Long Case

CLOSED FRACTURE DISTAL RADIUS

SINISTRA
Liberty Yuliana Mandaha
1408010029
Pembimbing: dr. Su Djie To, Sp.OT
Distal Radial Fracture

• Common Injury
• Potential for functional impairment and frequent
complications
Incidence

• Fractures of the distal radius account for up to 20%

of all fractures seen in the emergency department.
• Occurs through distal metaphysis of radius.
• May involve articular surface
• FOOSH ( fall over outstretched hand)
- forced extension of carpus.
- impact loading over distal radius
• Associated injuries may accompany distal radius
fractures.
Diagnosis: History and Physical
Findings

• History of a FOOSH
• Visible deformity of the wrist, with the hand most
commonly displaced in the dorsal direction.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out.
• General physical examination of the patient,
including an evaluation of the injured joint, and a
joint above and below it
• Radiograph of the injured joint
• CT scan – in selected instances
Epidemiology

• Radius fracture is one of the most common fractures of the upper

extremity. More than 450,000 occur every year in the United States.
• The incidence of distal radius fracture in old age is always associated with
osteopenia and rises in incidence with increasing age, almost in parallel
with increased hip fracture complications. Distal radius fractures that
occur at a young age, are caused by trauma.
• Risk factors for radius fracture in the elderly include bone loss minerals,
female sex, white race, family history, and early menopause.
 Anatomy
• scaphoid and lunate fossa
-Ridge normally exists
between these two
• sigmoid notch: second
important articular surface
• triangular fibrocartilage
complex(TFCC): distal edge
of radius to base of ulnar
styloid
• Articular Surface
- Scaphoid facet
- Lunate facet
- Sigmoid notch
Patofisiology

• In most activities, the dorsal side of the distal radius

depends difficult, the volar side of the distal radius
relies on compression, this depends on the form of
integration of the cortex on the distal side of the
radius, while the dorsal side is thicker and stronger
elastic. Excessive loads and changes in trauma that
occur when the hand will determine the shape of the
fracture line that will occur.
Injuries related to fractures

• More than 68 percent of the fractures in the distal

radius and ulna correlate with soft tissue injuries,
such as partial and total tear of the TFCC, ligament
schapolunatum, and lunotriquetral ligament.
Mechanism of Fracture
• The general mechanism of fracture of the distal radius at a young age includes
falling from a height, motor vehicle accidents, or injury due to exercise. In the
elderly, distal radius fractures often arise from low energy mechanisms, such
as falling during walking, or slipping. The most common mechanism of injury is
falling into the outstretched hand with the wrist in dorsiflexion. Distal radius
fractures occur when dorsiflexion of the wrist varies between 40 and 90
degrees, with lower degrees of force required at smaller angles. Impaction of
the bone metaphysis distal radius of the carpal bone is also common. In
addition, the strength of the mechanism of trauma also often results in
involvement of the articular surface. High energy mechanisms (for example,
vehicle trauma / traffic accidents) can result in very comminutive shifts or
fractures (fractures of more than three fragments) and result in unstable wrist
joints.
Clinical Evaluation

• Clinically the patient is usually seen with a deformity in the form of

a dinner fork deformity which usually occurs in fracture colles, with
a picture like a fork, where the distal from the displaced radius
shifts towards the dorsal. It can also be a garden spade which
usually occurs in smith fractures where the distal of the radius is
displaced towards volar. The wrist is usually swollen with
hematoma, tenderness and limitations in movement. The ipsilateral
elbow and shoulders should also be examined for related injuries.
Neurovascular assessment must also be carried out, with special
attention to median nerve function. Symptoms of carpal tunnel
syndrome also occur occasionally (13% to 23%) because of the
forced position of hyperextension of the wrist, direct trauma from
fracture fragments, hematoma formation, or increased
compartment pressure.
 RADIOLOGY
• Radial Inclination: an average of 23 degrees (range, 13-
30 degrees)

• Radial length: an average of 11 mm (range, 8 to 18

mm)

• Palmar (volar) tilt: average 11 to 12 degrees (range, 0-

28 degrees)

• Ulnar Variance: (+ / - 1mm)

Measurement of Radial Length and
Inclination
Classification of Distal Radius
Fractures
Frykman Classification
TREATMENT
TREATMENT GOALS

• Preserve hand and wrist function

• Realign normal osseous anatomy
• promote bony healing
• Avoid complications
• Allow early finger and elbow ROM
NON-OPERATIVE MANAGEMENT
Indications for ClosedTreatment

• Low-energy fracture
• Low-demand patient
• Medical co-morbidities
• Minimal displacement-acceptable alignment
Closed Treatment of Distal Radial Fractures

• Obtaining and then maintaining an

acceptable reduction.
• Immobilization:
- long arm
- short arm adequate for elderly
patients
• Frequent follow-up necessary in order to
diagnose redisplacement.
Technique of Closed Reduction
• Anesthesia
- Hematoma block
- Intravenous sedation
- Bier block
• Traction: finger traps and weights
• Reduction Maneuver (dorsally angulated fracture):
- hyperextension of the distal fragment,
- Maintain weighted traction and reduce the distal to the
proximal fragment with pressure applied to the distal
radius.
• Apply well-molded splint or cast, with wrist in neutral to slight
flexion.
• Avoid Extreme Positions!
Indications for Immediate Surgical
Treatment
• High-energy injury
• Open injury
• Secondary loss of reduction
• Articular comminution, step-off, or gap
• Metaphyseal comminution or bone loss
• Loss of volar buttress with displacement
• DRUJ incongruity
OPERATIVE MANAGEMENT
Internal Fixation of Distal Radius Fractures

• Useful for elevation of depressed articular fragments

and bone grafting of metaphyseal defects
• required if articular fragments can not be adequately
reduced with percutaneous Methods
• Fixation with a plate is the primary action for
unstable fractures of the volar and medial columns of
the distal radius.
Selection of Approach

• Based on location of comminution.

• Dorsal approach for dorsally angulated fractures.
• Volar approach for volar rim fractures
• Radial styloid approach for buttressing of styloid
• Combined approaches needed for highcenergy
fractures with significant axial impaction.
The principle of handling the distal radius is the
replacement of the function of the hand controlled
by the hand. Conventional plates can be used to
support or neutralization plates, plates with locking
screws are also now often used, generally for loss
(osteoporosis).
Percutaneous Pinning-Methods

• this is mainly used for extraarticular

fractures or two parts of intraarticular
fractures.
• most common radial styloid pinning +
dorsal-ulnar corner of radius pinning
• supplemental immobilization with cast,
splint and in conjunction with external
fixation.
• Pins can be removed 3 to 4 weeks after
surgery, with additional gyps added 2 to 3
weeks.
percutaneous pinning technique in fractures of the distal radius using Kirschner wire
EXTERNAL FIXATION
Spanning ( Ligamentotaxis)

• A spanning fixator is one

which fixes distal radius
fractures by spanning
the carpus; I.e., fixation
into radius and
metacarpals
Non-spanning

• A non-spanning fixator is
one which fixes distal
radius fracture by
securing pins in the radius
alone, proximal to and
distal to the fracture site.
External Fixation
- Disadvantages -
• Bulky
• Poor screw hold in porosis and comminution
• Screws do not buttress
• More invasive
AJUVAN FIXATION

• Additional grafts may be autograft, allograft, or

synthetic graft.
• Ajuvan Kirschner fixation wire can help for smaller
fragments.
Arthroscopic

• reduce articular incongruities

• diagnose associated soft tissue lesions
• minimally invasive
• Fractures that can benefit most from adjuvant
Arthroscopy are:
(1) Articular fracture complex without comminution
metaphysis, main fracture with central impaction
fragments; and
(2) Distal radius fracture with TFCC (Triangular
Fibrocartilage Complex) injury.
Complications

• Mal-union
• Pin track infection
• RSD / arthrofibrosis
• Finger stiffness
• Loss of reduction; early vs late
• Tendon rupture
CASE REPORT
Identity

• Name: Mr. OA
• Age: 42 years old
• Sex: Male
• No. MR: 513996
Anamnesis

• CC: The lower left arm was hit by a rice threshing machine this morning
before being hospitalized.
• History: A 42-year-old male patient was referred from the Naibonat
Hospital with complaints of the lower left arm being hit by a rice
threshing machine at 11.00 (1/6/19) with the diagnosis of open
fracture Os. Radial 1/3 distal left. According to the patient while
holding the rice stem with a sack, the patient's hand is pulled into the
mouth of the threshing machine and exposed to the propeller. The
patient was immediately taken to the Fatukanutu PKM and was
referred again to the Naibonat Hospital, at that time the wound was
only wrapped with gauze, at 19.00 (1/6/19) the wound was sewn, the
patient had also received IVFD RL 500 cc 20 tpm, Inj. Ceftriaxone 1 gr
IV, Inj. Ketorolac 30 mg IV, Inj. Tranexamat 500 mg IV acid. The patient
arrived at Johannes 02.10 Hospital (2/6/19) and had received an Inj.
Ketorolac 30 mg IV and Inj. Ranitidine 50 mg IV. At present the patient
complains of pain in the lower left arm and the fingers of the left hand
feel stiff and painful when moved.
Primary Survey

• A: Clear & Patent

• B: Development of symmetrical chest wall D = S,
Regular, Vesicular Sound Breathing, RR: 20x / minute
• C: BP: 120/70 mmHg, HR: 80x / minute, CRT <2 seconds
• D: Alert, Round Pupil, Isokor, Φ 2mm / 2mm, RCL (+ /
+), RCTL (+ / +)
• E: It appears that the lower left arm is covered in gauze
and attached a pair of spalks, multiple vulnus
laseratum at the manus dorsum manus sinistra
Secondary Survey
• General Condition: Appear to be moderate Awareness: Mentis Compos
(GCS: E4M6V5)
• Head: Black hair, not easily pulled out
• Eyes: Round pupil, isocor, mm 2mm / 2mm, RCL (+ / +), RCTL (+ / +), CA (+ /
+), SI (+ / +) Hidung: Rhinorhea (- / -)
• Mouth: The lips are dry, pale mucosa
• Ears: Otorhea (- / -)
• Neck: KGB enlargement (- / -)
• Thorax: Appear, symmetrical chest wall development D = S, tenderness (-),
crepitus (-)
• Pulmo: Sonor (+ / +), Vesicular (+ / +), Ronchi (- / -), Wheezing (- / -)
• Cor: Single S1, regular, murmur (-), gallop (-)
• Abdomen: Looks flat, distended (-), BU (+) normal impression, not
palpable mass, liver and spleen do not enlarge, Tympanic (+)
• Extremities: warm akral, CRT <2 second.
 Status Of Localis

• L: The lower left arm appears gauze

and a pair of spalks with seepage
(+) is attached, multiple vulnus
laseratum at the left manus, after
the gauze and spalk are released
appear the vulnus laseratum which
has been sewn on the cystic
volaroid along ± 7 cm, edema (+)
• F: Warm, tender (+), crepitus (+)
• M: ROM is limited due to pain and
stiffness
Foto antebrachii
sinistra

A:Tampak malalignment os radius s

dan malalignment metacarpal IV S
•B: Tampak fraktur komplit tertutup
pada 1/3 distal os radius sinistra
dengan garis fraktur transversal dan
displacement ke posterior, komplikasi
(-)
•Tampak fraktur 1/3 proximal
metacarpal IV S dengan garis fraktur
tranversal dan displacement ke
posterior,komplikasi (-)
•C: There is no widening or narrowing
on ankle joint
•S: Tampak soft tissue swelling
Assesment

• Closed Fracture Distal Radius Sinistra

• Closed Fracture Shaft Metacarpal IV Sinistra
Diagnosis

• Closed Fracture Distal Radius Sinistra

Therapy

• Debridement
• ORIF K-wire
FOLLOW UP
FOLLOW UP
05/06/2019
• Subjective: Pain in the left hand and
the five fingers of the left hand is
difficult to move because of pain
• Objective: Within Normal Range
• Assesment: Closed Fracture
TERIMA KASIH