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British Medical Books Health Issues Computerized Tomography

Distal Radius Fractures

Incidence

  • most common fractures of the upper extremity
  • account for one-sixth of all fractures treated
  • 5% of all theater cases in 1997
  • most common of all fracture-s in older people
    • postmenopausal osteoporosis

Anatomy

  • radio-carpal joint
  • ulno-carpal joint & TFC
  • DRUJ

Classification

  • commonly used eponyms - Colles, Barton, Smith fracture-s
    • not very useful
  • number of different classifications
    • guide optimal treatment
    • be of prognostic value

“Universal” classification - Modified Gartland & Werley

Fracture Type

  • I - Extra-articular, undisplaced
  • II - Non-articular, displaced
  • III - Intra-articular* without displaced joint surface
  • IV - Intra-articular* with displaced joint surface
    • A - reducible,stable
    • B - reducible,unstable
    • C - irreducible

Frykman classification

Fracture Type

  • Extra-articular, ulna intact (styloid process)
  • Extra-articular, fractured ulna
  • Intra-articular radiocarpal
  • Intra-articular radiocarpal, fractured ulna
  • Intra-articular radio-ulnar
  • Intra-articular radio-ulnar, fractured ulna
  • Intra-articular radiocarpal & radio-ulnar
  • Intra-articular radiocarpal & radio-ulnar, fractured ulna

AO system

  • Type A - Extra articular
  • Type B - Partial articular
  • Type C - Complete articular
    • each divided into three subgroups
    • further subdivided (eg. A1.1, C 3.2 etc)

Indications for surgery

  • very complex injuries with a variable prognosis
    • depends upon - fracture type
      • treatment given

Malunion

  • tendency to re-displace in plaster, mainly during the first 2 weeks
  • degree of disability after Colles fracture correlates with the amount of residual deformity
    • if malunion - 100% OA
    • 65% symptomatic

Patho-mechanism

Radio-carpal joint

  • dorsal tilt – >> pressure - OA
  • mid-carpal instability - DISI
  • articular incongruency

Ulno-carpal joint

  • ulno-carpal impingement
  • TFC tear

DRUJ

  • dorsal tilt of radius - non-congruent DRUJ
  • pain, << pro-supination

Methods that reduce residual deformity

  • Rush rods
  • percutaneous Kirschner wires
  • pins-in-plaster technique
  • external fixation
  • operative reduction & internal fixation

Radiographic evaluation

Measurements

AP view

  • radial inclination - 20-24°
  • radial length - 11mm
    • ulnar styloid to sigmoid notch
    • ulna variants - compare to N side

Lateral view

  • radial tilt - 11° volar

Good reduction

  • radial shortening < 5mm
  • inclination > 15°
  • radial tilt - < 20° volar & 15° dorsal
  • articular incongruency < 1mm

Can predict re-displacement in POP

  • dorsal angulation > 20 degrees
  • radial shortening > 3-5mm
  • surgical treatment should be done

Treatment

Extra-articular fractures

  • no comminution (stable) -> MUA & POP
    • max. 20° of flexion
  • comminution
    • < 50% diameter - > MUA & K-wires
    • > 50% comminution - > external fixator ± K-wires

Intra-articular fractures

  • simple without metaphyseal comminution (up to 4 fragments - Barton)
    • > MUA - K-wires
    • > ORIF - plate
  • metaphyseal comminution (> 4 fragments)
    • > external fixator
      • look out for superficial branch of radial N
      • radial pins - open, metacarpal pins stab wound
    • > if bone loss - > bone graft straight away

Distal radius fractures in children

  • common injury
  • fall on the wrist

True fracture

  • may involve distal ulna as well
  • usually unicortical - torus or buckle fractures
    • stable injury - MUA-POP
  • bi-cortical fracture
    • unstable - may angulate later - x-ray follow up

Physis injury

  • common - 6-10 yrs
  • usually Salter-Harris type I or II
  • MUA - POP for 4/52
  • good remodelling potential
  • may cause growth plate damage

Percutaneous Pin Fixation

Operative technique

  • done in theater
  • regional or general anaesthesia
  • torniquet
  • image intensifier-reduction checked
  • 1.6 mm K-wire inserted
    • from tip of radial styloid obliquely across fracture-site engaging the ulnar cortex
    • second pin inserted in a slightly more longitudinal direction
    • just penetrate the cortex of the proximal fragment

Other methods

  • at tip of the radial styloid, 45° angle with the long axis on AP ° aiming 10° dorsally
  • 2nd pin into the dorsal ulnar corner of the radius to cross the fracture in 45° on AP & 30° volarward on the lateral view
  • 3 - 4 K-wires inserted from the tip of the styloid process through the ulnar, dorsal & volar cortex of the prox. Fragment (Habernek et al.)
  • wire bent & cut above skin
  • below elbow POP in neutral position---post op X-rays
  • patient discharged on the next morning
  • check position in one week
  • K-wires removed under local anaesthesia at 6 weeks
  • active wrist movements started
  • final visit 3-4 weeks later
    • if function & X-rays satisfactory -> discharge
    • if function limited -> physiotherapy for 2-4/52 then discharge

Complications

  • anatomical studies -> following structures are in danger

1. Styloid process

  • m. brachioradialis, abD pollicis longus, extensor pollicis brevis, ECRL & B
  • r. superficialis n. radialis
  • v.cephalica.

2. Volar side

  • m. pronator quadratus, flexor digitorum superficialis, and occasionally the m. flexor pollicis longus
  • median nerve is endangered by unrestricted drilling of the volar cortex only.

3. Dorsal side

  • m. abductor pollicis longus, extensor pollicis brevis, extensor carpi radialis brevis and longus, extensor pollicis longus or extensor digitorum
  • posterior interosseous nerve and the accompanying vessels may also be damaged.

CLANCEY et.al.

  • no carpal tunnel sy.
  • no sympathetic dystrophy (Sudeck)
  • no loss of motion of the ipsilateral elbow or fingers
  • no infection, but pin migration in 2 patients with loss of reduction
    • wires are cut & allowed to retract subcutaneously (not bent)