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Distal radius fracture and Wrist injuries + science
Hans Tromborg, consultant hand surgeon, Associated professor, PhD
Odense University Hospital
Denmark
Undskyld
sprogforvirringen /
sammenblandingen
Disclaimer:
• Cochrane Distal radius fractures
• American Association Surgery of the
Hand 2012
The following is the opinion(s) of the author,
but with scientific backing
Problems (theoretical)
• When treatment shifts towards early mobilization after stable fixation of the fracture:
Will associated injuries then be treated adequately?
Do we sacrifice a few (young) patients in our quest for better results in the majority (elder)
• Are distal radius fractures/wrist injuries in the elderly and the young the same injury?
should treatment be different for the two groups
• Does conventional x-rays give us all the information we need about the lesion (fracture)?
Who need what kind of supplementary diagnostics
• Is acceptable reduction the same as acceptable position?
Problems (basale)
• Hvem skal opereres
Alder/aktivitetsniveau
• Hvilke skal opereres
Frakturtype, dislokation, ledsagelæsioner
• Hvornår skal der opereres
Akut/subakut, specialist/basalt, Ct først?
• Hvordan skal opereres
ORIF, ex-fix, k-tråd, “marvsøm”, artroskopi
Håndkirurgiske problemer (kendte)
eller: det er ofte os der forsøger at rage kastanierne ud af ilden
1. Smerter på ulnarsiden af håndleddet 2. Indskrænket sup/pro
3. Smerter i carpus evt med instabilitetsfornemmelse 4. Dem i kender:
CTS, seneruptur (mest EPL), infektion
5. ALDRIG (næsten) pseudoartrose
Epidemiology
(this is NOT a small problem)
• Incidence: 26/10.000
• 119/10.000 (women>80)
• 56/10.000 (women 50-80) ¾ displaced
Brogren 2007
Normal turnover
Osteoporose
Pearls and pittfalls
• BR hæfter distalt og strammes når armen ligger på armbord
• Fjern BR ved incerationen på distale radius.
Nærmest en fortykket periost.
Identificer evt APL/EPB i første kulisse med en længegående incision (så kan
du ikke tage fejl
Anatomic considerations
Brachioradialis
EPL
ANATOMY
• Dorsal side is NOT flat and smooth
• Radial styloid far distal and volar
• Sigmoid noch is
concave
Intra-operative Imaging
• • Traction view with anesthesia
• – May provide information without CT in acute
• setting
• • Fluoroscopy
• – PA, lateral
• – Multiple oblique views (pro, sup)
• – Tilt views (radial and volar)
• – Skyline or tangent views
Oblique, Tilt and Dorsal Tangent/Skyline Views
• • Increase the ability to detect intra-articular hardware, assess reduction and long dorsal screw tips.
• • They are used together to provide information
• • 11º for volar tilt
• • 15º-23º-30º degrees needed for radial tilt
• 15-23º for ulnar column
• 30º for the distal scaphoid facet
• • Ulnar column fixation is easier to see when placed first
45 proneret
45 supineret
•Recognize special fracture patterns
• Yellow = capitate
• Red =scafoid
• Green= Pisiform
Watch this!!
•
A 30 year old, right hand dominant woman was hit by a car
•
CT
Recommandations
• CT should be considered in young patients,
and when unacceptable intra-articular step
of cannot be ruled out (including the DRUJ)
Diagnostic
recommandations
• Classify
(but classification is not enough)
• Read the x-rays
(but do not trust them)
• Most of all: recognize problems
(and deal with them)
Most important???
X-ray or age
Of the many complications associated with distal radial fractures, post-traumatic arthritis is perhaps the most serious and disabling to the patient. Ghormley and Mroz stated, in 1932, that "any injury to the articular surface of the radius is bound to set up active traumatic arthritis in the radiocarpal joint.“ Frykman showed this to be true not only for the
radiocarpal but also for the DRUJ. Knirk and Jupiter found that intra-articular distal radius fractures that healed with
depression of an articular component of greater than 2 mm
resulted in radiographic evidence of post-traumatic arthritis in
more than 90% of the patients
Ældre (evidens)
• Over 55 år ingen
evidens for ORIF over konservativ
• Alle undersøgelser med meget svag power
• MÅSKE mere et udtryk for at vi
Classification system
Including recommandations on
acceptable position of fracture
AO
Un-acceptable reduction/position of the fracture
• More than 2 mm step of in articular surface
• More than 2 (3) mm shortening
• More than 12 (22) degrees of dorsal angulations
• More than 5 degrees of volar angulation
• (Rotation?)
Recommandations on
reduction/fixation.
Radiologic evaluation of stability
Lafontaine, injury 1989; Nesbitt J-Hand-Surg 2004, Mackenney JBJS 2006
