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1、Outline,Epidemiology Anatomy and biomechanics Radiographical and arthroscopic evaluation Classification Criteria for acceptable reduction predictors of instability Complication AAOS-guidelines Debates,Epidemiology,Frequency Distal radial fractures account for 1/6 of all fractures seen in the ED Race
2、 No racial preferences have been reported,Age Peaks at ages 5-14 years and at ages 60-69 years. Young patients intra-articular Elderly patients extra-articular Gender Postmenopausal women, female-to-male ratio 4:1 Adolescent boys and girls, the ratio is 3:1,Anatomy,volar radial tuberosity,lunate fac
3、et buttress,PQ = Pronator Quadratus Line, or PQ Line WS = Watershed Line, X = Volar Radial Tuberosity VR = Volar Radial Ridge,Biomechanics,80% of the load is taken on the distal radius and 20% of the load is taken on the TFCC,DIC=dorsal intercarpal ligament DRC=dorsal radiocarpal ligament,Radiograph
4、ic Assessment,X-ray CT MRI Arthroscopic evaluation,X-ray,0.9mm,10-15,正面切线位（11）,侧面切线位（21）,标准侧位,关节面切线位,CT,CT,MRI,Arthroscopy,Classification,Fracture classification systems are, in effect, tools. The purpose of the tool is to help the surgeon to choose an appropriate method of treatment for each and ev
5、ery fracture occurring in a particular anatomical region. The classification tool should not only suggest a method of treatment, it should also provide the surgeon with a reasonably precise estimation of the outcome of that treatment.“ -Albert H. Burstein, PhD, Deputy Editor for Research, Journal of
6、 Bone and Joint Surgery,Colles fracture is an extraarticular low energy fracture primarily sustained in the elderly, a fracture almost unique to caucasian women.,a “classic“ Colles fracture,Sir Abraham,Colles Fracture (1814),Smiths fracture 1847,Robert William Smith considered this “an injury of exc
7、eedingly rare occurrence,“ but its description heralded the age of vehicular trauma in 1847: The patient, in endeavouring to save himself from being run over by a car, fell with great violence upon the back of his hand . . .,Robert William Smith (1807-1873),woodcut from Smiths original description,T
8、he classic Bartons fracture describes the dorsal rim fracture subluxation, a shear-type injury. John Rhea Bartons addresses the difference between a true dislocation and this fracture: a dislocation typically has no crepitus, and once reduced tends to remain that way,John Rhea Barton (1794-1871),Bar
9、tons Fracture (1838),Die punch,“die punch“ fracture, or lunate load impact fracture of the posteromedial corner of the radius, was more recently described by Scheck,The absence of ligamentous attachments to the depressed fragment precludes reduction. In high energy trauma, one component of an unstab
10、le displaced fracture,the axial load through the lunate creates an impact fracture on the lunate facet,A case report,a1,a2,Chauffeurs fracture,The backfire, or Chauffeurs fracture, was “extremely common in these days of voluminous traffic“ according to Harold C. Edwards, who described 42 fractures s
11、ustained from the impact of the downward swing of the automotive crank handle.,This is a high energy styloid fracture with carpal subluxation.,Salter-Harris Classification (1963),Pediatric Fracture Classification The growth plate is the weakest structure in the developing ends of long bones, and the
12、refore a common site for injuries, including the distal radius.,Frykman 1967,Fernandez 1996,Type I: bending,Type II: Shearing,Type III: Compression,Type IV: avulsion, including radiocarpal injuries,Type V: combined, high energy fractures,type A extra articular type B partial articular,AO (1987),type
13、 C complete intra-articular,Medoff Anatomy Classification (1999),Five predictors of instability,a patient over 60 an intra-articular fracture dorsal incomminution dorsal angulation of more than 20 an associated ulnar fracture,Treatment options,Closed reduction and immobilization Closed reduction and
14、 Percutaneous pinning External fixation Arthroscopically assisted reduction and Ex. Fixation of intraarticular fracture. ORIF with plate fixation Bone grafting,There is no consensus on the management of theses fractures But definitions seem unclear in many papers.This might be the reason of discrepa
15、ncy,Treatment of Type C3 Distal Radius Fracture,Guidelines for Reduction of Distal Radial Fractures,Radial shortening 15 degrees Sagittal tilt on lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt Intraarticular step-off or gap 2 mm of radiocarpal joint Articular incongruity
16、 2 mm of sigmoid notch of distal radius,Functional Evaluation,Analysis of Complications,(1) Tendon Irritation or Rupture Due to Past-pointing of Distal Screws,All screws are past the dorsal cortex and into the tendons, but none will be seen as too long on a lateral x-ray.,A Case Report,Irritation or
17、 Rupture of Volar Tendons due to Prominent Plates or Backing Out of Distal Screws,too distal-into the joint too proximal-not support the sub-chondral bone too radial-plate tilts on the volar radial tuberosity and may become palpable,Ulnocarpal Impaction Syndrome,Nerve Injury Is Also A Possibility,Pa
18、in was persistent and disabling,The patient is a 79 years old who had a distal radius fracture which was treated with an volar plate,Intraoperative view with the screw tip impinging on the posterior interosseous nerve,Another intraoperative view with a better view of the screw tip.,Screws into Radio
19、carpal Joint,PA facet view Tilt to 11,Facet lateral view tilt to 21,True lateral view,Non-union,Complex Regional Pain Syndrome,The incidence of CRPS after distal radius fracture ranges from 2% to 39% stiffness, difficulty sleeping, burning pain, and cold sensitivity are the common symptoms Vitamin C
20、 at a dose of 500 mg/d has been shown to decrease the incidence,Consensus - 3,X-rays in nonoperative fractures for 3 weeks and start of ROM. Re-evaluate patients with unremitting pain during follow-up. Patients perform active finger ROM. “In the absence of reliable evidence it is the opinion of the
21、work group that . . .”,Moderate - 5,ORIF for post-reduction radial shortening 3mm, dorsal tilt 10 degrees, or intra-articular displacement or step-off 2mm Rigid immobilization removable splints for displaced fractures treated non-operatively Patients do not need to begin early wrist motion Vitamin C
22、 for the prevention of disproportion-ate pain.,14 Inconclusive Results,To perform nerve decompression when nerve dysfunction persists after reduction Casting as definitive treatment for unstable fractures that are initially adequately reduced Any one specific operative method for fixation of distal
23、radius fractures,Operative treatment for patients over age 55 with distal radius fractures Locking plates in patients over the age of 55 who are treated operatively Immobilization of the elbow in patients treated with cast immobilization Using of bone graft (autograft or allograft) or bone graft sub
24、stitutes for the filling of a bone void as an adjunct to other operative treatments using of supplemental bone grafts or substitutes when using locking plates,Over-distraction of the wrist when using an external fixator Fixation of ulnar styloid fractures associated with distal radius fractures Usin
25、g external fixation alone for the Management of distal radius fractures where there is depressed lunate fossa or 4-part fracture (sagittal split) Using the occurrence of distal radius fractures to predict future fragility,Questions and Debates,The absence of large, prospective outcome trials of the
26、different methods of treatment is surprising ? Is anatomical restoration of the distal radius necessary to achieve good long-term function ? Does the early mobilization allowed by volar locking plates improve outcome? There does not appear to be a clear correlation between radiological degenerative change and a poor clinical outcome,What is the cost of the procedure and does the cost of the surgery and the implant balance any earlier return to normal function?,Thanks for Your Attention,