Distal Radius Fractures: Staying Out of Trouble Brad Palmer, MD Allegheny General Hospital Pittsburgh, PA Disclosures Nothing to Disclosure in the past 12 months, neither my spouse nor myself have had a financial relationship with a commercial interest (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients; with the exception of providers of clinical service directly to patients) Epidemiology Most common fracture of UE 1/6 of all fractures in ER 74% of all forearm fractures 195.2/100,000 persons per year $164,000,000 was spent on hospitalizations related to distal radius fracture in 2007 Bimodal High energy in predominantly young males Low energy in predominantly older females 1
History Abraham Colles (1814) This fracture takes place at about an inch and a half above the carpal extremity of the radius The carpus and base of the metacarpus appear to be thrown backward so much as on first view, to excite a suspicion that the carpus is dislocated. Treatment Trends Trend towards ORIF Finland 1998-2008 2x increase in surgical treatment 13x increase in use of open reduction and plate fixation ASSH Members more often treated patients with ORIF vs nonmembers (33% vs 16%, P<0.001) Mattila VM, Huttunen TT, Sillanpaa P, Niemi S, Pihlajamaki H, Kannus P. Significant change in the surgical treatment of distal radius fractures: a nationwide study between 1998 and 2008 in Finland. J Trauma 2011;71:939 942. Chung KC, Shauver MJ, Yin H. The relationship between ASSH membership and the treatment of distal radius fracture in the United States Medicare population. J Hand Surg 2011;36A:1288 1293. AAOS Guidelines December 5, 2009 Large work group Evidence based literature review Treatment of distal radius fracture in patients older then 19 years 2
AAOS Guidelines 219 page document 29 recommendations 14 inconclusive Could not recommend for or against a treatment modality 6 limited Treatment modality is an option 6 moderate Suggest treatment modality based on evidence 3 consesus Not enough evidence to support a modality but the work group all agreed the modality was reasonable AAOS Recommendation We are unable to recommend for or against any one specific operative method for fixation of distal radius fractures. Inconclusive AAOS recommendation Closed reduction and percutaneous fixation vs. ORIF Non-bridging vs. bridging external fixation Augmented bridging external fixation vs. percutaneous pinning Augmented bridging external fixation vs. bridging external fixation Augmented bridging external fixation vs. plate Augmented bridging external fixation vs. volar locking plate Bridging external fixation vs. percutaneous pinning Bridging external fixation vs. medullary pinning Bridging external fixation vs. pins and plaster Dorsal locking plate vs. dual plating 3
ORIF Indications: shearing marginal fx of joint surface Barton s fx, reverse Barton s fx, radial styloid fx unstable, extra-articular fx complex intra-articular fx irreducible fx radiocarpal fracture-dislocation associated carpal fx ipsilateral forearm or elbow fx ORIF Volar Plating Bridge Plating Volar Plating Evolution of the blade plate Locking distal screws Fixed angle device Now many versions with fixed or variable angle distal locking screws 4
So many choices Limthongthang R, Bachoura A, Jacoby SM, Osterman AL. Distal Radius Volar Plate Design and Associated Vulnerability of the Flexor Pollicis Longus. J Hand Surg Am. May 2014 39(5): 852-860. Adverse Events Carpal tunnel syndrome Tendon ruptures Intra-articular screw protusion Loss of fixation Carpal Tunnel Symptoms 12 of 60 patients treated nonoperatively 20% 17 of 69 patients treated with volar plating 25% Griffin JW, Chhabra AB. Complications After Volar Plating of Distal Radius Fracture: An Evidence Based Review. J Hand Surg Am. June 2014. 39: 1183-1185. 5
AAOS Recommendation We are unable to recommend for or against performing nerve decompression when nerve dysfunction persists after reduction. Inconclusive Volar Approach Volar Approach 6
Volar Approaches Eighty-three patients entered the CTR group. Thirty-one patients showed median nerve dysfunction 6 weeks after surgery. 91 patients entered the HRY group. Temporary median nerve paraesthesia was seen in 4 patients in the HRY group 6 weeks after surgery. After 1 year, persistent median nerve irritation was observed in 4 patients of the CTR group and none of the HRY group. Grip strength, range of motion, and Patient- Rated Wrist Evaluation were similar after 1 year. Lattmann T, Dietrich M,Meier C, Kilgus M. Comparison of 2 Surgical Approaches for Volar Locking Plate Osteosynthesis of the Distal Radius. Sept 2008. JHS:33:1135-1143. CTS after Volar Plating 10 patients Volar plate ORIF Insert slit catheters 24 hour continuous monitoring of carpal canal Fuller DA, Barrett M, Marburger RK, Hirsch R. Carpal canal pressures after volar plating of distal radius fractures. J Hand Surg Br. 2006;31(2):236e239. CTS after Volar Plating 10 patients 9 patients Pressures below 40 mmhg 1 patient 65 mmhg No patients had median nerve sypmtoms Fuller DA, Barrett M, Marburger RK, Hirsch R. Carpal canal pressures after volar plating of distal radius fractures. J Hand Surg Br. 2006;31(2):236e239. 7
Adverse Events Carpal tunnel syndrome Tendon ruptures Intra-articular screw protusion Loss of fixation Has been reports as high as 12% Many potential causes Previous steroid injections Plate material Plate prominence Plate/hardware placement Tendon Ruptures Soong, M., Earp, B.E., Bishop, G., Leung, A., and Blazar, P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011; 93: 328 335 Plate Position Retrospective review 4 year period 2 Groups Compared complications Group 1: 72 patients Group 2: 93 patient Soong, M., Earp, B.E., Bishop, G., Leung, A., and Blazar, P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011; 93: 328 335 8
Plate Position Grade 0 Dorsal to red line Grade 1 Volar to red line but proximal to the volar rim Grade 2 Plate at the rim or beyond Soong, M., Earp, B.E., Bishop, G., Leung, A., and Blazar, P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011; 93: 328 335 Plates at rim had more tendon ruptures Consider plate placement and design Soong, M., Earp, B.E., Bishop, G., Leung, A., and Blazar, P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011; 93: 328 335 Volar Plate Positioning Retrospective Review Patients SP ORIF of DR with volar plate 8 patients with flexor tendon ruptures Evaluate for radiographic parameters to identify risk factors for flexor tendon ruptures Kitay A, Swanstrom M, Schreiber JJ, Carlson MG, Nguyen JT, Weiland J, Daluiski A. Volar Plate Position and Flexor Tendon Rupture Following Radius Fracture Fixation. J Hand Surg Am. 2013;38(6):1091-1096. 9
Volar Plate Position A The measurements of plate position and prominence are demonstrated on this facet lateral radiograph. The plate to critical line distance (PCL) is measured with negative values for plates dorsal to the critical line (like the plate in this figure) and positive values for prominent plates volar to the critical line. The plate to volar rim (PVR) distance is measured with positive numbers for plates proximal to the volar rim (as demonstrated in the figure) and negative values for plates distal to the volar rim. The facet lateral radiograph in this figure was chosen for clarity, but for analysis, all PCL and PVR measurements were made on standard lateral radiographs. B The plate is Soong grade 0 because it is both dorsal to the volar critical line and proximal to the volar rim. Soong 1: plates volar to the volar critical line (but proximal to the volar rim). Soong 2: Distal plates that extend to the level of the volar rim or beyond. Volar Plate Position Risk Factors for flexor tendon rupture following distal radius fracture fixation with volar plates. recommend considering elective hardware removal after union in symptomatic patients with plate prominence greater than 2.0 mm volar to the critical line or plate position within 3.0 mm of the volar rim. Kitay A, Swanstrom M, Schreiber JJ, Carlson MG, Nguyen JT, Weiland J, Daluiski A. Volar Plate Position and Flexor Tendon Rupture Following Radius Fracture Fixation. J Hand Surg Am. 2013;38(6):1091-1096. Adverse Events Carpal tunnel syndrome Tendon ruptures Intra-articular screw protusion Loss of fixation 10
Screw Protusion Intra-articular screws Radiocarpal degeneration Out the dorsal cortex EPL tendon ruptures Intra-articular Screws 22 o tilted lateral view Standard lateral Tilted Lateral Lundy DW, Quisling SG, Lourie GM, Feiner CM, Lins RE. Tilted Lateral Radiographs in the Evaluation of Intra-articular Distal Radius Fractures. J Hand Surg Am. March 1999:24(2):249-256 Dorsal Screw Protusion Extensor tendon ruptures Difficult to accurately evaluate on Lateral or angled lateral views 11
Dorsal Horizon View Joseph SJ, Harvey JN. The Dorsal Horizon View: Detecting Screw Protusion at the Distal Radius. J Hand Surg Am. Oct 2011:36(10):1691-1693. Lateral views can be inaccurate Need to drill the dorsal cortex? Joseph SJ, Harvey JN. The Dorsal Horizon View: Detecting Screw Protusion at the Distal Radius. J Hand Surg Am. Oct 2011:36(10):1691-1693. 12
Screw Length Biomechanical SawBones Study Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed With Volar Locking Plates. J Hand Surg Am. March 2012:37(3):446-453. Adverse Events Carpal tunnel syndrome Tendon ruptures Intra-articular screw protusion Loss of fixation Loss of Fixation 72 year old female Slipped in the tub Volar <1cm open wound No neurologic deficits 13
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ORIF 4 weeks postop Lunate Facet Fragment Fixation can be challenging Attachment of the volar ligaments Loss of reduction leads to loss of extension and supination Ruch, D.S., Wray, W.H. III, Papadonikolakis, A., Richard, M.J., Leversedge, F.J., and Goldner, R.D. Corrective osteotomy for isolated malunion of the palmar lunate facet in distal radius fractures. J Hand Surg Am. 2010; 35: 1779 1786 15
Recognition Tear drop angle Lateral view Longitudinal axis of the radius Line parallel with the subchondral bone Normal ~70 o If <45 o there is marked dorsal tilt Medoff, R.J. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005; 21: 279 288 How to Fix? careful positioning of a volar plate on the ulnar-most aspect of the distal radius can allow for at least 2 points of fixation into the lunate facet fragment Volar plate fixation can also be augmented by adding a single cannulated screw with a washer to secure the lunate facet fragment Fragment-specific fixation low-profile plates wire loop fixation Kitay A, Madgal C. Volar Carpal Subluxation Following Lunate Facet Fracture. J Hand Surg Am. Nov 2014;39(11):2335-2341. How to Fix? 16
Specific Plates Specific Plates Comminuted Volar Rim 17
AAOS Recommendation In order to limit complications when using external fixation, it is an option to limit the duration of fixation. Limited Bridge Plating Spanning wrist plate internal external fixation Ligamentaxis Supplemental fixation High energy distal radius fractures Allow weightbearing Bridge Plating in the Elderly 33 patients (mean age, 70 y) distraction plating for comminuted distal radius fractures all fractures had healed radiographs demonstrated mean palmar tilt of 5 and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20 Mean values for wrist flexion and extension were 46 and 50, respectively. Mean pronation and supination were 79 and 77, respectively. At final follow-up, the mean DASH score was 32. Richard MJ, Katolik LI,Hanel DP, Wartinbee DA, Ruch DS. Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fracture in Elderly Patients. J of Hand Surg. May 2012:37:948-956. 18
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Take Home Points Volar Plating Plate Position Beware the lunate Facet fracture Dorsal Horizon View and Tilted Lateral View Bridge Plate Contact bpalmer1@wpahs.org 22