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Operative treatment of distal radius fractures


Indications

Operative management is indicated for distal radius fractures that have a dorsal tilt greater than 10 degrees, radial inclination angle of less than 15 degrees, radial shortening greater than 5 mm, positive ulnar variance greater than 3 mm, and/or an intraarticular step-off greater than or equal to 2 mm.

Clinical examination

  • The wrist should be assessed for deformity and any open wounds. Open fractures require urgent washout, fracture treatment, and antibiotics.

  • Significant displacement of the ulna may indicate ligamentous injury. The distal radioulnar joint (DRUJ) should be assessed for instability.

  • A complete neurovascular examination should be performed, with specific attention paid to median nerve function. Findings that indicate compromised median nerve function include numbness over the volar thumb, index, and middle finger, and numbness along the radial aspect of the ring finger and the corresponding part of the palm.

  • The elbow should be assessed for tenderness and deformity. These findings could indicate an associated radial head fracture or dislocation. Fracture patterns commonly associated with radial head trauma include:

    • Essex-Lopresti injury: A fracture of the radial head with disruption of the forearm interosseous membrane and DRUJ dislocation.

    • Monteggia fracture: Ulnar shaft fracture with associated radial head dislocation.

Imaging

  • Anteroposterior (AP), lateral, and oblique images of the wrist should be obtained. Proper reduction should restore radial inclination to 22 to 25 degrees, radial height to 10 to 15 mm, and volar tilt to 11 to 15 degrees ( Fig. 32.1A–C ).

    FIGURE 32.1, (A) Radial inclination is measured on the anteroposterior (AP) view as the angle of the articular surface of the radius relative to a line perpendicular to the shaft. (B) Radial height is measured on the AP view as a distance between two parallel lines perpendicular to the radius. One line is drawn at the top of the radial styloid, and another is drawn at the base of the articular surface. (C) Volar tilt is assessed on the lateral view. It is the angle between the radial articular surface and a line perpendicular to the long axis of radius.

  • The fracture pattern of the distal radius is assessed, such as whether the fracture pattern is intraarticular or extraarticular.

  • The ulna should be assessed for injury and the carpal bones assessed for displacement, abnormal spacing, or concomitant fracture.

  • Pay attention to the integrity of the radial shaft and metacarpals to ensure that these are available to provide sites for external fixation if necessary.

  • Computed tomography (CT) and magnetic resonance imaging (MRI) are usually unnecessary. Nevertheless, these imaging modalities can provide more detailed information for cases with comminuted articular fracture or suspicion of an associated lesion, such as ligament and carpal bone injuries.

Percutaneous pinning of distal radius fractures: Kapandji pinning technique

Indications

Indications for this procedure include:

  • Displaced and unstable extraarticular distal radius fractures, with minimal comminution ( Fig. 32.2A–C ).

    FIGURE 32.2, (A–C) A distal radius fracture that is indicated for operative management because of excessive radial shortening, decreased radial height, and dorsal tilt.

  • Simple two-part or three-part intraarticular distal radius fractures.

  • Displaced distal radius fractures in children or adolescents.

Surgical anatomy

  • Extensor tendons, the cephalic vein, and the superficial radial nerve are at potential risk for injury when inserting the pins.

  • Radial-sided pins are placed between the first and second dorsal compartments.

  • Dorsal-ulnar pins are placed in the intermediate column of the radius between the fourth and fifth extensor compartments.

Positioning

A radiolucent hand table is used with the forearm placed in a pronated position.

Exposures

  • Percutaneous Kirschner wire (K-wire) pinning can be performed in most cases. The K-wires are relatively blunt and will not skewer the tendons and nerves during the drilling process. Therefore most cases will not need open exposures.

  • For some patients who present with previous trauma or scar tissue over the insertion site, a so-called “mini-open” technique using 1 to 2 cm incisions can be performed to prevent injury to the underlying tendons and nerves during pinning. With the open approach, the soft tissue flaps are elevated, and the skin is retracted. Branches of the superficial radial nerve are identified and carefully protected.

Procedure

Step 1

  • The first 0.062-in (1.57-mm) K-wire is inserted into the radial aspect of the dorsal fracture line until the volar cortex is felt ( Fig. 32.3A–B ). This step is necessary to achieve suitable dorsal volar inclination of 11 degrees.

    FIGURE 32.3, (A–C) A Kirschner wire (K-wire) is inserted into the ulnar aspect of the dorsal fracture line. The wire driver and wire are then moved distally to reduce the distal radius fragment.

  • Using the dorsal cortex as a lever’s fulcrum, the wire driver and wire are then moved distally to lever and buttress the distal radial fragment into reduction (see Fig. 32.3C ).

  • With the fracture reduced, this pin is advanced into the volar cortex to secure the reduction. Be sure not to pass the K-wire back and forth over the volar cortex, which will enlarge the drill hole and loosen the K-wire.

  • A second pin should always be placed in the dorsoulnar aspect of the fracture to further support the reduction ( Fig. 32.4A–C ).

    FIGURE 32.4, (A–C) A second pin is placed in the dorsoradial aspect of the fracture to further support the reduction.

STEP 1 PEARLS

  • If there is difficulty in reducing the fracture, a blunt Freer elevator can be placed percutaneously. This can be inserted into the fracture site dorsally and used to lever the fracture into a reduced position.

  • To maintain stability in the volar cortex, the K-wire should be drilled only once. Drilling, reversing, and then redrilling can lead to loosening of the wire and fixation.

STEP 1 PITFALLS

Care should be taken not to over-reduce the fragment. Excessive flexion can displace the fragment volarly.

Step 2

  • A third pin is inserted in the radial aspect of the fracture line, perpendicular to the dorsal-volar pins ( Fig. 32.5A–B ). The aim of this pin is to restore radial inclination and prevent radial translation of the distal segment.

    FIGURE 32.5, (A–B) A third pin is inserted in the radial aspect of the fracture line perpendicular to the dorsal-volar pins. (C–D) The entire pin is translated distally to restore radial inclination.

  • The entire pin is then translated distally, with the surgeon’s fingers levering and pushing the distal fragment to restore radial inclination (see Fig. 32.5C–D ). Do not bend the K-wire during this reduction maneuver. Gently lever the distal fragment using pin and finger pressure.

  • The pin is then driven through the ulnar cortex of the radius to secure its position ( Fig. 32.6 ).

    FIGURE 32.6, The pin is then driven through the ulnar cortex of the radius to secure its position.

STEP 2 PITFALLS

Applying a lever force at the tip of the wire will lead to bending of the wire without reducing the fracture. Force is applied as close to the bone as possible while pushing with fingers to guide the distal fragment into reduction. An acceptable reduction is achieved when the thick volar cortices are aligned, rather than overlapping.

Step 3

A fourth pin is placed through the cortex of the radial styloid and advanced into the ulnar cortex to secure the reduction achieved by the intrafocal wires ( Fig. 32.7 ).

FIGURE 32.7, A fourth pin is placed through the cortex of the radial styloid and advanced into the ulnar cortex.

STEP 3 PEARLS

Percutaneous pinning can lead to tethering of the surrounding skin. Skin incisions may be necessary to release tethering around any pins.

STEP 3 PITFALLS

Because the radial styloid can be easily fragmented, avoid multiple passes of the K-wire.

Step 4

  • Several different percutaneous techniques have been described and can be tailored to the fracture pattern ( Fig. 32.8A–D ):

    • (A)

      Multiple radial styloid pins

    • (B)

      Cross radial pins

    • (C)

      Radial styloid and radial-ulnar pins, which can stabilize the DRUJ

    • (D)

      The De Palma technique, which uses the ulna to support the radius. Pins are placed from the ulna toward the radial styloid, targeting both the volar or dorsal cortex of the radius with separate pins.

    FIGURE 32.8, (A) Multiple radial styloid pins. (B) Cross radial pins. (C) Radial styloid and radial-ulnar pins, which can stabilize the distal radioulnar joint (DRUJ). (D) De Palma technique.

  • Pediatric fractures of the epiphysis in some cases can be treated adequately with a single radial pin ( Fig. 32.9A–D ).

    FIGURE 32.9, (A–D) Pediatric fractures of the epiphysis in some cases can be treated adequately with a single radial pin.

Postoperative care and expected outcomes

  • Patients are seen after 2 weeks for a dressing change and are converted to a removable thermoplastic splint.

  • The removable splint provides stability and enables cleaning of the pins. Active range of motion (ROM) of the fingers and elbow are initiated.

  • Pin tract infection ( Fig. 32.10 ) is a potential complication of percutaneous pinning, which presents with redness, warmth, swelling, and continuous discharge at the pin sites. If pin tracts become infected, pins are removed immediately, although this premature removal may lead to fracture collapse if the fracture has not reached full stability. Failure to promptly recognize and treat pin tract infections can cause the infection to progress to osteomyelitis, a disastrous complication that must be avoided at all costs.

    FIGURE 32.10, Redness, swelling, and discharge at the pin sites indicate pin tract infection.

  • To prevent pin tract infections, K-wires should be inspected and cleaned several times daily with 50% peroxide solution.

  • The K-wires are removed 6 weeks after surgery.

POSTOPERATIVE CARE PEARLS

Prolonged immobilization delays restoration of motion. Pins should be removed, and motion initiated as soon as there is evident callus formation to provide stability from displacement.

POSTOPERATIVE CARE PITFALLS

For older patients who do not have attendant care, or if a patient is at risk for poor hygiene habits, pins should be buried beneath the skin at the time of the initial operation to reduce infection risk. The pins can be retrieved later with a short second procedure under local anesthesia.

External fixation of distal radius fractures

Indications

Indications for this procedure include:

  • Distal radius fractures with severe comminution.

  • Fractures with significant impaction ( Fig. 32.11 ).

    FIGURE 32.11, Preoperative films of a patient with an impacted, dorsally angulated, and comminuted fracture.

  • Open injuries with significant soft tissue loss that may preclude the use of internal fixation.

Surgical anatomy

  • The distal pins are placed along the dorso radial aspect of the second metacarpal. The superficial radial sensory branch runs near the incision site and must be elevated away and protected.

  • The proximal pins are placed along the dorsal radial shaft of the radius. The position is proximal to the crossing of the tendons of the first compartment and distal to the insertion of the pronator teres (PT). The radial sensory nerve is also located in this area and should be protected.

Exposures

  • A 3-cm longitudinal incision is made along the dorsal radial side of the second metacarpal ( Fig. 32.12 ).

    FIGURE 32.12, Two 3-cm longitudinal incisions ( black dotted lines ) are made along the dorso radial aspect of the second metacarpal and the dorso radial aspect of the radius.

  • Another 3-cm longitudinal incision is made on the dorso radial aspect of the radius, 8 to 12 cm proximal to the wrist (see Fig. 32.12 ). Blunt dissection is used to expose the radius and proceeds between the tendons of the brachioradialis (BR) and extensor carpi radialis longus (ECRL).

EXPOSURES PITFALLS

Pure percutaneous placement or open incisions without adequate visualization increase the risk for iatrogenic nerve injury.

Procedure

Step 1

  • A 3-mm partially threaded pin ( Fig. 32.13 ) is inserted in a plane parallel to the metacarpals near the base of the index finger metacarpal using a double pin guide. The pin is driven perpendicular to the index finger metacarpal shaft ( Fig. 32.14 ). Be sure that the pin is centered over the bone to avoid iatrogenic fracture.

    FIGURE 32.13, The 3-mm partially threaded pins are used for external fixation.

    FIGURE 32.14, The pins are inserted in a parallel plane using the double pin guide.

  • The pin is centered between the dorsal and volar cortex and then driven from the radial cortex of the metacarpal to the ulnar cortex.

  • The parallel pin guide is used to place a second pin distal to the first. The guide facilitates insertion of the second pin at the same angle and plane as the first pin.

STEP 1 PITFALLS

  • Avoid oversinking the pins. This may inadvertently injure the interossei muscles.

  • A pin placed too dorsal or volar can risk fracturing the cortical bone of the metacarpal.

Step 2

  • After exposure of the radius, a 3-mm partially threaded pin is inserted perpendicular to the radial shaft between the BR and ECRL tendons in the same plane as the metacarpal pins.

  • A second pin is inserted distal to the first pin using the parallel pin guide.

  • All pins should be in a similar plane and angle ( Fig. 32.15 ).

    FIGURE 32.15, All pins should be in a similar plane and at the same angle.

STEP 2 PITFALLS

The partially threaded pins used for this procedure are self-tapping. Therefore these pins should be inserted with enough force to avoid getting stuck at the far cortex, which can lead to widening of the hole in the near cortex and pin loosening. An alternate pin site needs to be chosen if this happens.

Step 3

  • The proximal and distal incisions are closed with 4-0 nylon sutures around the pins.

  • A single distraction rod is applied, and the fracture is reduced into anatomic alignment using ligamentotaxis by distracting the wrist joint and using the ligaments around the wrist to reduce the fractures ( Fig. 32.16 ).

    FIGURE 32.16, A single distraction rod is applied and the fracture is reduced. Anatomic alignment is verified radiographically.

  • More complex fractures may require a multibar system.

  • Percutaneous pins or open reduction and internal fixation can be used to supplement external fixation for adequate restoration of the articular surface.

  • The pins are wrapped with petroleum gauze to protect the incisions until they heal.

STEP 3 PEARLS

Ensure adequate skin-to-fixator distance so that the device will not impinge on the soft tissues as they swell postoperatively.

STEP 3 PITFALLS

Take care not to injure the radial nerve and branches during closure because these structures lie directly beneath both incisions.

Postoperative care and expected outcomes

  • Dressings and sutures are removed at 10 to 14 days.

  • Patients can use soap and water to clean around the pins but should not wet the entire fixator in the shower or bath.

  • Finger ROM is encouraged after suture removal ( Fig. 32.17 ).

    FIGURE 32.17, Finger motion is encouraged after suture removal. This patient achieved excellent recovery of range of motion at 1 month.

  • The fixator is removed in the office at 5 to 6 weeks.

  • Patients can achieve excellent ROM at follow-up, but it may take several months because of prolonged wrist immobilization.

Volar plate fixation

Indications

Indications for this procedure include:

  • Comminuted or unstable intraarticular fractures ( Fig. 32.18 )

    FIGURE 32.18, Preoperative films of a patient with an intraarticular fracture of the distal radius with dorsal displacement and angulation.

  • Unstable extraarticular fractures

  • Volar shearing fractures

Surgical anatomy

  • The palmar cutaneous branch of the median nerve is ulnar to the flexor carpi radialis (FCR). For incisions radial to the FCR, there is no need to visualize this nerve during exposure ( Fig. 32.19 ).

    FIGURE 32.19, Surgical anatomy of volar plating.

  • The dissection takes place along the border of the FCR through the subcutaneous tissue to find the flexor pollicis longus (FPL).

  • Retracting the FPL ulnarly protects the median nerve.

  • A superficial branch of the radial artery courses slightly ulnar near the distal aspect of the dissection and should be protected.

Positioning

  • The upper extremity is extended on a hand table with the forearm supinated.

  • A tourniquet is placed on the upper arm.

Exposures

  • A 7- to 10-cm longitudinal incision is made along the radial border of the FCR, starting at the wrist crease and proceeding proximally. If more distal exposure is needed, the incision is extended as a zigzag over the joint ( Fig. 32.20 ).

    FIGURE 32.20, Longitudinal incision along the radial border of the flexor carpi radialis (FCR), extended as a zigzag over the joint if more distal exposure is necessary.

  • Use a sharp blade to perform the dissection. Identify and protect the radial artery and associated veins by retracting them radially. Crossing arterial branches are cauterized.

  • The FPL tendon and its muscle belly are manually swept away using a finger ( Fig. 32.21 ) and then retracted ulnarly to expose the pronator quadratus (PQ; Fig. 32.22A ).

    FIGURE 32.21, The flexor pollicis longus (FPL) tendon and its muscle belly are manually swept away.

    FIGURE 32.22, (A) The flexor pollicis longus (FPL) is retracted ulnarly to expose the pronator quadratus (PQ). (B) The PQ is divided along its radial and distal border.

  • The PQ is divided with an L-shaped incision along its radial and distal border, then elevated (see Fig. 32.22B ).

  • An elevator is used to strip the periosteum and expose the fracture ( Fig. 32.23 ).

    FIGURE 32.23, An elevator strips the pronator quadratus and exposes the fracture. The white arrow indicates the comminuted metaphyseal region.

EXPOSURES PEARLS

A blunt, rather than sharp, self-retaining retractor should be used to hold the exposure and avoid puncturing critical structures.

EXPOSURES PITFALLS

Take care not to disrupt the volar carpal ligaments from the radius, which can occur if the surgeon dissects too far distally.

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