Tricks and Tips In the Management of Smashed Distal Radius Fx

INSTRUCTIONAL COURSE 2: Tricks and Tips In the
Management of Smashed Distal Radius Fx: Beyond Volar
Plating
Handouts
Thursday, September 18 * 4:45 - 6:00 PM
69TH ANNUAL MEETING OF THE ASSH
SEPTEMBER 18-20, 2014
BOSTON, MA
Moderator(s): Sanjeev Kakar, MD
Faculty: Peter J. Stern, MD
Jesse B. Jupiter, MD
David S. Ruch, MD
Jorge L. Orbay, MD
DISCLOSURES
Consulting fees: Arthrex, Skeletal Dynamics , Contracted Research: Arthrex (Kakar)
No relevant conflicts of interest to disclose ( Stern, Jupiter)
Royalties: Acumed, Zimmer, Speakers Bureau: Acumed, Other financial relationships: Lab
Support from Synthes (Ruch)
Royalties: Biomet (Orbay)
822. West Washington Boulevard
Chicago, Illinois 60607
Phone: (312) 880-1900
Fax: (847) 384-1435
Web: www.assh.org
Email: [email protected]
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement
or presentation made is to be regarded as dedicated to the public domain.
Pushing the Indications for
Volar Plating
ICL 2
September 18 2014
Boston, Massachusetts
Jorge L. Orbay MD.
Osteoporosis
1
Subchondral Scaffold
3-Part Articular Fracture
2
Removing hematoma allows reduction
Extended FCR Approach
3
FCR
Released
Flexor
Retinaculum
Distal FCR Release
Radial Septum Release
4
Fracture Debridement
Plate used as reduction template
5
1
2
3
4
Dorsal Fracture-Dislocation
Ligamentous and Bony Stability
6
4 Week Old Nascent Mal-Union
Standard Fixation Technique
Exision of contracted dorsal periosteum allows reduction
7
Extensor Tendon Anatomy
Dorsal Mal-Union
8
Sagittal Plane Correction
Coronal Plane Correction
9
Restoration of Radial Length
Cancellous Bone Graft
10
Fragment Specific Fixation in the
Management of
Distal Radius Fractures
Sanj Kakar MD, MBA
Associate Professor of Orthopaedics
Mayo Clinic
Rochester, MN
Disclosures
• Basic Science Research Grants
• ASSH
• Mayo Foundation
• Consulting
• Arthrex
• Skeletal Dynamics
1
Functional Anatomy of Distal Radius
• Distal Radius
composed of 3
concave articular
surfaces
• Scaphoid fossa
• Lunate fossa
• Sigmoid notch
• Stability maintained
by intrinsic &
extrinsic ligaments
Anatomic Goals In Management of
Distal Radius Fractures
• Articular congruity
within 1mm
• Loss radial
inclination < 50
• Radial shortening
< 2-3mm
• Neutral to volar tilt
better (0 to 110
volar)
2
When to Operate on Closed Distal
Radius Fractures
Unstable Fracture
1.
2.
3.
4.
5.
6.
Dorsal comminution
Dorsal angulation  20°
Intraarticular involvement
Ulnar fracture
Shortening  5 mm
Carpal malalignment
Treatment Methods
• Cast
• Pins & plaster
• Intrafocal pinning
• External fixation +/- k wire fixation
• Dorsal plates
• Volar plate fixation
• Distraction plating
• Intramedullary fixation
• Fragment specific fixation
3
One Treatment Does Not
Suit All !!!
Individualise tx based on the frx
Volar Plating
4
Volar Plating - Advantages
• Good soft tissue
envelope
• Can see volar cortex well
for frx reduction
• Fixed angle construct
• Preserve dorsal soft
tissue
Volar Plating - Advantages
• Avoids dorsal hardware & tendon irritation
• Locked subchondral distal
peg construct
→ ↓ subsidence
• Obviates need for bone graft
• Stable fixation → Early ROM
5
Volar Plating - Disadvantages
• If placed too distal → intraarticular hardware
• Extensor & flexor tendon
rupture
• One plate doesn’t suit all
fractures !!!!
Volar Plate - Limitations
• Indirect reduction
• No visualization of the
articular surface or
interosseous ligaments
• Difficult to address
• Unstable dorsal-ulnar frx
• Communited radial styloid frx
• ? role in mx of volar rim
fractures (past watershed
line)
6
Volar Marginal Rim Fractures
Inadequate fixation
• 7 pts (volar shearing frx)
• ORIF (volar plate)
• ALL pts → carpal subluxation (loss of volar corner fixation)
• 4 pt → repeat ORIF, 1 pt → radiocarpal fusion
7
Principles of Fragment
Specific Fixation
What are the fracture fragments ?
8
Putting this back into the column
concept
• Radial Column
• Radial styloid
• Intermediate Column
• Dorsal ulnar / volar ulnar corner
• Dorsal wall
• Free intra-articular
• Metaphyseal defects
• Ulnar Column
• Ulnar fractures
Build from the strongest foundation
• Volar Ulnar Corner
9
Fixation Order
5
2
1
3
4
Fragment Specific Systems
10
Trimed Fragment Specific Fixation
Components
What Does The Literature Show
As To Efficacy of Tx !!!
11
Biomechanical stability of volar locking screw plate
vs fragment specific fixation in distal radius fracture
model Cooper et al 2007
• Cadaver model
• Volar locking plate vs fragment specific
• Osteotomy with 4mm dorsal wedge excised
dorsal communition
• 4 point bending machine
• Stiffness ≡ both groups
• Frag specific fixation: ↓ linear displacement
& angulation
• 81 pts over 32 month (85 intra-articular DRF)
•
•
•
•
•
Gartland & Werley:
51 exc & 24 good
DASH score:
9
ROM:
~ 88% uninjured side
Grip:
92% uninjured side
62% pts:
normal rotation by 6 wks
• Complications:
10 pts DSRN & 5 pts ROH
12
• 14 pts [frag specific] & 85 pts [volar plate] over 1 yr
• Volar plate
• ↑ grip, pinch, ROM & MHQ scores (6M)
• ↑ radiographic parameters
• ↓ complications [3 major & 1 minor] 5%
• Frag specific fixation:
• ↑ complications (p<0.05) [8 major] 57%
• ROH (tendon or nerve irritation)
• Loss of radial height & volar tilt
But the devil is in
the details!!!
13
• Frag specific cohort
• ↑ intra-articular frx (type C)
• ↓ ability to correct initial volar tilt in OR
• Learning curve with technique !!!
• 21 pts [AO type C2 & C3] over 1 yr
• ROM:
• Flexion & extension
→ 500 & 630
• Pronosupination arc
→ 1490
• PRWE score
→ 20
• Post op radiographs
• Articular step off <2mm → 20/21 pts
• Mean volar tilt
→ 80
• Radial inclination
→ 250
• Complications
• ↑ OR times (120-236 mins)….learning curve!!!
• 3 major complications
“powerful tool to treat difficult frx”
14
Summary
• Each DRF is unique & should be
treated as such
• Carefully assess the frx to determine
optimal fixation
• It’s the SURGEON & not the hardware
that is most important for the eventual
outcome
15
• Fragment specific fixation is a powerful tool
for tx of multifragmented DRF
• Restores articular congruity
• Steep learning curve !!!
• Combined techniques may be best in
complex fractures
• Need better outcome studies to assess
efficacy
Thank You For Your Attention
Email:
[email protected]
16
The Use of Distraction Plating in Distal Radius Fracture Management
David S Ruch, MD
Professor and Vice Chair Department of Orthopedic Surgery
Chief of Division of Hand Surgery
Duke University Medical Center
Disclosures
Consultant for Synthes Acumed Zimmer
Research Support Synthes
Royalties from Zimmer, Acumed
External fixation is still a reasonable option
Palmar cortex reduces anatomically
External Fixation
Reduce Intermediate column
OutcomeRadial Length –Neutral to –1mm
Tilt –10 degrees to neutral
? Superior functional outcomes
“Indirect reduction and percutaneous fixation versus ORIF for displaced
intra-articular fractures of the distal radius” Kreder,HJ Hanel, DP Agel, J et
al JBJS 87-B 2005
179 Patients
Prospective randomized
Outcomes
Subjective-MFA
Objective -Radiographic/Physical Exam
Functional
“External Fixation Versus Open Reduction Internal Fixation for Intra-articular
Fractures of the Distal Radius” Kreeder et al OTA
External Fixation superior
Grip/pinch/range of motion
Functional outcome scores
No difference in xrays
Gap
Step
Problem: High Energy Injuries/ proximal extension/poor distal bone
q u a l i ty
Bridge Plates
Favorable biomechanics
“Internal” external fixator
Pin spread
Proximity to bone
Distraction Plate: Indications
Metaphyseal defect and soft tissue injury which precludes conventional forms
of fixation ie. non spanning plate or external fixator
Poly trauma patients requiring weight bearing on upper extremities
Bone loss with or without open fracture in osteo- penic bone (elderly) which
precludes non bridging fixation
Salvage of non union or malunion of articular fragments which preclude
internal fixation with conventional techniques
“The Use of Distraction Plating for Salvage of Meta-diaphyseal Fractures”
Ruch et al JBJS 2001
26 patients(13M/11F)
50.3y(19-93y)
9/24 polytrauma
Articular (C-2 or C-3)
+
Diaphyseal extension
High energy injuries: Soft Tissue Management
9/24 open fxs
1 STSG
3 flap closure
Lateral Arm/ Tendon transfer
Bone Defect
10/24 allograft
4 Tricortical graft
Bone Defect
4 osteomyelitis
4 antibiotic spacer
4 Tricortical graft
Polytrauma Patients
6 with ipsilateral humeral fraactures
9 patients with pelvic or femoral shaft fractures
Polytrauma Patients
2year follow-up
Results
Salvage – 15/24 >2 surgeries
DCP plate ave. 130 days (68-240d)
post op
No splint
Aggressive OT
Radiographic Results @ 2y
Ulnar variance:
0 degrees
Mean palmar tilt: 5.6 degrees
Radiocarpal congruity : 21/22 pts
Radioulnar congruity: 19/21pts
Expanded Indications
Elderly
Osteopenic
Open fx
Needs “prolonged fixation and a bone graft”
Expanded Indications
A Multicenter Study of Distraction Plating for the Treatment of Highly
Comminuted Distal Radius Fractures in Elderly Patients
Marc J. Richard, M.D., Leonid I. Katolik, M.D., Douglas P. Hanel, M.D.,
Michael Miller, B.S., and David S. Ruch, M.D.
Results
10 male
23 female
Age 60 – 82 (70 yrs)
12 UW, 21 Duke
7 open fxs
All C2, C3
Results
All fractures healed
Plate removal at mean of 126 days
Results
Mean palmar tilt 5.4°
2/33 dorsal tilt
Mean ulnar variance –0.7mm
30/33 congruent articular surface
Results
Mean flexion and extension
44° and 50°
Mean pronation and supination
82° and 80°
Mean DASH
35
Neutralization following intraarticular osteotomy
Stable DRUJ
“Corrective osteotomy for isolated malunion of the palmar lunate facet in distal
radius fractures” Ruch DS et al JHS 2010
13 patients with a malunion of the palmar facet
All with characteristic loss of extension and loss of rotation
Treatment consisted of osteotomy of the lunate facet and support with plate
Adjunctive dorsal bridge plate needed in two
Extension 53 degrees to 84
Supination 37 to 87 degrees
Delayed union / infection/
Hardware failure
Salvage of non unions after failed fixation of distal radius fractures Ruch, DS
et al JHS2014
10 patients 6F 4M
Ave age 62
Failed fixation
Distal fragement less than 2cm
All with hardware removal and spanning plate
3month
All united ave arc of motion 55 degrees
Restoration of anatomy is more critical than the technique used to treat the fracture
Why Would Anyone Want to Use An
External Fixator ?
JESSE JUPITER MD
1
2
J Am Acad Orthop Surg, Vol 17, No 6, June
2009
Lateral radiograph of a patient who presented with an
extensor pollicis longus rupture 8 months after
volar fixed-angle plating of a distal radius fracture.
Benson et al evaluated the third extensor compartment through a
limited dorsal incision in a clinical study of 10 patients. The
authors identified postreduction bone spurs, dorsal gapping at
the fracture site, and prominent screw tips as potential causes of
EPL rupture.
Flexor Tendon Problems after Volar Plate Fixation
of Distal Radius Fractures
Mehdi N. Adham & Margaret Porembski
HAND 1558-9447 (Print) 1558-9455 (Online) 2009
Recent studies have reported an incidence of FPL rupture of from 2% to
12%.Drobetz and Kutscha-Lissberg reported adhesion of flexor tendons requiring
tenolysis in one patient. Arora et al reported flexor tenosynovitis in 9 of 141
patients; all 9 patients were treated with hardware removal. In addition to FPL
rupture, rupture and inflammation of the flexor digitorum profundus to the index
finger have been noted
3
J Am Acad Orthop Surg, Vol 17, No 6, June 2009, 369-377.
Complications of Volar Plate Fixation for Managing Distal RadiusFractures
Lisa M. Berglund, MD and Terry M. Messer, MD
Neurovascular complications
Arora et al reported CTS in 3 of 141 patients who presented between 4 and 9 months postoperatively. All three patients required carpal tunnel release
and plate removal. Other series have reported an incidence of between 2% and 14%.
Inadequate exposure is the leading cause of failure to achieve reduction
The Extended Flexor Carpi Radialis Approach: A New Perspective for the Distal Radius Fracture
Orbay, Jorge L. M.D.; Badia, Alejandro M.D.; Indriago, Igor R. M.D.; Infante, Anthony D.O.; Khouri, Roger K. M.D.; Gonzalez, Eduardo M.D.; Fernandez, Diego L. M.D.
Techniques in Hand and Upper Extremity Surgery: 2001 ‐ Volume 5 ‐ Issue 4 ‐ pp 204‐211
loss of reduction is typically the result of one of three mechanisms: dorsal collapse leading to excessive dorsal tilt, loss of radial length, or loss of reduction involving the lunate facet.
4
5
6
7
EXTERNAL FIXATION
FRACTURES OF THE DISTAL RADIUS
MAIN INDICATIONS
1. COMBINED INJURY UPPER LIMB
2. OPEN FRACTURES
3. INFECTED FRACTURES
EXTERNAL FIXATION
FRACTURES OF THE DISTAL RADIUS
FURTHER INDICATIONS
5. AS DISTRACTOR FOR INDIRECT REDUCTION
6. TEMPORARY STABILISATION OF COMPLEX
FRACTURES
7. “SUBSTITUTION“ OPPOSITE CORTICAL DEFECT
(J. MAST)
8. FIXATION OF WRIST FRACTURES IN SEVERELY
MULTIPLE TRAUMATIZED PATIENTS
8
9
10
11
12
13
14 year follow up
14
15
16
17
18
SURGICAL TECHNIQUE
19
FRACTURES OF THE DISTAL RADIUS
EXTERNAL FIXATION
bridging external fixator
non-bridging external fixator
20
21
22
One year
AUGMENTATION OF EXTERNAL FIXATION
Direct stabilization of fracture fragments
with percutaneous K-wires
Fernandez DL, Jakob R, Büchler U, l983 - Seitz et al, 1991
1. decreased dependency on ligamentotaxis
a) minimizes extremes of positioning
b) reduction of wrist distraction
23
AUGMENTATION OF EXTERNAL FIXATION
2.
styloid pins neutralize deforming
brachioradialis forces (Wolfe et al, 1998)
3.
converts fixator to neutralization device
4.
opportunity for early motion, since
fixators may be removed at 6 weeks
Bridging external fixation of wrist fractures
A NUMBER OF STUDIES HAVE
REPORTED HIGHLY SATISFACTORY
FUNCTIONAL RESULTS
• flexion-extension
120°
• forearm rotation
150°
140° -
on average
24
Case
• 55 year old college
professor
• Avid squash player
• Closed fracture
• Neurovascular
intact
25
NON-BRIDGING EXTERNAL FIXATOR
26
27
NON-BRIDGING EXTERNAL FIXATOR
indications for its use depends on:
- SIZE OF THE DISTAL FRAGMENT(S)
- PIN PURCHASE (good bone quality, no comminution)
a) EXTRA-ARTICULAR UNSTABLE BENDING FRACTURE
b) 3-PART REDUCIBLE INTRA-ARTICULAR FRACTURE
NON-BRIDGING EXTERNAL FIXATOR
advantages:
• DIRECT CONTROL OF DISTAL FRAGMENT
• RESTORATION OF VOLAR TILT (joy sticks)
• INCREASED FRACTURE STABILITY
• EARLY WRIST MOTION POSSIBLE
28
MEASURES TO ENHANCE FRAME RIGIDITY
• increase pin diameter
• increase pin separation
• increase number of pins
• use converging oblique pin positioning
• radial preload (pin-bone interface)
• reduce distance between bone and rods
• additional side rods
COMPLICATIONS
• accidental nerve injury
• loss of reduction
• median nerve irritation
• pin tract infection
• Sudeck‘s dystrophy (RSD)
• non-union / mal-union
29
HOW TO AVOID POSTOPERATIVE
COMPLICATIONS
• instruct patient on pin desinfection
• apply physiotherapy measures
• X-ray control (1 – 2 – 6/7 weeks)
• restore neutral wrist postion at 3 – 4 weeks
• use dynamic splinting after fixator removal
in presence of contractures
30
PIN CARE:
a) „wrap around“ bulky
gauze dressing
b) clean with H202
CONCLUSIONS
1. DON‘T THROW YOUR FIXATORS AWAY !!
2. THIS TREATMENT MODALITY IS STILL A
VALID ALTERNATIVE IN THE MANAGEMENT
OF DISTAL RADIUS FRACTURES
3. HIGHLY RECOMMENDED IN.:
severe articular comminution
complex trauma + soft tissue damage
wrist fractures in the multiple injured patient
infected cases
31
ISTHEREAROLEFOREXTERNALFIXATIONOFDISTALRADIUSFRACTURESIN
2014?
JESSEBJUPITERMD
HANSJORGWYSS/AOPROFESSOR
HARVARDMEDICALSCHOOL
I.
ACCEPTEDROLESIN2014
A. HIGHENERGYTRAUMAWITHSOFTTISSUEINJURY
B. ADJUVANTSUPPORTFORPOTENTIALLYUNSTABLEINTERNAL
FIXATION
C. INFECTEDFRACTUREPOSTINTERNALFIXATION
D. PRELIMINARYFIXATION
II.
RECOGNIZEDADVANTAGESOVERCASTANDINTERNALFIXATION
A. MINIMALLYINVASIVE
B. MINIMALSCARRING
C. COMPLICATIONSMOSTLYMINOR(PINTRACK)
III.
APPLICATIONS
A. BRIDGINGvsNONBRIDGINGCONSTRUCTIONS
B. FAMILIARITYWITHTECHNIQUESANDFRAMES
WOLFESANDKANGLRECOMMENDATIONS
1. useminiincisionstoavoidnerveinjury
2. usepowerdrillandsalinecooling
3. supplementalfixation—k‐wiresorbonegraft/substitute
4. intraoperativefluoroscopy
5. avoidoverdistraction
6. avoidskintensionaroundpins
IV.
EVIDENCE
A. COCHRANEREVIEWCASTvsEXTERNALFIXATION
Evaluated1022patientstreatedfordorsallydisplacedfractures
Externalfixationsignificantremaintainingreduction
Nosignificantdifferenceinmajorcomplications
B. KREDERHJ,HANELDPetalORIFVSINDIRECTREDUCTION,EXTFIX,
Extfixpatientsrecoveredearlier
Nomajordifferenceincomplications
C. EgolKetalEXTFIXPLUSKWIREvsVOLARPLATING
LeungIFetalCOMPARISONEXTFIXPLUSPINSANDVOLARPLATE
XUCAetalCOMPARISONEXTFIXANDVOLARPLATES
Overallbetterresultswithvolarplating
V.
AREVOLARPLATECOMPLICATIONSUNDERREPORTED?
VIREFERENCES
1WolfeS,KangL.Bridgingexternalfixationwithpinaugmentation.InSlutskyD,
OstermanAL.Fracturesandinjuriesofthedistalradiusandcarpus.Elsevier2009,
pp55‐62.
2.HandolHHGetalExternalfixationvsconservativetreatmentfordistalradius
fracture.CochraneLibrary2007;1‐81.
3.McQueenMM.Non‐spanningexternalfixationofthedistalradius.HandClin2005:
21:375‐80.
4.GradlG,JupiterJBetal.Fracturesofthedistalradiustreatedwithanonbridging
externalfixationtechniqueusingmultiplanark‐wires.JHandSurg2005;30A:960‐
8.
5.EgolKetal.BridgingexternalfixationandsupplementaryK‐wirefixationvsvolar
lockedplatingforunstablefracturesofthedistalradius;arandomizedprospective
trial.JBoneJointSurgBr;2008:90:1214‐21.
6.KrederHJ,HanelDPetal.Indirectreductionandpercutaneousfixationfor
displacedintraarticularfracturesofthedistalradius:arandomizedcontrolledtrial.
JBoneJointSurgBr2005;87:829‐36.
7.LeungIFetal.Comparisonofexternalfixationandpercutaneouspinswithplate
fixationforintraarticulardistalradiusfracture:arandomizedtrial.JBoneJointSurg
Am2008;90:16‐22.
8.XuCGetal.Prospectiverandomizedstudyofintraarticularfracturesofthedistal
radius;comparisonbetweenexternalfixationandplatefixation.AnnAcadMed
Singapore2009;38:600‐6.
[Typetext]
[Typetext]
PeterJ.Stern,MD
ASSH,September2014
Boston,MA.
Management of Associated Injuries with Distal Radius Fractures
Causes of Median Nerve Compression
 Stretch
 Compression 2° to antebrachial hematoma
• Other hand fractures*
• Iatrogenic
– Cotton-Loder position
– Rare today
*Dyer G. JHS, 2008
Acute CTR: My Indications
• Progressionorpersistentsignsorsymptomsafterreduction&positioning
wristinneutral
• Literaturesuggests:nobenefittoprophylacticCTR
• Technique:
– separateincision
– ExtendedFCR*
• Bottomline:Almostnothingtolose
withCTR
*WeberandSanders,JHS,1997
ReleaseforChronicCTS
• ChronicCTSmaypresentindelayedfashion
• ResultsofCTRinferiortohistoriccontrols
• Nocorrelationwithseverityoffracture
• Outcomedoesnotcorrelatewithseverityofelectricalstudies
AssociatedFractures
 Incidence;5‐7%
o Carpus(thinkscaphoid)
o Elbow(thinkradialhead)
AssociatedFractures(Scaphoid)
 Youngmale
 Highenergy
 UsuallyrequiresI.F.withheadlessscrew
Komura,JHS,2012
CRPS‐II(Difficulttodiagnose)
Threeclinicalfindings
1. Disproportionatepain/tenderness
2. Swelling
[Typetext]
[Typetext]
PeterJ.Stern,MD
ASSH,September2014
Boston,MA.
3. Vasomotor/Sudomotor
CRPS (Treatment)
• Early recognition & treatment
• Vitamin C: 500mgm/ day (???)
• Physiotherapy (range of motion & edema control)
• Sympathetic blocks
• Meds.: (tricyclics, Prozac, gabapentin)
• Surgery *:if identifiable nerve lesion: decompress
*Jupiter et al. JBJS; 76A: 1376-84, 1994
Placzec et al. JHS 30A, 2005
Intercarpal Ligament Injuries*
Common but usually do not require surgical stabilization
• TFCC: 43%
• SLIL: 32%
• LT: 15%
*Geisler W et al. JBJS, 1996
SL Ligament Disruption*
 Common and usually does not require surgery
*Mudgal C, Hastings H. JHS, 1993
Adaptive Mid-carpal Instability*
 Dorsal subluxation of the carpus + DISI
 13 patients
o 6 recurrent dynamic midcarpal subluxation
o 7 midcarpal synovitis without dynamic subluxation
 Dynamic “snap” felt in ulnar deviation
 TREATMENT: Distal radius osteotomy
*Taleisnik and Watson, JHS, 1994
Radial Artery Aneurysm*
 Usually iatrogenic
 Treatment: ligation or interposition graft
*Dao KD, JHS, 2001
[Typetext]
[Typetext]
PeterJ.Stern,MD
ASSH,September2014
Boston,MA.

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