distal radius fractures: science and · distal radius fractures: science and art thomas trumble,...
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Distal Radius Fractures: Science and Art
Thomas Trumble, M.D.
Greetings from the Seattle
Comparing ORIF vs Closed Treatment
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Intra-articular vs Extra-articular
Paradigm of Intra- versusExtra-articular Fractures
> 20 years with deformity from extra-articular fracture
without symptoms
Pain and degeneration only 14 months after unrecognized
intra-articular fracture
• Plain radiographs< 1.0 mm
Plains X-rays can Dx Fx Displacement
Accurate Diagnostic Imaging
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Distal Radius Fractures
CT > radiograph accuracy: Cole JHS 1997
What is the most reliable fracture
classification
• Universal (Mayo)
• Frykman
• Melone
• A.O.
Classification B4 (Die Punch):
Die Punch fractures are added to the type B patterns
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Classification B4 (Die Punch):
Results
Function Decreases if Incongruity > 1.0mm:
Distal Radius Fractures
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Distal Radius Fractures
Classification C (Complex)
Disruption of articular surface
Plus disruption of metaphysis
Anatomy
22 mm
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Indications for Surgery
Step or Gap > 1.0 mm
1.0 mm
1.0 mm K-wire
2.0 mm
JHS 1986
Biomechanical Effect of Congruity
Biomechanical Effect of Congruity
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Biomechanical Effect of Congruity
> 1.0 step produces major load shift
What Type of Remodeling Occurs?
Intra-articular Fractures
The Effect of 1.0 mm Step OffTrumble et al, J Ortho Trauma 2002
Unloaded Area
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Cartilage Remodeling
Unloaded side Hypertrophies
Loaded side Compresses
Intra-articular Fractures
Remodeling the architecture of the Cartilage
100 micrometers
Overlapping Cartilage
Fracture Plane
Reduction in Extra-Articular Fractures?
• one cortex = pin
• two cortex = pin + Ext Fix
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Can You Use Percutaneous Pinning for Intra-articular Fractures?
•> 6 mths Pain score not different
Are Plates Stronger Than Pins?
Are Plates Stronger Than Pins?
36 52 68 84 100
Force (N)
0
1
2
3
4
Ave
rage
Mov
emen
t (m
m)
FixationPins
Plate
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Are Locking Screws Better than Pegs
Fracture Displacement with Extra-articular Fractures?
• one cortex = pin
• two cortex = pin + Ext Fix
Fracture Displacement with Extra-articular Fractures?
• 5 mm ulnar translate
• 10 mm radial shorten
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What Causes Pain after Distal Radius Fractures?
• dorsal angulation ≥ 20°
• ulnar shortening ≥ 2.0 mm
Science and Art: Summary
Intra-articular Fractures
• X-rays are sensitive but CT gives more detail
• Fracture Classification = KISS
• ORIF = ≤ 1.0 mm displace
• Plates > pins
• Locking screws > pegs
Science and Art: Summary
Extra-articular Fractures
• Pins are OK if only one cortex with comminution
• Ulnar translation (5 mm( and radial shortening (10 mm) cause loss of motion
• Ulnar wrist pain if ≥ 2 mm shorten or 20 °angulation
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Results: Function
Author F/U Age Flex/Ext Rad/Ulnar
Grip
Catalano(21 Pts)
7.1 30 126°(86%)
33 (89%)
88%
Trumble
(43 Pts)
2.5 37 120°(80%)
40 (88%)
69%
Results: Radiographic/Subjective
Author OA % > 2mm Step/Gap
Satisfaction
Catalano(21 Pts)
76% 13/21 (62%) All good/
excellent
Trumble
(43 Pts)
12% 1/43 (2%) (85%) no pain
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Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
Fixed angle of insertion
Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
15° Variable angle of insertion
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Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
Locking bearings = completely variable angle of insertion
Locking Plates
Locking Plates
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Locking Plates
Locking Plates
Dorsal Anatomic
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Dorsal anatomic
Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
Micronail: Wright Medical
Arthroscopic Reduction and Internal Fixation (ARIF)
Set up
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Arthroscopic Reduction and Internal Fixation (ARIF)
1. Stabilize Radial styloid
2. Reduce Lunate facet
Radial Styloid Fx
ARIF 3-Part Distal Radius Fracture
• Comminution Ext Fix + bone graft
Kotsu for Distal Radius Fractures
Avoid External Fixation
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Distal pin placement in Distal Radius Fractures
Retract 1st DI
• Protect RSN branches
•Retract 1st dorsal interosseous (DI)
External Fixation for Type C Fractures
• Use interval between ECRB and ECRL to protect RSN
Kotsu for Distal Radius Fractures
Avoid External Fixation
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Kotsu for Distal Radius Fractures
Avoid External Fixation Problems
Kotsu for Distal Radius Fractures
Avoid External Fixation Problems
Shiubumi for Distal Radius Fractures
Avoid External Fixation Problems
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Shiubumi for Distal Radius Fractures
Avoid External Fixation
Kotsu for Distal Radius Fractures
Avoid Painful Bone Graft Donor Sites
Bone Graft Substitutes
Goals?
• Provides mechanical filler
• Function as a grout to aid fixation
• Sets in 1-2 minutes not 15-20
• Absorbed as the fracture heals
• Inexpensive
• Injectable for minimally invasive procedures
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Synthetic Grafts: CaPO4
•Nonresorbable
• Injectable
• Slow setting
• Expensive
Synthetic Grafts•CaPO4 ± K-wire
Synthetic Grafts• Extrusion into the Joint
Medical and Legal concerns
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Grafts and Growth Factors
Thank you!
Kotsu = critical step for success or victory
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Synthetic Grafts• CaPO4
CaPO4
Synthetic GraftsMore to read?
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Complex Radius Malunion
• Stage I: debride osteomyelitis + IV antibiotics
• Stage I: ulnar shortening to relieve ulnar wrist pain
• Stage II: corrective osteotomy of radius if the patient still has clinical deformity and symptoms after osteomyelitis has resolved
Ulnar Shortening
Sequestrum
After Ulnar Shortening
6.0 mm shortening
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After Ulnar Shortening
6.0 mm shortening
After Radius Osteotomy
After Radius Osteotomy
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6.0 mm Lengthening
After Radius Osteotomy
Paradigm
Radius osteotomy provides more complete correction that ulnar shortening.
Volar Radius Malunions
• > clinical deformity per degree of malrotation
• Length is more difficult to assess because the dorsal rim is the landmark of AP x-rays
• A volar approach is required for corrections.
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Volar Radius Malunions
Dorsal Rim
Volar Radius Malunions
Volar Radius Malunions
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Volar Radius Malunions
A.O. C3 Radius Fracture
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A.O. C3 Radius Fracture
A.O. C3 Radius Fracture
Thank you!
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Cartilage Remodeling
Diagnostic Imaging
When to Order CT Scans?
• Complex fractures
• Volar rim fractures (die punch)
• Radial styloid (dorsal vs. volar)
Value of CT Imaging
Significant depression??
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Kotsu for Distal Radius Fractures
Perfection of anatomic reduction
• Knirk and Jupiter : > 1.0 mm = 90% DJD
• Fernandez and Geissler: ≤ 1.0 = 95% G&E results
• Trumble et al: ≤ 1.0 mm = increased grip strength and ROM
Thank You!