Update on Current Practice: Fractures of the Distal Radius Greg Rafijah, MD UCI Hand Surgery Nothing to declare! Distal Radius Fractures • Very common fracture • Wide range of complexity High Energy Injuries • Modern civilization – High velocity transport – Extreme sports – Falls from heights Treatment of Distal Radius Fractures CRPP Ex-Fix ORIF Non-displaced Fractures • Usually very stable • Immobilize 4-6 wks • Late EPL ruptures! EPL Rupture • Roth JHS May 2012 – 61 Non-displaced distal radius fractures – 3 EPL Ruptures (5%) – All females EPL Rupture • Roth JHS May 2012 – Average rupture 6.6 weeks after fracture – Etiologies • attrition • entrapment by callous, • 3rd dorsal extensor compartment syndrome Surgical Indications for DRFx • • • • • • Articular step off > 1-2 mm >10o dorsal tilt Radial inclination < 10o > 5 mm radial shortening Articular shear fractures Instability ASSESMENT OF STABILITY • Degree of initial displacement • Comminution > 1/3 of diameter • Articular fractures • Distal ulnar fractures • Loss of Reduction Stability vs Bone Mineral Density • Robin JHS May 2014 – Lumbar spine and femoral neck T-scores had no correlation to fracture stability following closed reduction and splinting AGE • Patient age affects decision making • Young / active patients – Do best with anatomic reconstruction • Low demand / elderly patients – tolerate significant deformity with good clinical and subjective results DVR vs Non-surgical treatment of Distal Radius Fractures >65 years • Arora JBJS 2011 – Prospective randomized trial of 73 patients – ORIF with VLP (36) vs CR and cast (37) – Cast group: 100% malunion rate – At 12 months • equivalent rom PRWE and DASH Scores • ORIF group had better grip strength CRPP • Minimally invasive • Effective in uncomplicated fractures • Poor fixation if bone soft or comminuted CRPP • Minimally invasive • Effective in uncomplicated fractures • Poor fixation if bone soft or comminuted External Fixation • Reduction tool – ligamentotaxis • Neutralization – supplement CRPP or ORIF • High complication rate – Mostly iatrogenic Ex-Fix Complications • Overdistraction: – Stiffness – Nonunion • Lunate: – < 1mm distraction • Fingers: – Supple full prom Ex-Fix Complications • Malposition – CTS – Stiffness – Pain – CRPS • SRN Injury • Metacarpal fracture • Pin tract infections Locking Internal Fixation • Supports comminuted articular fragments • Reduces need for bone grafting The VLP Revolution • JHS 2002 • 31 patients • Excellent clinical and radiographic results Intra-articular with Dorsal Displacement • • • • 60 y/o female musician Master of 7 instruments “Freaked out” Comminution, osteopenia Intra-articular with Dorsal Displacement • ORIF with all volar approach • Allograft bone putty VLP Plate vs EX-fix +/- CRPP • • • • • • • Kreder JBJS Br 2005 – Randomized 179 patients to ORIF vs Ex-fix – No significant differences Maragaliot JHS 2005 – No difference between ORIF vs external fixation Leung JBJS 2008 – Compared 144 AO Type C Fractures – ORIF non-locking distal radius plates vs EX-Fix +/- CRPP – ORIF resulted in better 24 month radiographic and functional outcomes over ex-fix McFayden Injury 2011 – VLP vs CRPP: better in functional and radiographic assessment in 56 patients Richard JHS 2011 – VLP vs EX-fix: better functional and radiographic results with VLP. More complications with external fixation Rozental JBJS 2009 – Randomized 45 patients to ORIF vs CRPP – No difference in DASH scores at one year Wilkensen JHS 2013 – 111 unstable DRF – Randomized to ORIF vs EX-fix +/- CRPP – Overall comparable results, but VLP with better supination at 1 year. – 15 VLP required removal • No significant differences VLP: Evolutionary Changes • Waljee JHS May 2014 – Younger surgeon more likely to perform ORIF – Older ASSH surgeon more likely to choose ex-fix +/- CRPP – Older non-ASSH surgeon more likely to treat non-operatively VLP Placement • Insert distal screws within 3 mm of subchondral bone • VLP placement distal to the “watershed line” increases risk of flexor tendon ruptures • Watershed line: volar rim attachment of the volar wrist capsule and transition in slope creates a sharp edge Volar Plate Placement Tanaka JHS 2011 • FPL at greatest risk when VLP plate is positioned distal to the “watershed line” Implant Design vs Tendon Rupture • Soong JBJS 2011 – VLP placement vs FPL rupture – 168 fractures – FPL ruptures vs plate placement • Proximal to watershed: 0 • Distal to watershed 4% Implant Design vs Tendon Rupture • Limthongthang JHS May 2014 – FPL at 54% maximum width of the distal radius – 19 mm from volar-ulnar corner DVR Plate: Distal Screws • Distal locking screws of VLP should not penetrate the dorsal cortex • Extensor tendon injury may occur DVR Plate: Distal Screws • Dorsal distal radius has a convex surface • Difficult to asses screw lengths in the lateral view • Go 2-3 mm shorter than measured to prevent inadvertent screw penetration VLP Plate: Distal Screw Lengths • Wall JHS 2012 – Biomechanical study of VLP plating of osteoporotic distal radius bone models – Locking distal screw of 75% length produced the same construct stiffness as bicortical fixation. – Shortening the distal screw length reduces extensor tendon injury risk without sacrifice of fracture stability. Intraoperative Flouroscopy • Essential for VLP application to ensure precision • Oblique views to can reduce late complications Tilt Views of DR Fractures • Eliminates overlap of articular surfaces that occurs in the standard projections • Improves assessment of articular surface reduction and intra-articular hardware Tilt Views of DR Fractures • Lateral tilt: – Angle beam parallel to inclination of radial styloid (10-20°) – Clear view of lunate fossa • PA tilt: – angle beam parallel to volar tilt (11°) Joseph JHS 2011 • “Dorsal Horizon View” in 15 cases of ORIF with VLP • 4 cases of dorsal screw penetration only detected with dorsal horizon view • Recommend oblique and dorsal horizon view intraoperatively to detect screw protrusion Radiographic Assessment • Ozer JHS May 2012 – 4 radiographic views of cadaver distal radii – Screw penetration of 1-3 mm • Standard lateral • 45° supination • 45° pronation • Dorsal tangential Ozer JHS May 2012 • Routine lateral: failed to detect all screw penetrations • Oblique views: screw penetration to the 2nd and 4th DC • Dorsal tangential: best to detect screw in 3rd DC DRUJ Evaluation • Avoid screw penetration to the DRUJ • AP view in full supination / slight shoulder ER – Clear view of the DRUJ – Intra-articular hardware – DRUJ Widening (< 1 mm gap) Articular Shear Fractures • Unstable intra-articular fractures • Carpal subuxation Articular Shear Fractures • Best treated with ORIF – VLP – Radial styloid plates Radial Styloid Plating • Excellent fixation of large radial styloid fragments • Pin plates • Locking plates Compression Fractures • • • • Comminuted intra-articular fractures Joint depression (“die punch”) Volar / dorsal lunate fragments Metaphyseal comminution and angulation possible The Volar-ulnar Corner: Volar Rim Fragment • 26% of intra-articular fractures – Short radiolunate ligament – Mandziak JHS 2011 • May result in volar carpal subluxation if not stabilized Volar Ulnar Corner • Must be certain to capture with VLP • Late subluxation may occur The Volar-ulnar Corner: Volar Rim Fragment • Keystone fragment in intra-articular fractures • Must be certain to capture with VLP The Volar-ulnar Corner: Volar Rim Fragment • Keystone fragment in intra-articular fractures. • Small distal fragments need low profile devices • Best addressed with a volar-ulnar approach Volar Ulnar Corner Fragment • Beck J, Harness N; JHS April 2014 – Prospective review • 52 fractures in 51 patients • AO B3.3 fractures at risk for loss of reduction Volar Ulnar Corner Fragment • Beck J, Harness N; JHS April 2014 – Increased risk for loss of fixation if: – Fragment length < 15 mm – Subsidence > 5mm Volar-Ulnar Approach • Extended carpal tunnel incision • FCU sheath (limited approach) Volar-Ulnar Approach • Allows exposure and access of volar-ulnar corner for accurate ORIF Volar-Ulnar Approach • Excellent visualization of volar-ulnar corner • Improved ability ORIF volar rim fractures • Complete median nerve decompression Compression Fractures: Fragment Specific Fixation • Complex patterns may need implants that can address and stabilize each fragment type 32 y/o male fall from ladder Fragment Specific: 2 months post op Compression Fracture • Fragment specific with locking plates Compression Fracture • Fragment specific with locking plates and pin plates ORIF DR Fx with Dry Arthroscopy • • • • del Piñal JHS 2011 Technical tips from > 700 dry wrist arthroscopies Dry arthroscopy prevents fluid extravastion ORIF with locking plates possible since no fluid to leak from the open incisions Arthroscopic Distal Radius Surgery • Del Piñal JHS May 2014 – Good results in small series of highly comminuted intra-articular distal radius fractures – Dry arthroscopic joint surface reduction Arthroscopic Distal Radius Surgery • Del Piñal JHS May 2014 – – – – Restoration of length Create a stable platform (VLP + 2 distal locking pegs) Fine tune reduction of the articular surface arthroscopically Finalize locking screw / peg insertion Distraction Plating • Excellent results reported by Ginn JBJS 2006 • Option for severe joint and metaphyseal comminution • “Internal external fixator” – Ligamentotaxis facilitates reduction • Biomechanically stronger than ex-fix Distraction Plating • • • • Reduces many risks of external fixation More durable than ex fix pins Eliminates the risk of pin tract infections Allows digit rom Distraction Plating: Technique • 3 limited dorsal incisions: – 2nd or 3rd metacarpal – dorsal to the fracture at 3rd compartment • epl transposition • May perfrom limited fixation and bone grafting – radius at least 4 cm proximal to the fracture Distraction Plating: Technique – Use 3.5 DCP or 2.4 mm distal radius plate – Slide the plate distal to proximal and secure Ruch JBJS 2005 • 22 patients with highly comminuted fractures of the distal radius treated with 3.5mm distraction plate to 3rd metacarpal • Limited ORIF articular surface Ruch JBJS 2005: Distraction Plate • All fractures united by 110 days, hwr: 124 days • One year: fl/ext = 57°/65°, p/s = 77°/76° • Grip 69% vs contralateral Final radiographic results: 4.6° palmar tilt, ulnar variance = 0 mm • 21/22 pts had articular step-off < 2mm Richard JHS 2012 • Distraction plating of highly comminuted distal radius fractures in older patients • 33 patients > 60 y/o (Mean age 70) • Mean follow-up: 47 weeks • Good maintenance of reduction – Wrist f/e=46°/ 50°; P/S= 79° / 77° • All fractures healed • HWR avg 119 days after fracture (70-280 days) • Effective management of osteoporotic comminuted distal radius fractures in elderly patients Nonunion Treatment with Spanning Plate • Mithami JHS May 2014 – Effective in 8 patients – Avg age 68 – Time to HWR avg 148 days – F/E: 36/39 – P/S: 79 / 72 DRUJ Assessment • Evaluate stability of DRUJ after fixation of distal radius fracture • All positions of forearm rotation • Splint in most stable position – Typically supination – Until suture removal – 3 wks if concern for instability DRUJ Assessment • High energy distal radius fracture • Displaced ulnar styloid DRUJ Assessment • If unstable in all forearm positions: • consider TFCC or ulnar styloid repair • If still unstable, cross pin DRUJ DRUJ Assessment • If unstable in all forearm positions: • consider TFCC or ulnar styloid repair • If still unstable, cross pin DRUJ Post-op Care • Splinting – Long arm splint in full supination until suture removal • 3 weeks if unstable DRUJ • Elevation – Strict elevation • ROM – Immediate digital AROM • OT Occupational Therapy • Souer JBJS 2011 – 94 patients s/p ORIF DRF with VLP – Randomized prospectively (Level 1) – OT vs surgeon directed home exercises Occupational Therapy • Souer JBJS 2011 – Independent exercise group had better outcome over the OT group at 3 and 6 months: • Superior wrist flexion/ extension – 129° vs 118° • Superior supination – 90° vs 84° • Grip strength – 92% vs 81% • No difference in DASH scores – Concludes OT does not improve outcome after VLP of DRFx Complications of Distal Radius Fracture Treatment • • • • • • • • Malunion CTS CRPS / RSD Infection Tendon ruptures Nonunion DRUJ instability ROM Loss Vitamin C Prevents CRPS? • Zollinger: 2 prospective randomized studies – Lancet 1999: prospective randomized study • vitamin C reduced the risk of CRPS by unknown mechanism – JBJS 2007: 416 patients with 427 wrist fractures randomized to placebo, 200mg, 500mg and 1,500 mg per day • Placebo group 10.1% incidence CRPP and 2.4% in the vitaminc C group • 200 mg group same as placebo • 500 mg group same as 1,500 mg group Vitamin C Prevents RSD? • Consider using Vitamin C 500 mg / day x 50 days to prevent CRPS in distal radius fracture – Minimal risk – Minimal expense – Why not?? 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