14. orbay distal radius fractures · 2018-04-16 · 9/24/2015 1 current solutions in orthopedic...

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Current Solutionsin

Orthopedic Trauma

September 19, 2015

Jorge L. Orbay MD.

Distal Radius FracturesState of the Art

Disclosure

Skeletal Dynamics

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6-8 weeks post-op

Two Pervasive Problems

• Volar Marginal Fragment

• Tendon Ruptures

1995

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Extensor Tendon Ruptures

PQ

1997

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1998 - 2013Volar Plate Evolution

Load Transmission Through the Wrist in the Extended Position

Masataka Majima, MD, Emiko Horii, MD, Hiroshi Matsuki, MD, Hitoshi Hirata, MD, Eiichi Genda, MD

( J Hand Surg 2008;33A:182 – 188.)

Ligament Contribution to Patterns of ArticularFractures of the Distal Radius

Daniel G. Mandziak, MBBS, Adam C. Watts, MBBS, Gregory I. Bain, PhD, Journal of Hand Surgery. 2011.07.014

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AMF

PMF

RF

Scaphoid Fossa Lunate Fossa

Scaphoid Fossa Lunate Fossa

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Scaphoid Fossa Fixation

Scaphoid Fossa

Lunate Fossa Fixation

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Lunate Fossa

Watershed Line

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Watershed Line

3 mm

Watershed Line

2 mm

Watershed Line

Watershed Line to Plate Distance

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5 mmVolar Marginal Fragment

Volar Lunate Fragment

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Volar Rim Hook Plate…

Volar Rim Hook Plate…

Extensor Tendon Problems

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Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal

Radius: A Cadaveric Study  

Steven D. Maschke & Peter J. Evans & David Schub &

Richard Drake & Jeffrey N. Lawton

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Lister’s Tubercle

EPL

Dorsal Horizon View: Detecting Screw Protrusionat the Distal Radius

Samuel James Joseph, MBBS, Jason N. Harvey, MBBS, FRACS

Dorsal Horizon View: Detecting Screw Protrusionat the Distal Radius

Samuel James Joseph, MBBS, Jason N. Harvey, MBBS, FRACS

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Extended Tangential View

Subchondral Support Line

orSubtract 2mm from DG measurement

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Standard Fixation Technique

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FDP IIFPL

Most Frequently Flexor Ruptured Tendons

#1 #2

Watershed Line

Watershed Line

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--------Volar Rim Lunate Fossa

Volar Radial -------Tubercle

Inter Fossa Sulcus

Bridging Effect

FPL

Tendon Center to Bone 4.5mm

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Tendon Center to Bone 4.5mmPlate to Tendon Surface ≈ 0mm

FPL

Distal Radius Volar Locking Plate Design and Associated Vulnerability of the Flexor Pollicis

Longus

Roongsak Limthongthang, MD, Abdo Bachoura, MD, Sidney M. Jacoby, MD, A. Lee Osterman, MD YJHS March 2014

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Volar Approach for Dorsal Fracture Not Trivial

Two difficult scenarios

• Inveterate fracture (> 2 weeks old)

• Complex articular fracture

Standard Fixation Technique

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Standard Fixation Technique

Removing dorsal hematoma allows reduction

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Extended FCR Approach

• Release FCR tendon sheath

Extended FCR Approach

• Release the radial septum

• Release FCR tendon sheath

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Extended FCR Approach

• Release the radial septum

• Pronate the proximal fragment

• Release FCR tendon sheath

Extended FCR Approach

• Release the radial septum

• Intrafocal Exposure

• Pronate the proximal fragment

• Release FCR tendon sheath

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FCR

Released Flexor

Retinaculum

Distal FCR Release

Intermuscular Membrane

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Release the Brachioradialis

Pronate Proximal Fragment

Fracture Debridement

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Fracture Debridement

Supinate Radius

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Proximal to Watershed Line

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Provisional K-Wire Fixation

K-Wire Guides

2 mm Rule

2 mm

2 mm

1- Reduce and Pin Lunate Fossa

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2- Reduce and Pin the Scaphoid Fossa

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Subchondral Support Scaffold

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Thank You!