dr.y.nageshwarao neglected wrist fractures

NEGLECTED WRIST TRAUMA

Dr.Y.Nageswara rao

OSSAPCON 2012 RajahmundryOrganisng secretaryProf.Dr.C.Hanumanta Rao

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NEGLECTED TRAUMA AROUND WRIST

Distal radius#

Radius# DRUJ disruption

Carpal injuries

20% all skeletal injuriesWillful negligence

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WRIST&HAND

Highly evolved part of musculoskeletal system

It Occupies major part of motor cortex But most common neglected

anatomical region in trauma The natural fascination for hip in

academics and in practice has kept many sub specialities in low esteem

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WRIST EVOLUTION

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DISTAL RADIUS

The distal end of the radius is the anatomic foundation of the wrist joint.

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WGLECTED WRIST TRAUMA

Willful negligence

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1773--1843

“One consolation only remains, that the limb will at some remote period again enjoyperfect freedom in all its motions, andbe completely exempt from pain; thedeformity, however, will remain undiminishedthroughout life.”

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“enjoy perfectfreedom in all . . . motions, and exemptfrom pain,”

an Exception, rather a rule

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‘IT IS WHAT we THINK WE KNOW THAT KEEPS US FROM LEARNING’ ----------CLAUDE BERNARD

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OVERLOOKED WRIST TRAUMA

Distal radius malunions 1.Extra articular A. Dorsal malunion B. Volar malunion C. ulnar angulated molunion 2.Intraarticular malunions

3.Rotational malunion

Distal radius nonunoin

.

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WORK OUT

Radiological examination PA view &lateral view Comparative– x-rays in neutral position CT scan--------rotation of distal fragment MRI------------carpal abnormalities, TFCC

injuries, DRUJ evaluation

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RADIOLOGICAL PARAMETERS

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PATHOANATOMY & PATHOMECHANICS

RADIAL INCLINATION Normal 22degr Acceptable range >15deg

Decreasing the radial inclination shifted the load distribution so that there was more load in the lunate fossa and less load in the scaphoid fossa.

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PATHOANATOMYRADIAL TILT

11 degreeAcceptable – dorsal-15 volar-20

<10 degree dorsal angulation-normal FA rotation>30 degree gross restriction of FA>30 degreewrist motor function is significantly affected

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PATHOANATOMY

RADIAL LENGTH Normal-11mm Acceptable-<4mm

>4mm increased load on lunate facet

PATHOANATOMYULNAR

VARIANCENormal-0-neutralAcceptable—4mm

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Aro and Koivunen4 classification 3 types radioulnar relationships at theDRUJ after distal radius fractures.Axial shortening of the radius byless than 3 mm, designated grade 0,. Grade1- 3 to 5 mm of shortening. Grade 2- >5mm poor prognosis >2.5mm ↑40% ulnar load

Ulnar impaction syndrome

PATHOANATOMYROTATATIONAL

MOLUNIONDorsal angulation-supination deformity

Volar angulationPronation deformityMinimal role in FA rotationsSoft tissue contracture plays major role The Journal of Hand Surgery / Vol. 29A No. 1 January 2004

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38 degr rotation is required is to diagnose rotational mol union by cortical mismatchVolar shifting of ulna is an indication of rotational Correction per operative assesment-

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CARPAL MECHANICS

wrist instability in two distinct patterns:

(1) dorsal radiocarpal subluxation,with normal midcarpalalignment, and (2) adaptivemidcarpal dorsal intercalated segmentinstability (DISI) deformity

poor functional outcome, with a radiolunate angle > 25°

DRUJ BIOMECHANICS

Axial load at wrist 80% radius 20% ulna Ulnar variance of >2.5mm increases ulnar load by 42% Radial shortening& Dorsal angulation shifts center of rotation proximaxlly stretches dorsal radio ulnar ligaments

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DR ARTICULAR#S&RADIOCARPAL ARTHRITIS

step-off of >2 mm 100% incidence of

radiological arthritis 93% were said to be

symptomatic. AP distance of the injured

wrist when healed by >4mm

Tear drop angle(normal 70o ) decreased angle in lunate fossa depression

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MANAGEMENT STRATAGIES

Surgical management consists four major independent components:

1.Osteotomy, closed or open 2.Bone grafting, structural or

nonstructural 3.Fixation, dorsal-more stable volar-better soft tissue coverage volar fixed angle locking plate 4.Ulnar-side procedures

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CORRECTIVE OSTEOTOMIES

Closing Wedge osteotomies Opening Wedge osteotomies Variations

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CORRECTIVE OSTEOTOMIES

Closed wedge osteotomy

Open wedge osteotomy

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OSTEOTOMY VARIATIONS

Sliding osteotomy for correction

Thivaios GC, McKee MD: J Orthop Trauma 2003;17:326-333.)

Trapezoidal osteotomy

Watson HK,Castle TH Jr: J Hand Surg [Am] 1988;13:837-843. 1998,

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OSTEOTOMY &BONE GRAFTING

structural bone graft from the iliac crest the olecranon resected

portion of the distal ulna,

local graft from the radius

Non structural bone graft is equally good in long term results

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ROTATIONAL OSTEOTOMY

Sagittal rotational malunion after distal radius

osteotomy through the “hinge” point, and correcting the dorsal tilt A pure derotational osteotomy corrected

the apparent shortening of the radius and restored the volar tilt (Hand Surg Eur Vol April 2009 vol. 34 no. 2 160-165)

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TIMING OF OSTEOTOMY

Nascent malunion(8-12wks) Mature malunion long term results are equal

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MALUNITED ARTICULAR FRACTURES

The indication for the osteotomy

Dorsal or Volar subluxation of radiocarpal joint

Articular incongruity of >2 mm as on a PA radiograph

surgery is not based on symptoms because,by the time that symptoms develop,there may already be irreversible articular damage

ARTICULAR MAL UNION- SURG OPTIONS AS PER SAFFAR

Description of malunion Surgical options

1.Scaphoid Facet malunion

1.Intra articular osteotomy2.Radial styloidectomy3.Proximal Row carpectomy

2. Lunate facet malunion

1.Intra articular osteotomy2.Radio Lunate Fusion

3. Global wrist arthrosis

1.Early osteotomy2.Wrist denervation3.Wrist Arthrodesis

4.Anterior or Posterior Rim malunion

1.Rim excision

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ARTICULAR MALUNION

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MALUNITED ARTICULAR FRACTURES

The limitation of articular access

additional

articular damage still

challenging.

LIMITATIONS

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MALUNITED ARTICULAR FRACTURES

CONTRAINDICATIONS for osteotomy Established, advanced arthrosis Low-demand and infirm patients Patients with an age > 70 years have few symptoms and adequate wrist function:

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ULNAR SIDE PROCEDURES

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MILCH ULNAR SHORTENING

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DARRACH’S EXCISION

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SAUVE –KAPANDJI PROCEDURE

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MANAGEMENT OPTIONS IN LATE STAGES

Other Surgical Options(Salvage options )

Proximal row carpectomy, Radio scaphoid fusion, RadioScaphoLunate fusion Total wrist arthroplasty Total wrist fusion is the ultimate salvage procedure as a last resort.1

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PROX ROW CARPECTOMY

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TAKE HOME MESSAGE

Clinically asses the functional deficit “Willful negligence” concept to be applied

very cautiously Restore radial height, Restore radio ulnar relation Most cases require ulnar side procedure Be aggressive in treating young patients You cannot plead innocence because you

are ignorant------it could be legal negligence

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THANK YOU