome type1

29 Postoperative care Splint the wrist in extended, postoperatively. Instruct Instruct the patients to begin active finger motion immediately. Begin Begin active wrist motion at 1 to 2 weeks postoperatively. Begin Begin passive stretching of wrist at 3 to 4 weeks postoperatively. Use Use a removable wrist splint for 4 weeks postoperatively.

30 Associated DRUJ lesions Assess the stability of the DRUJ, following fixation of the radius. Injury pattern osseous injury fx ligamentous injury Prediction of the instability of the DRUJ shortening > 4mm4 dorsal angulation > 15 fx of the sigmoid notch and/or the ulnar styloid process injury disruption of the TFCC Effect of distal radius fracture malunion on wrist joint mechanics. Pogue DJ / The Journal of Hand Surgery / Vol.15A 1990

31 Managements of associated DRUJ lesions The Fernandez classification Type Ⅰ stable A+B early pronation-supination excercises. Type Ⅱ unstable A closed treatment. reduse subluxation,sugar tong splint in 45 supination 4 to 6 weeks. A+B operative treatment. Type Ⅲ potentially unstable A anatomic reduction. if residual subluxation tendency present immobilize as in type Ⅱinjury. B functional aftertreatment to enhance remodelling of ulnar head.

32 Unstable DRUJ after fixation of radius Osseous injury Ligamentous injury Sigmoid notch Ulnar styloid process Base Tip fracture fracture Dose it reduce in supination? Repair or Immobilization in supination for 4w Yes Immobilization in supination for 4w No ORIF Current Concepts in the Treatment of Distal Radial Fractures David S. Ruch etc. / AAOS Instructional Course Lectures Trauma

33 ILLUSTRATIVE CASE 1 RI 14 UV 2mm VT -2 67y/o female Rt distal radius fx Fernandez typeⅢ AO 23-C3

34 ILLUSTRATIVE CASE 1 RI 22 UV 1mm RI 22 UV 2mm VT 7 VT 8 DF/PF 85/80 Supin/Pron 85/70 Grip Strength 20kg(18kg) P/O P/O 17M

35 ILLUSTRATIVE CASE 2 RI 19 UV 2mm VT y/o male Lt distal radius fx Fernandez typeⅠ AO 23-C3

36 ILLUSTRATIVE CASE 2 RI 20 UV 0mm RI 20 UV 1mm VT 1 P/O VT 1 P/O 6M DF/PF 85/55 Supin/Pron 90/60 Grip Strength 33kg(39kg)

37 ILLUSTRATIVE CASE 3 RI 19 UV 2mm RI 14 UV 3mm VT weeks after cast immobilization VT y/o female Rt distal radius fx Fernandez type Ⅰ AO 23-A3

38 ILLUSTRATIVE CASE 3 RI 21 UV 0mm VT 8

39 ILLUSTRATIVE CASE 4 RI 25 UV 3mm VT 12 83y/o female Lt distal radius fx Fernandez typeⅠ OTA 23-C2

40 ILLUSTRATIVE CASE 6 RI 22 UV 0mm VT 10

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