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
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
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
Classification B4 (Die Punch):
Results
Function Decreases if Incongruity > 1.0mm:
Distal Radius Fractures
Distal Radius Fractures
Classification C (Complex)
Disruption of articular surface
Plus disruption of metaphysis
Anatomy
22 mm
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
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
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
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
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
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
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
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
Kotsu for Distal Radius Fractures
Rigid Fixation
• Locking plates
• Anatomic plates
• Fracture nails
Locking bearings = completely variable angle of insertion
Locking Plates
Locking Plates
Locking Plates
Locking Plates
Dorsal Anatomic
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
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
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
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
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
Synthetic Grafts: CaPO4
•Nonresorbable
• Injectable
• Slow setting
• Expensive
Synthetic Grafts•CaPO4 ± K-wire
Synthetic Grafts• Extrusion into the Joint
Medical and Legal concerns
Grafts and Growth Factors
Thank you!
Kotsu = critical step for success or victory
Synthetic Grafts• CaPO4
CaPO4
Synthetic GraftsMore to read?
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
After Ulnar Shortening
6.0 mm shortening
After Radius Osteotomy
After Radius Osteotomy
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.
Volar Radius Malunions
Dorsal Rim
Volar Radius Malunions
Volar Radius Malunions
Volar Radius Malunions
A.O. C3 Radius Fracture
A.O. C3 Radius Fracture
A.O. C3 Radius Fracture
Thank you!
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??
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!