Professional Documents
Culture Documents
09.20-09.35 - DR - Dr.heri Suroto - When To Operate
09.20-09.35 - DR - Dr.heri Suroto - When To Operate
09.20-09.35 - DR - Dr.heri Suroto - When To Operate
Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg
2004;29A:11281138
Nesbitt KF, Failla JM, and Les C. Assessment of Instability Factors in Adult Distal Radius Fractures. J Hand Surg
2004;29A:11281138
Initial
Postreduction
8 w post
reduction
3 m post
reduction
Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture
Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture
Osseous Anatomy
Distal radius 80% of axial
load
Scaphoid fossa
Lunate fossa
Sigmoid notch DRUJ
Distal ulna
Anatomy
scaphoid and lunate
fossa
Ridge normally exists
between these two
Orbay and Touhami (2006) dened the Watershed line as a transverse ridge
bordering the pronator fossa distally.
- The watershed line is a useful surgical landmark for positioning a volar plate.
- Implant placed on or distal to it can impinge on flexor tendon and cause
injury
Mechanism Of Injury
Low energy trauma:
In young adult, injury usually is as
result of high energy trauma &
results in comminuted, intraarticular
injuries
Tension on the volar cortex,
comminution of the dorsal cortex,
and ligamentous injury
Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture
Diagnosis
History
Physical exam, look for other injury
injury should be evaluated for:-
open/closed
degree of soft tissue injury
neurovascular injury- median nerve injury
common
Imaging
Wrist PA, Lat, and oblique
AP and lat. Of the contralateral wrist
Ct scan
Radiographic Assessment
radial inclination
volar tilt
radial length
Any intra-articular gap or step
Radial length
Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800
Radial Inclination
Radial inclination was
measured on the
posteroanterior view by
determining the angle
between a line
tangential to the distal
radial articular surface
and a line perpendicular
to the shaft of the radius
Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800
Cole RJ, et al. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal
radius: reliability of plain radiography versus computed tomography. J Hand Surg 1997;22A:792800
Ulnar variance
Vertical distance between
a) a line drawn parallel to
the proximal surface of the
lunate facet of the distal
radius and
b) a line parallel to the
articular surface of the
ulnar head.
Usually negative variance
(e.g. -1 mm) or neutral
variance
Computed Tomography
Indications:
Intra-articular fxs with multiple
fragments
centrally impacted fragments
DRUJ incongruity
19 consecutive fx, CT had
better sensitivity for
intraarticular frag
et al: J Hand Surg, 1997
management change in 5Cole
pts
Classication of
Distal Radius Fractures
Ideal system should
describe:
Type of injury
Severity
Evaluation
Treatment
Prognosis
Common Classications
Gartland/Werley
Frykman
Weber (AO/ASIF)
Melone
Column theory
Fernandez
(mechanism)
Frykman Classication
Extraarticular
Radio-carpal joint
Radio-ulnar joint
Both joints
Same pattern as
odd numbers,
except ulnar
styloid also
fractured
Presentation outline
1. Anatomic and biomechanic of distal
radius
2. Diagnostic establishment of distal
radial fracture
3. Nonoperative treatment of distal
radial fracture
4. Operative treatment of distal radial
fracture
Treatment Goals
Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review.
J Hand Surg 2008;33A:421429
Lafontaine et al suggested 5
factors that indicated
instability:
1. initial dorsal angulation
greater than 20,
2. dorsal comminution,
3. radiocarpal intraarticular
involvement,
4. associated ulna fractures,
5. age greater than 60
years.
Important radiographic
parameter
Anatomic studies
have determined
average values for
these important
radiographic
parameters:
radial inclination
(23),
palmar tilt (11),
radial length (12 mm)
Friberg S, Lundstrm B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol
Diagn 1976; 17:249 256.
A variety of pinning
methods have been
described;
The most popular is
oblique radial styloid to
proximal ulnar cortex,
as well as placement of
the pins through the
fracture site.
EXTERNAL FIXATION
It employs ligamentotaxis to
improve the length and
alignment of the fracture.
External xation:
The treatment of choice
for distal radius fractures
in the 1980s
Static
AO
Ace
Non-spanning
Hoffman 2
Cobra
Zimmer
AO
Nonbridging external
xation
A non-spanning xator is
one which xes distal radius
fracture by securing pins in
the radius alone, proximal
to and distal to the fracture
site.
In this instance, frag-ments
are reduced by direct
manipulation. The nonbridging method requires a
sizeable extra-articular
distal fracture fragment
DORSAL PLATES
Radius fractures with metaphyseal comminution typi-cally collapse in a dorsal
direction and a dorsal ap-proach will provide excellent articular surface
visual-ization and allow for buttressing of these fragments.
Disadvantages are that the plate is placed under the extensor tendons, which
may lead to extensor tendon irritation and rupture.
The lift-off method places the distal screws rst and then uses the
plate to correct the dorsal mal-alignment of the fracture.
Johannes Schneppendahl, MD, JoachimWindolf, MD, Robert A. Kaufmann, MD. J Hand Surg 2012;37A:17181725.
Anterior approach
Incision line over the
flexor carpi radialis
tendon.
Anterior approach
Anterior approach
Retractors are placed
gently to expose the
pronator quadratus
(arrow).
A smooth
Kirschner wire
is placed from
the radial
styloid across
the fracture
line to achieve
provisional
xation of the
fracture.
Jesse B. Jupiter, MD, M. Marent-Huber, and the LCP Study Group*
J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 1):96-106
Case Presentation
Summary
The standard of treatment for most fractures of the
distal radius remains closed reduction and
immobilization.
Surgical intervention should be considered when
an acceptable reduction cannot be achieved or
maintained by closed means.
Thank you