Distal Radial Fractures Keep your options open!

1. Distal Radial FracturesKeep your options open! Mr G Shyamalan Consultant Hand Surgeon HEFT

2. Learning Objectives • Understanding the radiograph • Classification • Imaging and consent • Approach • Surgical case based discussion • Classic volar plate • Conclusion

3. Gilula’s Lines

4. Lunate and Scaphoid Facet and Volar side with Radial Styloid

5. Radial and Volar side

6. Lateral Vs a True Lateral - Sigmoid notch

7. True Lateral

8. Dorsal

9. Extrinsic Ligaments - Dorsal

10. Extrinsic Ligaments - Volar

11. Classification • Colles

12. Classification • Smiths and Bartons

13. Classification • Chauffeur’s and Lunate die punch

14. Classification • Frykman’s

15. Classification • Melone’s

16. Classification AO – Too complex Mayo – Extra/Intra-articular Reducible/Irreducible Fernandez – mechanism classification

17. Classification Fragment Specific – Robert Medoff (intra-articular fractures) . Radial styloid, dorsal wall, impacted articular fragments, dorsal ulna corner (die-punch), volar rim fragment (tear drop)

18. Columnar Classification • Daniel Rikli & PietroRegazzoni • Lateral – length and alignment • Intermediate – weight bearing and notch • Medial - rotation

19. Shyam’s Classification • Low energy Vs High Energy • Normal Vs Osteoporotic • Dominant Vs Non – Dominant • Occupation and Functional Demands • Soft tissues (skin, nerves, tendons) • Pre-morbid conditions including MTS • Patient choice! • Fracture patterns and mechanism • Ulna fracture or carpal injury • Timing of consult

20. Consent • Continued pain • Malunion • Infection • Stiffness • Chronic regional pain syndrome (500mg Vitamin C daily for 6 weeks) • Nerve/Vessel/Tendon Injury • Non-union • Instability carpus and ulna • Removal of metal work • Carpal Tunnel Syndrome

21. What kit do you need? • Bring the kitchen sink! • Volar plates, dorsal straight plates, k-wires, Ex-fix, hand plating system

22. Approach • Volar Henry’s releasing brachioradialis • Dorsal • Combined

23. How to fix • Volar plate • Dorsal plate • Fragment specific • Percutaneous Wires • Bridge plating • Ex-fix • ? Arthroscopic assisted • Bone graft or bone graft substitute • Bit of everything • Plan for a two stage?!

24. Surgical case 2

25. Post Fixation – Looks alright

26. Six weeks post fixation

27. Look again at the anatomy

28. Surgical case 2

29. Look again at the fixation!

30. 6 months post initial injury

31. Surgical Case 3

32. Steps for volar plate • Have an assistant who knows what they are doing • Traction the fracture closed • Open and Reduce +/- K wire • Put plate on shaft and gliding hole screw and screen • Plate can be rotated and pushed up or down depending on xray • Fill ulna holes distally, check lateral and then put in radial ones and complete proximally

33. Tips • Don’t go bicortical distally • Check screw length on xray • Angle screws out of joint

34. Tips • Don’t be afraid to put a K-wire and a plate on the radial styloid • If in doubt do a carpal tunnel decompression • Always release brachioradialis • If problems with dorsal fragment reduction, put in screws distally first and reduce fragment onto shaft • Continuous traction or Ex-fix can help with fixation • Multi-fragmentary fractures, intra-articular fractures try bridge plating

35. Tips • Look at scapho-lunate interval on both wrists • Screen in radial and ulna deviation with sometimes compression • Look at ulna position, stress views and examine other side • Have no issues about implant removal • If in doubt do nothing and send to specialist

36. Theatre films

37. ConclusionFix well or don’t fix at all!