Distal Radius Fractures - Adam Rumian 8/8/2006
BACKGROUND
Approx 1/6
th
of all # seen
CLASSIFICATION
Eponymous
Colles
1814. Description of clinical deformity. NB: no mention in his paper of old women / osteoporotic bone!
“This fracture takes place at about an inch and a half above the carpal extremity of the radius”
“One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain”
Pouteau 1783 described similar #: often quoted in French literature, but mysteriously not much mention in
Barton 1838
Smith 1847
Edwards 1910: radial styloid # “chauffeur’s #”
Scheck 1962: “die punch #”
Frykmann 1967
1
Relates mainly to Colles’ type fractures
Does not reflect initial fracture displacement, degree of comminution or shortening
AO Classification
Fernandez Classification 1993
2
Based on mechanism, proposes treatment:
Type 1: bending
Type 2: shearing
Type 3: compression
Type 4: avulsion; radial-carpal #-dislocation
Type 5: combined, high velocity
Complexity of bone lesion and probability of associated soft tissue disruption increases consistently from type 1 to type 5.
Provides separate grouping of DRUJ injuries. Important as one of most common causes of disability after fracture is post-traumatic DRUJ derangement.
Imaging
Xray: cannot reliably measure 1mm articular step-off
CT
Kreder, et al. (J Hand Surg, 1996)
3
16 observers examined 6 plain xrays
- two experienced observers would be expected to disagree by 3 mm 10% of the time, and repeat measurements by the same observer would be expected to differ by 2 mm 10% of the time
- weakness of method: could not tell what actual measurement was and therefore true accuracy of readings
Cole, et al. (J Hand Surg, 1997)
4
- 5 observers examined 19 sets of xrays, including plain films and CT scans
- more reproducible values were produced by CT scans, but a poor correlation between CT and plain xray measurements
- thirty percent of measurement from plain xrays significantly underestimated or overestimated displacement compared to CT scan measurement
- weakness of method: could not tell whether CT or plain film was actually more accurate
Treatment Goals and Considerations
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- restoration of articular congruity and axial alignment
- maintenance of reduction
- achievement of bony union
- restoration of hand and wrist function.
Other factors
- low functional demand
- significant medical illness
- inability to comply with postoperative instructions
- previous fracture and deformity
INDICATIONS FOR REDUCTON
- Accept no more than 10 degrees volar tilt
(Based on combination of biomechanical studies in cadavers showing increased contact pressures with increased amounts of tilt, plus several clinical studies correlating outcome).
ARTICULAR CONGRUITY
Biomechanical studies
-
increases in contact stresses with stepoff as small as 1 mm
-
carpal alignment shifts and lunate flexion reduces with step- off
-
lunate fossa depression of 3 mm caused significant pressure in scaphoid fossa
-
scaphoid fossa depression of 1 mm caused increased pressure in lunate fossa
Clinical studies
Knirk and Jupiter (1986, JBJS)
5
-
retrospective study of 43 fractures with intraarticular displacement, with mean follow-up of 6.7 years
-
stepoff > 2 mm (8 of 8): 100% radiographic DJD
-
any radiographic stepoff (22 of 24): 91% radiographic DJD
-
BUT later papers show radiographic DJD not necessarily symptomatic
6
Kopylov (1993, JHS[B])
7
-
retrospective review of 76 patients, 26-36 years after distal radius fracture
-
articular incongruity was the main factor in the development of radiographic DJD and was frequently associated with pain and stiffness clinically
-
incongruity of > 1 mm had 250% increased risk of DRUJ DJD
-
incongruity of > 1 mm had 237% increased risk of RC DJD
Trumble (1994, JHS)
8
-
retrospective study of 52 intraarticular fractures
-
strongest correlation with outcome was with articular incongruity (both stepoff and gap)
RADIAL SHORTENING
Biomechanical studies
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