Memuat...

29 Mar 2011

DISTAL FRACTURES OF THE RADIUS

Author: David L Nelson, MD, Consulting Surgeon, Private Practice

Introduction

Distal radius fractures (DRFs) in the time of Hippocrates and Galen were thought to be wrist dislocations. Pouteau first varied from this tradition when he described a variety of forearm fractures in the French literature, including a DRF. As a result, DRFs are termed Pouteau fractures in the French-speaking world. However, politics and communications being what they were, the English-speaking world did not recognize the Pouteau description.

The Irish surgeon Abraham Colles (pronounced collis) described DRFs in the 1814 volume of the Edinburgh Medical Surgical Journal. Colles based his descriptions on clinical examinations alone because radiography had not yet been invented. Despite this limitation, his description of the fracture itself is quite accurate, and his name is most often associated with this fracture in the English-speaking world. Colles stated, "One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain...." This claim that all DRFs, despite displacement, will fare well has been a source of criticism.
Over time, other eponyms have been added to the various subclassifications of DRFs, such as the Smith fracture, Barton fracture, and volar Barton fractures. The fractures are also referred to as various stages of classification systems, such as a Melone IV or an AO (ie, Arbeitsgemeinschaft für Osteosynthese, or Association for the Study of Osteosynthesis) C3 fracture, or are referred to the region of the fracture, such as a chauffeur's fracture.
In current practice, as a result of greater knowledge of the varieties of fracture configurations, eponyms are best avoided and a direct description of the fracture is preferred. The term designation DRF properly covers all fractures of the distal articular and metaphyseal areas. Although all classification systems have serious problems, general agreement exists regarding what some of the classification terms mean, such as the Melone IV or AO C3 fracture, and they do add some degree of specificity and understanding to the generic designation DRF.

The image below depicts a distal radial fracture.


Posteroanterior radiograph demonstrating the typi...

Posteroanterior radiograph demonstrating the typical features of a common distal radius fracture: loss of radial length, loss of radial tilt, and comminution at the fracture line.

Problem

The ultimate goal of treatment is to restore the patient to his or her prior level of functioning. The goal, therefore, is not the same in all patients. For example, a 21-year-old athlete wants to resume competition, but an 82-year-old person usually only wants to return to activities of daily living (ADLs).1,2 Because the goals are different, the treatment options are different; but also, because people now remain active until an older age, the definition of "prior level of functioning" is changing. For example, a 92-year-old patient who was being treated in the emergency department had only one concern when conversing with his physician: how soon could he return to playing golf (he had a tournament the next week). Treatment goals, therefore, must be tailored to each patient. Specifically, age should not determine the treatment; the activity level should determine the treatment.

Frequency

Distal radius fractures (DRFs) are among the most common type of fracture, and many authors state that they are the most common type of fracture. DRFs have a bimodal distribution, with a peak in younger persons (aged 18-25 y) and a second peak in older persons (>65 y) persons. The mechanism of injury is unique to each group, with high-energy injuries being more common in the younger group and low-energy injuries being more common in the older group.

Etiology

Younger patients have stronger bone and require more energy to create a fracture. Motorcycle accidents, falls from a height, and similar situations are common causes for a distal radius fracture (DRF). Trauma is the leading cause of death in the 15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas.
Older patients have much weaker bones and can sustain a DRF from simply falling on an outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to these injuries being termed fragility fractures, with the implication that a workup for osteoporosis should be a standard part of treatment. As the population lives longer, the frequency of this type of fracture will increase.

Pathophysiology

The pathophysiology of a fracture is rather obvious: more load is imparted than the bone can sustain. However, the patient should be questioned regarding the circumstances of the injury, especially older patients. Heart attacks or transient ischemic attacks can cause a distal radius fracture (DRF) and should not be overlooked. In addition, more problems may be involved with the injury than just the fracture. A useful perspective is that a DRF is a soft-tissue injury surrounding a broken bone, and the immediacy of the radiographic diagnosis should not distract the surgeon from carefully assessing systemic issues or forearm soft-tissue issues.3

Presentation

The history should be directed toward ascertaining the probable amount of energy involved. A fall from 20 feet can be associated with quite a different constellation of injuries (ie, more than just the fracture seen on the radiograph) from a fall from a standing position. A history of prior fractures should be sought. A history of fragility fractures helps predict the stability of any reduction. A history of multiple high-energy fractures in a younger patient helps predict the ability of the patient to comply with directions.
The median nerve is always compressed after a fall on the palmar aspect of the hand that results in a distal radius fracture (DRF), and the chart note should specifically document the quality (not just the presence or absence) of the median nerve function. Most treatments have median nerve implications. A cast or splint without a reduction may result in median nerve compromise due to pressure. A reduction, whether closed or open, involves some level of anesthesia, temporarily compromising the ability to assess the median nerve. Careful documentation of median nerve function at the first assessment is critical to planning and assessing treatment, not to mention protecting the surgeon from subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

Indications

Introduction to indications
No consensus has been reached on classification systems, indications for surgery, or a particular choice of surgery since the orthopedic community first rejected Colles' contention that all distal radius fractures (DRFs) heal well. Gartland and Werley are generally credited with starting the revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the discussion into the modern era with his 1986 paper that emphasized the importance of reduction.
Despite the large number of papers published each year on DRFs, no consensus has been reached on treatment and no indications are evident that a consensus might be developing. Indeed, with one approach advocating immediate motion using a fixed-angle volar plate and another advocating motion at 3 months using an internal joint-spanning plate, the treatment options seem to be diverging rather than converging.
One area of agreement is that fractures in active adults should be reduced anatomically; however, unfortunately, the term "anatomically" also has not had any consensus definition.
Even with classification, no consensus has been reached. The International Federation of Societies for Surgery of the Hand formed a working group of the most distinguished minds in DRF management to investigate for the existence of a consensus on the best classification system or, if one did not exist, to develop one. The group concluded that no available system was universally useful or accepted and none could be developed by the working group. Please see the report How to Classify Distal Radial Fractures.
The consensus has been reached that the goal of treatment is to restore the patient to the prior level of functioning, and this is the starting point for all discussion.

Classification
The goals of any classification system are to stratify the injuries, guide treatment, facilitate discussion, and predict outcome. Each classification system has its merits and weaknesses with respect to each goal, and often, more than one classification system is needed. Please see the report How to Classify Distal Radial Fractures.
The classification systems used most frequently are the Frykman, Melone, AO, and Fernandez systems.
  • The Frykman classification highlights the injury to the distal radioulnar joint.
  • The Melone classification, based on the paper by Scheck, highlights the fragmentation of the articular surface, especially the dorsoulnar corner of the distal radius.
  • The AO classification emphasizes the location as extra-articular, partial articular, and completely articular.
  • The Fernandez classification is based on the mechanism of injury, deduced from the displacement of the bone and the location of the fracture lines.
A classification system that approaches the topic from another angle categorizes fracture patterns according to the 3-column concept of the wrist and proposes treatment accordingly. This approach was independently developed by Rob Medoff, MD, in 1994 (personal communication) and by Rikli and Rigazzoni.4 The 3 columns are the lateral column (the radial half of the radius, including the radial styloid and the scaphoid facet, although Medoff differentiates these 2); the central column (the ulnar half of the radius, including the lunate facet); and the medial column (the ulna, the TFC, and the DRUJ). Each column is considered separately as to its need for reduction and stabilization. It should be noted that this conceptual approach does not exclude any other approaches but, rather, is complementary to them.

The 3-column concept.

The 3-column concept.

Indications for reduction and/or operative treatment For more information, please see Indications for Reduction in Distal Radial Fractures.
The goal of treatment is to return the patient to prior level of functioning. Most authors advocate an anatomic reduction. This admonition has 2 problems. First, not all patients need an anatomic reduction to be able to resume their normal activities. Second, the concept of anatomic reduction is not defined. No authorities advocate operative reduction if the stepoff is 0.5 mm; however, a stepoff of 0.5 mm is obviously not anatomic. On the other hand, a 20° dorsal tilt is not anatomic, yet inactive elderly adults can easily return to their previous level of functioning with this alignment.
The indications for reduction or operative treatment need to be tailored to the individual patient. Also avoid erring in the opposite direction — that is, considering that any patient who is old does not require an anatomic reduction. Balanced judgment is required.
Most authors would recommend anatomic reduction in a patient who is active in recreation (remember that golf and tennis are common activities for persons older than 70 y.) or engages in forceful activities at work. Conversely, if the patient is sedentary, a lesser reduction may allow return to full activities. Usually, 3 parameters are relevant: intra-articular stepoff, dorsal tilt, and radial length. Radial tilt is generally considered a lesser parameter.
  • Intra-articular stepoff
    • Defining anatomic reduction in terms of intra-articular stepoff is challenging. Most authors would accept less than 1 mm of intra-articular stepoff but not more than 2 mm; neutral dorsal tilt but not more than 10° (the range is quite large in the literature, with some authors not accepting more than neutral); and 2 mm of radial shortening but not more than 5 mm. The challenge can be in making a reliable determination of these parameters — that is, how to distinguish between less than 1 mm and greater than 1 mm. Please see Indications for Reduction in Distal Radial Fractures for more information. The challenge is that these opinions are based on studies using routine plain radiographs, which cannot accurately measure stepoffs with an accuracy of 1 mm.
    • The threshold of 1 mm for intra-articular displacement is commonly cited in the literature, referencing a 1986 landmark paper by Knirk and Jupiter.5 However, Jupiter has stated repeatedly that this threshold is not the benchmark that subsequent authors have used, that the 1986 study had methodologic flaws, and that ligamentous injuries may better account for the functional limitations of the patients than the intra-articular stepoff. Surgeons need to review the literature with this in mind, because it changes the reliability of the conclusions reached by many authors after 1986.
  • Dorsal tilt: Fewer comparative studies have been published on dorsal tilt (both basic science and clinical), but this has not limited authors from making pronouncements. The range of anatomic alignment for dorsal tilt has reportedly been from 0-10°, with no proviso for less active patients. A neutral (0°) alignment represents an 11° loss of volar angulation, so even the most conservative figure is not truly anatomic. Commonly, some older, inactive patients have full resumption of their activities with dorsal tilts of 45° or more. Although orthopedic surgeons may find the radiographs of these patients disturbing and the clinical deformity not much better, some patients are quite satisfied and able to function in all of their ADLs, which calls into question any rigid threshold of dorsal tilt, whether it be 0° or 10°. Most authors recommend no more than neutral to 10° of dorsal tilt in healthy, active individuals.
  • Radial length: The basic science of radial length is clear. Shortening of 2 mm of radial length doubles the load through the triangular fibrocartilage and the ulna. The clinical relevance of this fact in the context of distal radius fractures (DRFs) is unclear. Additionally, altering the radius length relative to the ulna affects the function and forces associated with the distal radioulnar joint. On the basis of less well-defined clinical grounds, most authors would not accept more than 2-5 mm of shortening.
Stability of reduction Another topic that has not been resolved is the stability of the reduction if performed in a closed procedure and without operative support to the fracture fragments. Some authors believe that a 30° dorsal tilt or any radial shortening will not be stable and will subside. If function requires that reduction is achieved, surgery is needed to maintain it.
Agreement has been reached that weekly radiographic assessment is required for approximately 3 weeks. Fractures do not commonly subside after 3 weeks, but this is not a certainty. Care must be observed to compare the current radiograph with the postreduction radiograph because subsidence is gradual and can be difficult to detect.

Relevant Anatomy

See the following images for anatomical descriptions of the radius:
Image below shows the volar surface. The large lunate facet is seen on the left, projecting out from the surface of the radius. The volar radial tuberosity is at the right margin of the bone. The surface is covered with the pronator quadratus (PQ). The cortical bone is quite thick and is strong, even in osteoporotic patients.
Volar surface.

Volar surface.

Image below shows the dorsal surface of the radius. The Lister tubercle is seen in the center. This bone is a thin cortical shell, with little structural strength.
Dorsal surface.

Dorsal surface.

Image below shows the radial surface of the radius.
Radial surface.

Radial surface.

Image below shows the ulnar surface of the radius, with the sigmoid notch for articulating with the ulna.
Ulnar surface.

Ulnar surface.

Image below shows the distal articular surface of the radius. The scaphoid facet is to the right, and the lunate facet is to the left. This bone is the strongest of all the surfaces, and even if it is osteoporotic, it is quite strong.
Distal surface.

Distal surface.

Image below shows a normal posteroanterior radiograph of the radius. The ulna is generally within (plus or minus) 2 mm of the radius.
Posteroanterior radiograph.

Posteroanterior radiograph.

Image below shows a normal lateral radiograph. Note that the center of the lunate facet overlies the volar surface of the bone.
Lateral radiograph.

Lateral radiograph.

Image below shows anatomic landmarks important for the volar approach to the radius.
Volar anatomic landmarks important for the volar ...

Volar anatomic landmarks important for the volar approach. The region marked pronator fossa is covered by the pronator quadratus (PQ) muscle. It extends distally to the PQ line, marked in blue. The watershed line marks the highest crest (most volarly projecting) surface of the radius. The red X marks the volar radial tuberosity, which lies just off the pronator quadratus. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR marks the volar radial ridge.


Workup


Imaging Studies


  • Plain radiographs are all that is needed for most fractures.
  • CT scans are useful for evaluating the articular fracture lines and degree of comminution, and they are sometimes useful for planning the approach. Remember that plain films underestimate the number of fracture lines and that CT scans overestimate the number of fracture lines. CT scans are necessary when planning intra-articular osteotomies for nascent malunions and mature malunions. Three-dimensional reconstructions may look impressive in presentations, but to date, the resolution has not been very helpful in preoperative planning or postoperative assessment.
  • MRI is not indicated for evaluation of bony anatomy.

Diagnostic Procedures


  • Plain radiographs are the foundation of treatment. If the fracture is placed in traction as an early part of treatment, traction radiographs are very helpful. Often, the fragments cannot be adequately identified or assessed on the injury films; the traction views are often the first radiographs that define the fragments. Final reduction films need to be evaluated for adequacy of reduction and for an assessment of stability, even though this is an area with no clear guidelines.
  • CT can be useful to assess the articular comminution. Importantly, however, note that plain films underestimate the number of fragments, while the CT scan overestimates them. Three-dimensional reconstructions are usually not useful.
  • The threshold for treatment, while not clearly defined, often involves assessing the displacement in terms of millimeters. Both plain films and CT scans have been evaluated for their accuracy at the 1 mm level. Neither modality can reliably be read at the 1 mm level, adding to the challenge of treating distal radius fractures (DRFs).

 

Treatment


Medical Therapy

Nonsurgical treatment
The goal is to return the patient to prior level of functioning. The physician's role is to discuss the options with the patient, and the patient's role is to choose the option that best serves his or her needs and wishes. This treatment paradigm is highlighted by a recently developed approach to surgically treat stable fractures that are in acceptable alignment. For a case discussion of this approach, see Radius Fracture with Immediate Return to Work.
Many distal radius fractures (DRFs) can be treated nonoperatively.6 Fractures that are undisplaced or minimally displaced (the definition of minimally displaced is controversial and varies with age and activity level [see Indications ]) can be treated in a cast for 6 weeks. In most instances, unless the distal ulna is fractured and unstable (type I and II ulna fractures are not usually unstable), it can be treated in a short arm cast. Long arm casts are not required if the ulna is stable; additionally, these casts significantly disable the patient during the treatment of the fracture.7
Some fractures in elderly persons that are compressed dorsally can be minimally painful and can appear to be clinically stable. These fractures may be treated with a splint only. This variant is somewhat rare.
Elderly, low-activity patients can have very high function and return to prior activities even with a significantly displaced fracture. A 45° dorsal tilt can be highly functional in a patient who drives and is active out of the home but does no sports. They have an unsightly wrist clinically (with a prominent ulnar head) that has limited supination and flexion, but they do not have symptoms with ADLs. Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.

Surgical Therapy

Surgical treatment has been traditionally reserved for displaced, irreducible fractures or reducible but unstable fractures. One approach that is becoming more popular is to surgically treat patients who cannot or do not want to accept the constraints of cast treatment because of ADL, work, or recreational concerns.No consensus has been reached as to which surgical treatment is best. Several options are available, each with its own variations.


Volar fixed-angle plate using the Orthofix Contou...

Volar fixed-angle plate using the Orthofix Contours VPS plate, posteroanterior view. This is a facet posteroanterior view, which is tilted at the same angle as the tilt of the distal articular surface, which allows assessment of the intra-articular versus extra-articular placement of the screws. Note that the distal screws engage both the radial styloid fragment and the dorsal ulnar fragment.



Volar fixed-angle plate using the Orthofix Contou...

Volar fixed-angle plate using the Orthofix Contours VPS, lateral view. This is not a facet lateral view, and the distal articular surface is not seen tangentially, which makes some of the screws appear to be intra-articular. However, the posteroanterior view demonstrates that they are not. Note also that the distal screws do not past-point the dorsal cortex, but instead, they stop a few millimeters short of the dorsal cortex. Due to the difficulty of evaluating screw length, even with fluoroscopy, the screws should stop 2-4 mm short of the dorsal cortex.



PA view of fragment-specific fixation (courtesy o...

PA view of fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware to the radial side is a radial pin plate. The pins hold the fragment in place, and the pin plate gives greater stabilization to the pins. The hardware to the ulnar side is a dorsal pin plate (also see image below), which holds the dorsal ulnar corner in place.


Lateral view of a fragment-specific fixation (cou...

Lateral view of a fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware on the volar side is called a wireform and is supporting the subchondral bone. The hardware in the center of the image is a pin plate along the radial border of the radial styloid and serves to hold the large radial styloid fragment in place. There is a small pin plate along the dorsal surface.




Closed reduction and percutaneous pinning Closed reduction and percutaneous pinning has been popular for many years and continues to be one of the most popular techniques internationally. The pinning can be of several varieties, including Clancey pinning (ie, 0.062-inch wires into the radial styloid and the dorsal ulnar corner of the radius, crossing the fracture site) and Kapandji pinning (ie, wires or arum pins placed into the fracture site dorsally and used as levers to reduce the fracture and then to stabilize it).8
Percutaneous pinning with the Clancey technique, ...

Percutaneous pinning with the Clancey technique, posteroanterior view.



Percutaneous pinning with the Clancey technique, ...

Percutaneous pinning with the Clancey technique, lateral view.



External fixation
External fixation became the most popular treatment throughout much of the world in the decades after the development of a radius-specific fixator by Anderson in 1944. The proper technique of application of external fixators, however, was not defined until 1990 by Seitz. More than 25 brands of external fixators are now on the market, which is a testimony to the popularity of the technique. Small open incisions are used to avoid injuring the sensory branches of the radial nerve and to ensure central placement in the second metacarpal and the radial shaft. This technique continues to be one of the most popular techniques internationally.9,8
Many variations of external fixation have been developed. One variation of the fixator allowed early motion with the fixator still in place. The concept was originated by Clyburn and popularized internationally by Pennig. The axis of motion of the fixator was placed over the center of motion of the wrist, thought to reside in the center of the head of the capitate. This approach has largely been abandoned because of theoretical criticisms and clinical experience. Theoretical criticisms are related to the location of the rotation—that is, whether it is an instant center or a constant center and whether or not it is possible to place the center of motion of the fixator reliably over the center of motion of the wrist. An additional practical consideration is the impossibility of having a center of motion of the fixator not coaxial with the center of the wrist.
Clinical studies also noted a decrease in final range of motion and an increase in complications related to the device; thus, early motion in external fixation has largely been abandoned. Some researchers are still investigating this technique, and it is still used clinically in some regions of the world.
Dorsal plating
Dorsal plating had its greatest popularity in the 1990s, with the development of plates specifically for the distal radius. The technique has lost most of its appeal for most fractures because of tendon irritation problems.
Fragment-specific fixation
Fragment-specific fixation was originated by Fernandez, which he called the limited open approach, and was developed and popularized by Medoff, who coined the term fragment-specific. Fragment-specific fixation uses very small, low-profile plates that are specifically designed for the radial column, the central column, or the ulnar column of the radius. They lend themselves to many types of fractures, but the technique is difficult to learn and, many times, the plates must be removed.
Nonspanning external fixation
Nonspanning external fixation was popularized by McQueen and capitalized on the strength of the subchondral bone and the volar cortex. While the proponents touted the possibility of early motion, others found that the range of motion was poor.
Volar plating
Volar plating, especially for dorsally unstable fractures, was independently developed by Orbay, Jennings, and Drobetz, but Orbay successfully developed a practical device, promoted it internationally, and was the first to publish information on it.10,11 Orbay is properly considered the grandfather of the technique. It is gaining in popularity, but its complications, particularly the incidence of tendon rupture, are now becoming recognized.12,8,13,14,15,16
Spanning internal fixation plates
Spanning internal fixation plates were originated by Becton and popularized by Ruch,17 and several companies make such plates. The screws are placed into the metacarpals and the midradial shaft, and the plates are removed at 3 months. This technique is very new and only a few series have been published.
Surgical techniques internationally


Despite the many techniques and the large number of studies on distal radius fractures (DRFs), no consensus has been reached on the best surgical approach. Strong regional tendencies exist, such as volar plating in the United States, Kapandji pinning in France, and traditional external fixation in the United Kingdom and in Italy. In some regions (eg, Japan, Germany), the plates are typically removed; however, in others (eg, the United States), they are rarely removed.

Intraoperative Details

Percutaneous pinning (Clancey technique)
After adequate anesthesia is established, prepare the skin. Many surgeons find that placing the fingers in finger-trap traction assists with reduction. Reduce the fracture, and place a 0.062-inch Kirschner wire into the radial styloid. Using image intensification, drive the Kirschner wire across the fracture site and into (but not through) the opposite cortex. Pin migration can be limited by not going through the opposite cortex, but the pin must be securely in the cortex to maintain the reduction. The second pin is placed into the dorsal ulnar corner of the radius. Under image intensification, drive the pin across the fracture site and into the opposite cortex. Additional pins can be placed if needed for stability.
Percutaneous pinning (Kapandji technique)
Prepare as above, but place the pins into the fracture site dorsally. Lever the distal fragment into place with the pin, observing the reduction with image intensification, and then drive it into the volar cortex. Usually, more than one pin is used. Kapandji has developed special pins called arum pins for this purpose.
Volar plating
The skin incision is made directly over the flexor carpi radialis (FCR) tendon. The incision should be approximately 10 cm long and does not need to cross the wrist crease. Mobilize the FCR tendon radially, and incise the floor of the FCR tendon sheath. Distally, be aware that the course of the branch from the radial artery to the superficial palmar arch is variable and can cross the FCR tendon. Divide the septum between the FCR tendon and the flexor pollicis longus tendon distal to the wrist crease. This avoids making a skin incision distal to the wrist crease. If, subsequently, the distal portion of the surgical field cannot be visualized adequately, release this septum further. Release the muscular fibers of the flexor pollicis longus, originating from the shaft of the ulna or the septum between the radius and the first dorsal compartment. The pronator quadratus (PQ) is seen, often with a tear in its fascia where the shaft has displaced and torn it at the moment of fracture.
Release the PQ just 1-2 mm distal to the line marked by the distal end of the muscular fibers and the proximal end of the fibrous tissue that continues distally to become the wrist joint capsule. This line is called the PQ line. Release the PQ radially 1-2 mm beyond the radial margin of the muscular fibers of the PQ by including a small margin of fibrous tissue from the septum of the first dorsal compartment. The fibrous rim, distally and radially, allows a secure repair of the PQ and protects the tendons from the plate. Reflect the PQ and release the brachioradialis (BR). Clear the fat from the volar wrist capsule.
There are 2 different approaches: (1) reduce the fracture and place the plate or (2) partially reduce the fracture, place the distal row(s) of screws, and then use the plate to obtain the final few degrees of volar tilt.
If unreduced intra-articular comminution is noted, a different approach is required. Release the BR, if not released previously. Release the first dorsal compartment from the radius, and pronate the radius shaft away from the articular fragments. Using the carpus as a template, reduce the intra-articular fragments, pin and/or bone graft as necessary, and then supinate the radial shaft and continue as above.
Document the reduction using the facet lateral view and the facet PA view with the mini C-arm and with fluoroscopic views in the facet manner, aligning the view with the joint surface, not the clinical position of the forearm.
Be careful to assess the position of the tip of each distal screw. The radial styloid screw may be either in the joint or outside the radial cortex radially. The distal screws should not extend beyond the dorsal cortex; indeed, they probably should be 2 mm short of the dorsal cortex. The dorsal cortex is very thin and usually comminuted; therefore, it provides no increase in fixation security. Past-pointing of even 1 mm can shred a dorsal tendon if it is precisely in the wrong place. Carefully check for past-pointing.
Close the PQ securely with interrupted sutures. No intermediate closure is needed. Close the skin.
External fixation
The key to external fixation is placing the pins through small, open incisions. Blind percutaneous placement or placement through small stab incisions increases the rate of nerve and tendon injury and makes it easier to create open section defects and off-center placements into the bones. Proximally, the plane of dissection should be dorsolateral, not straight lateral, through the extensor carpi radialis longus and brevis or through the extensor carpi radialis brevis and the extensor digitorum communis. This avoids placing the pins near the radial sensory nerve and injuring it upon pin insertion or removal or subjecting it to the minor cellulitis of the pin tract.

Postoperative Details

Postoperative management varies.
Most casts are kept on for 6 weeks, but some compressed fractures require only a splint. Most external fixators are kept in place for 6 weeks, but 8 weeks is also common; and some fractures that are not bone grafted still collapse at 3 months. Volar fixed-angle plates are moved anywhere from 3 days to 3 weeks. Spanning internal fixation plates are usually removed at 3 months, and therapy is initiated at that time. It is difficult to make useful generalizations.
It is advantageous to discuss postoperative hand therapy with the patient and arrange the appropriate appointments prior to surgery, including obtaining required authorization. Otherwise, the full benefits of the procedure may be lost because of paperwork issues.

Follow-up

Fractures treated with a cast require close follow-up to observe for subsidence. Although fractures that have been reduced are the most at risk, even fractures that were accepted and not reduced can still subside further and require reassessment. The general rule for fractures that were reduced is to obtain a radiograph at weekly intervals for the first 3 weeks, being careful to compare the current film with the original reduction film. Minor degrees of subsidence may not be evident if compared with the most recent film. Instability and the likelihood of further subsidence are demonstrated by any loss of the original reduction. A common error is to accept the minor increase in loss of reduction at each week, expecting that the subsidence will cease, and then discovering at 3 or more weeks that the current alignment is unacceptable after the fracture has healed and is not reducible by closed means.
Fractures stabilized operatively should be followed at 7-10 days, as the surgeon prefers. Subsidence should not be an issue.

Complications

Distal radius fractures (DRFs) heal quickly. Nonunion is usually not an issue; the most common problem is malunion before or after treatment is initiated. Careful attention to follow-up radiographs helps avoid this problem.
Each operative treatment has its own complications.18,19,20
Percutaneous pinning


Percutaneous pinning has 2 principal areas of complications: insertion problems (injury to the radial sensory nerve) and late problems (infected pin sites). The former can be mitigated by limiting the number of times a pin is placed; the latter, by appropriate pin care. While no consensus has been reached on appropriate pin care, most agree that the pin site should be kept clean and that showering helps in this endeavor. Early oral antibiotic therapy is usually successful for controlling pin site problems; if not, prompt pin removal usually cures the problem. Osteomyelitis is rare (<1%).
External fixation


External fixation also has 2 areas of complications: insertion problems (injury to the radial sensory nerve, tendon injuries, open section defects in the bone) and late problems (infected pin sites). Insertion problems were addressed in a landmark paper by Seitz in 1990, in which he advocated open pin placement. Insertion problems with this technique should be rare. As with percutaneous pinning, early oral antibiotic therapy is usually successful for controlling pin site problems; if not, prompt pin removal usually cures the problem.
Dorsal plates


Dorsal plate complications are primarily related to the close apposition of the extensor tendons to the bone. While many plates claim to be low profile to avoid this problem, 2-mm plates in a 1-mm space are still too large and may cause tendon irritation. Tendon rupture is also a potential problem likely related to specific plate design or application and perhaps influenced by the composition of the fixation device. Many authors routinely remove their plates. The dorsal approach has largely been relegated to fractures that can only be addressed by a dorsal approach.
Volar plates


Volar plate complications are only now becoming identified, and they can be classified as dorsal or volar problems. Dorsal problems are related to past-pointing (screw tips extending beyond the bone) of the distal screws. Most orthopedic screws are designed with cutting flutes at the tip, and optimum bicortical purchase requires approximately a screw diameter of past-pointing. However, due to the design of most volar fixation systems in which the screws lock to the plate, the dorsal cortex does not offer additional fixation. Additionally the dorsal cortex is thin and often comminuted. Secure fixation comes from the plate and the subchondral bone. Any past-pointing of the distal screws endangers the extensor tendons, which are in close apposition to the bone.21 For a case example, see David Nelson, Case 2.
Volar problems with volar plates come from contact of the tendons with the plates, particularly with titanium plates. This can be due to poor plate design (extension distal to the PQ, out over the volar capsule; or excessive thickness at the distal margin of the plate such that it extends volar to the PQ) or loss of reduction, such that the flexor tendons are forced to use the plate as a fulcrum.
Spanning plates
Spanning plates require a second surgical procedure for plate removal. While not a complication per se, because it is planned, it is a downside to the procedure that is not common to the other techniques.


Outcome and Prognosis

In spite of the number of unresolved controversies, most patients are able to resume their previous level of activity, including competitive sports. While many cases are described in which the return to function was not limited by malunion or complications, patients are, in general, living longer and continuing to be active longer than in previous generations. This places demands on the distal radius that have not been seen previously, and despite apparently good quality care, some patients are not able to resume their previous level of functioning.
All treatment approaches have a percentage of poor results, with decreased supination, prominent ulnar heads, ligamentous problems, distal radioulnar problems (usually instability), and degenerative joint disease being common problems. These are the cases that prompt researchers to continue to refine the techniques and devices.22
Patients, however, want more concrete prognostic statements. Most patients treated with a volar fixed-angle plate can resume nonforceful activities of daily living (ADLs) within 3 days to 2 weeks. Patients treated with a cast have the cast removed at 6 weeks and can then start ADLs. Grip strengthening can often be started at 2 months after any type of treatment, but forceful use of the hand should be delayed for 3 months. Contact sports or activities in which the likelihood of falling on an outstretched hand is high should be delayed for approximately 4 months. These are just general guidelines, and great variation exists among specific cases and specific physicians.
The long-term prognosis for a properly treated distal radius fracture (DRF) is good, even with an intra-articular fracture. Osteoarthritis is rare if the articular surface is not comminuted and is able to be reconstructed. Wrist range of motion will continue to increase, and wrist tenderness with forceful use will continue to decrease even beyond 2 years.

Future and Controversies

The field of distal radius fractures (DRFs) has always been an area of intense research and innovation. It has changed more rapidly in the last 5 years than in any previous 2 decades. While percutaneous pinning and external fixation remain the mainstays of treatment throughout much of the world, with strong and somewhat idiosyncratic national trends due to the prominence of individual surgeons in those countries, volar fixed-angle plating has become popular and dramatically shifted the landscape in several ways.12,23
For many surgeons, the volar approach for dorsally unstable DRFs, using fixed-angle devices, is the main treatment option. Orbay has popularized this treatment and broadened its applicability to highly comminuted intra-articular fractures with the extended FCR approach, pronating the radial shaft out of the way and looking directly at the undersurface of the articular bone. The low rate of complications and postoperative pain, the quality of the results, and the rapid return to activities has, for some surgeons, shifted the balance of risks to benefits such that they are offering patients the option of surgery versus a cast for stable undisplaced or stable reducible fractures.10,11 See Radius Fracture with Immediate Return to Work.
Volar fixed-angle plates have been used widely for approximately 6 years, and the rate of complications for this technique is not yet defined. The author has found 43 cases of tendon injury or rupture, but most cases seem to be due to failure to follow proper technique. One aspect of technique is to avoid any past-pointing of distal screws and, preferably, placing their tips 2-4 mm short of the dorsal cortex. A second important technique is to use a plate that does not extend distally as far as the volar wrist capsule and to completely and securely cover it with the pronator quadratus (PQ).
Arthroscopy continues to be a controversial adjunct to the management of intra-articular fractures. While the rate of unrecognized scapholunate, lunotriquetral, and triangular fibrocartilage tears in DRF has been shown to be greater than 60%, the role of arthroscopy continues to be controversial because of a lack of any outcome studies that have demonstrated improved results.


Sumber:  

  1. http://emedicine.medscape.com/article/1245884-overview 

  2. http://emedicine.medscape.com/article/1245884-diagnosis

  3. http://emedicine.medscape.com/article/1245884-treatment

  4. http://emedicine.medscape.com/article/1245884-followup