Describes the classification,management and complications of distal radius fractures .

1. PADMA C ANAND
DISTAL RADIUS
FRACTURES

2. • 20 % of all emergency orthopaedic admissions
• 3 main peaks:children:5-14 years
:males:<50 years
:females>40 years
• Young and athletic patients-high energy injuries
• Elderly female population – low energy or fragility fractures
-metaphysis :composed primarily of cancellous bone , one of
the primary sites of osteoporosis in elderly
• Fracture occur through the distal metaphysis of radius

3. THE ANATOMY

4. 80% of axial load : distal radius –scaphoid and lunate fossa
20% of axial load : distal ulna –sigmoid notch,DRUJ

6. Consists of articular disc,
meniscus homologue
dorsal and volar radioulnar ligament,
ECU(extensor carpi ulnaris) sheath

8. TFCC
• Main stabiliser of distal radioulnar joint
• Stabilises ulnar head in sigmoid notch
• Provides ulnocarpal stability
• Act as a buttress to support proximal carpel row
• Functions as a cushion of compressing axial forces
• 80% of axial load transmitted through from the hand throughth wrist:by distal
radius.The rest is borne by ulna via tfcc.

10. Jakob and his coauthers
Radial / lateral
column:scaphoid fossa and
radial styloid
Intermediate column:lunate
fossa and sigmoid notch
Ulnar /medial column:ulnar
styloid,tfcc,ulnocarpal ligaments

11. • Radial column : Impaction of the scaphoid on the articular surface - a shear
moment on the radial styloid,because of inclination of 22 degrees - failure
laterally at the radial cortex ; best stabilized by buttressing the lateral cortex
• The intermediate column consists of sigmoid notch and lunate fossa -
considered the cornerstone of the radius; critical for both articular congruity and
distal radioulnar function.
• Failure of the intermediate column occurs as a result of impaction of the lunate
on the articular surface with dorsal comminution. The column is stabilized by a
direct buttress of the dorsal aspect of radius

12. PATHOMECHANISM
• The theory of compression impaction (blow or counterblow ): ( dupuytren,
1834)
Body generates a counterblow from the surface of impact – transmitted through
the carpel bones – distal radius – causes fracture at corticocancellous junction
;where the bone is thinnest
• The avulsion theory (linhart,1869 ) – Fracture occur by the tensile forces
transmitted by the volar wrist ligaments.

13. • The incurvation theory ,meyer’s – three factors ;depends on position of the
hand , the extent of the area of impact , the magnitude of the applied force
• Mechanism by lewis : fall on hyperextened hand – loads the volar surface –
scaphoid and lunate – force transmitted towards radius causing fracture at its
weakest point
( as if a beam that is bended beyond its elasticity)

14. CLASSIFICATION
• EXTRA ARTICULAR
• Type1-undisplaced and stable
• Type 2-Displaced
a)Reducible and stable
b)Reducible and unstable
c) irreducible
INTRA ARTICULAR
•Type1-undisplaced and stable
•Type 2-Displaced
a)Reducible and stable
b)Reducible and unstable
c) irreducible
d) complex

15. CLASSIFICATION
• A)classification based on different fracture types
• 1)Colles fracture/pouteaus fracture
• 2)Smith fracture /reverse colles fracture
• 3)Barton fracture
• 4)Chauffer’s fracture/ radial styloid fracture/Hutchison fracture
• 5)Lunate load or die punch fracture

16. GARTLAND & WERLEY
1.Simple fracture without intrarticular
involvement
2.Comminuted fractures with intra-articular
extension without displacement
3.Comminuted fractures with intra-articular
extension with displacement
4.Extra-articular, undisplaced

17. FRYKMAN CLASSIFICATION
• On involvement of the radiocarpal and radioulnar joints.
• Type I: Extra-articular fracture
• Type II: Extra-articular fracture with ulnar styloid fracture
• Type III: Radiocarpal articular involvement
• Type IV: Radiocarpal involvement with ulnar styloid fracture
• Type V: Radioulnar involvement
• Type VI: Radioulnar involvement with ulnar styloid fracture
• Type VII: Radioulnar and radiocarpal involvement
• Type VIII: Radioulnar and radiocarpal involvement with ulnar styloid fracture

18. FRYKMAN CLASSIFICATION

19. FERNANDEZ CLASSIFICATION – BASED ON
MECHANISM OF INJURY

20. • TYPE 1
• Extra-articular bending fractures of
the metaphysis
• Colles (dorsal angulation) or Smith
(volar angulation) fractures.
• One cortex fails in tension, and the
opposite cortex is comminuted and
impacted.
TYPE 2
Shearing fractures of the joint surface
Volar barton,dorsal barton,radial styloid
fractures

21. • TYPE 4
• avulsion fractures of ligament attachments
• Includes radiocarpal fracture- dislocations
• TYPE 3
• Compression fractures at the joint
surface with impaction of
subchondral and metaphyseal
cancellous bone
• TYPE 5
High-velocity injuries
Involve combinations of bending, compression, shearing,
and avulsion mechanisms or bone loss

22. MELONE
Type I: Stable fracture without displacement.
Type II: Unstable “die punch” with displacement of the
characteristic fragments and comminution of the anterior
and posterior cortices
Type IIA: Reducible
Type IIB: Irreducible (central impaction fracture)
Type III: “Spike” fracture. Unstable. Displacement of the
articular surface and also of the proximal spike of the
radius
Type IV: “Split” fracture. Unstable medial complex that is
severely comminuted with separation and or rotation of
the distal and palmar fragments
Type V: Explosion injury
He identified 4 components of intraarticular fractures : shaft, dorsal medial,palmar medial,radial styloid

23. THE OTA/AO CLASSIFICATION
• Emphasizes the increasing severity of the bony injury.
• Type A: Extraarticular fracture. Subgroups are based on direction of
displacement and comminution.
• Type B: Partial articular fracture. Subgroups are based on lateral (radial
styloid) palmar or dorsal fragments.
• Type C: Complete articular. Subgroups are based on the degree of
comminution of the articular surface and the metaphysis

25. CLINICAL FEATURES
• SYMPTOMS
• History of a fall on the outstretched hand or an episode of trauma
• Deformity of the wrist
• Movement of the hand and wrist-painfulL

26. • Swollen and ecchymosed
• Radial and ulnar styloids at same level(laugier sign)
• Dinner fork deformity occurs in colles and dorsal barton fracture
• Gardenspade deformity occurs in smith or palmar bartons fracture
• The wrist should be examined for Median nerve function
• tendon action should be tested – EPL may be acutely injure over listers
tubercle or may present with late spontaneous rupture

27. • fractures of either the ipsilateral scaphoid fracture ,radial head or
supracondylar humerus

28. X-RAY PICTURE OF NORMAL WRIST:
• Radial length:Styloid process of the radius extends I cm beyond that of the
ulna
• The articular surface of the radius projects proximally and towards the ulna
(average 23°)- Radial angulation or inclination
• Palmar radial tilt :The plane of the radial articular surface slopes downwards
and forwards (average 11°).

29. Radial inclination

30. Radial length

31. Palmar tilt

32. THE DISTAL ARTICULAR SURFACE OF THE
RADIUS
• Volar tilt/palmar tilt of 11 degress
• Radial inclination of average 22 degrees ie;inclination of distal radius towards
the ulna
• Radial length of 11-12 mm
• Ulnar variance of 0-2 mm which indicates radial shortening
• Carpel malalignment

35. X-ray PA VIEW
• extraarticular 1)radial shortening/comminution
2)ulnar styloid fracture location
• intraarticular 1) depression of the lunate facet 2) gap b/n scaphoid and lunate facet
3)central impaction fragements 4) interruption of the proximal carpal row

36. • X-ray lateral view
• extraarticular fracture 1)palmar tilt
2)extent of metaphyseal communition
3)displacement of the volar cortex
4)scapholunate angle
5)position of the DRUJ

37. • intraarticular 1)depression of the palmar lunate
2)depression of central fragment
3)the gap b/n palmar and dorsal fragement
Oblique view
• extraarticular asses radial comminution
• For intraarticular asses 1) the radial styloid for split or depression
2) depression of the dorsal lunate facet
Tilted lateral view
• It eliminates the shadow of radial styloid
• And provide a clear tangential view of the lunate

38. • CT should be performed if conventional radiographs provide insufficient detail about radiocarpal articular
step-off and gap displacement.
communitive intraarticular fracture of the distal radius with
displacement of the volar rim of the radius together with
the carpus

39. • MRI scan :For evaluation of suspected soft tissue
injuries
Flexor or extensor tendon injuries
Median nerve injuries
Early diagnosis of necrosis of scaphoid or lunate
Rupture of carpal ligaments
injury to TFCC
a fracture of the ulnar styloid process not visible on
standard radiography, but clearly demonstrated with MR

40. RADIOGRAPHIC SIGNS

41. CRITERIA FOR STABLE AND UNSTABLE
JOINTS
• Marked dorsal comminution
• Dorsal angulation > 20 deg
• Radial shortening > 10 mm
• Articular step > 3 mm
• If after closed reduction ;loss of reduction with dorsal angulation > 10 deg or 5
mm or more radial shortening

42. COLLES FRACTURE
• It is an extraarticular fracture occurs at corticocancellous junction of distal end
of radius within 2cm from the articular surface
• It may extend into DRUJ with six displacements
• Impaction
• Lateral displacement
• Lateral rotation (angulation)
• Dorsal displacement – dinner fork deformity
• Dorsal rotation (angulation)
• Supination.
• often accompany fracture of the ulnar styloid - signify avulsion of the TFCC
and ulnar collateral ligaments

44. SMITH ‘S FRACTURE/REVERSE COLLE’S
FRACTURE
• Occurs at the same level on the distal radius as a colles' fracture.
• Distal fragment displaced in palmar (volar) direction with a "garden
spade" deformity.
• younger patients
• Results from high energy trauma on the volar flexed wrist

45. type I
• extra-articular transverse fracture through the
distal radius
• most common: ~85%
type II
• intra-articular oblique fracture
• equivalent to a reverse Barton fracture
• ~13%
type III
• juxta-articular oblique fracture
• uncommon: <2%

46. BARTON ‘S FRACTURE
• It is an intrarticular fracture dislocation or subluxation in which the rim of the
distal radius dorsally or volarly is displaced with the hand and carpus
• There are 2 types
Dorsal barton
Volar barton

47. Dorsal barton
• Dorsal rim fracture of distal radius
• Fall with dorsiflexion and pronation of the distal forearm on a flexed wrist.
Volar Barton:
• Palmar rim fracture of distal radius
• Due to palmar tensile stress and dorsal shear stress and is usually combined
with radial styloid fracture

48. comminuted intraarticular fracture of the distal radius
Volar rim maintains relationship with the carpus and both
are displaced proximally (blue arrow)
Fracture of radial styloid process with loss of radial
inclination (yellow arrow)

49. CHAUFFERS / HUTCHINSON’S FRACTURE
• Intraarticular fracture involving the radial styloid , the radius is cleaved in a
sagittal plane and the fragment is displaced proximally
• fairly common from backfiring of starting handle of car, from forced dorsiflexion
and abduction.

50. • Die-punch fracture
• A die-punch fracture is a depression fracture of the lunate fossa of the distal
radius.
• It is the result of a transverse load through the lunate
blue arrow indicates the depressed fragment of the lunate
fossa.

51. TREATMENT :
Aims to restore normal anatomy
• Differ depends on the patient,their demand & type of fracture

52. NONOPERATIVE TREATMENT
• Mainstay :plaster,splint with or without closed reduction
• INDICATIONS: undisplaced stable fracture
minimally displaced fracture
displaced fractures which are stable after reduction
impending complication which may be averted by early
reduction even if further treatment is necessary

53. TECHNIQUE OF REDUCTION
• Analgesia / pain relief:haematoma block/regional or general anaesthesia/iv
sedation
• Longitudinal traction to the forearm with an assistant providing countertraction
above the elbow
• This disengages the fragment ,allows direct pressure to be applied to the distal
radial fragment from dorsal to volar if dorsally displaced & volar to dorsal if volar
displaced
• Agee technique :a volar transition force is applied to the distal fragment of
radius,the lunate transelates on the distal radius causing distal fragment to tilt in
volar direction.

55. • Cast immobilisation:once the reduction process is completed,in slight flexion
and ulnar deviation
• Back slab/suger tong splint complete cast once the swelling is reduced
both forearm and b/e cast
Length
• Undisplaced fractures:very limited/no/minimal immobilisation
• Displaced fracture:5-6 weeks
• r/w the patient at 1 week interwell:to check for redisplacement
• Early instability : with in 2 weeks
• Late instability: after 2 weeks
• r/w the patient at 2 & 3 weeks of injury

56. OPERATIVE TREATMENT
• Metaphyseal unstable ,extra or minimally articular fractures
• Closed & percutaneous pinning , ORIF , external fixation

57. PERCUTANEOUS PINNING
• Minimally invasive
• Used for extra articular , minimal articular distal radius fracture , intraarticular
fracture
STEPS
• Sterile precautions
• Arm abducted on arm board
• Fracture should be reduced first and held by an assistant or by fingertraps

58. • Three basic constructs
1 Distal radius pinning : pins are placed across the fracture in the radius.
May be only radial styloid pin or a pin from the dorsal ulnar aspect to the
volar ulnar aspect of radius
11 Ulnar radial pinning : pins are placed from the radius across the ulna
111 Intrafocal/kapandji pinning : pins are inserted into the fracture ,used as
reduction tools and then driven into the proximal radius

59. • THE PROCEDURE
• Avoid damage to the dorsal sensory branch of radial nerve or tendons which
are close to the insertion point of both styloid and dorsal ulnar wires
• Small incision is made at the proposed point of pin entry , with blunt dissection
down to the bone ; to protect the nerves and tendons
• The styloid wire fixes the radial styloid to the radius and is usually placed first
from a starting point on the lateral cortex of radius either on / in 1 cm of the tip
of the radial styloid.
• The pin is then driven diagonally in an ulnar direction to engage the cortex
proximal to the fracture on the ulnar side
• The dorsal ulnar pin is placed from the dorsal ulnar corner of the radius and
driven across the cortex of the volar radial cortex
• Use of 2 radial styloid and 1 dorsal ulnar pin is the most stable construst

61. INTRAFOCAL PINNING
• Pins are driven into the fracture site and used as levers to reduce the fracture
• KAPANDJI recommends 3 wires placed laterally , posterolaterally and
posteromedially
• A small vertical incision is made at the fracture site
• On the radial side, pin is inserted in the plane between tendons of extensor
pollicis breves, abductor pollicis longus and wrist extensors
• Posterolateral incision: just above and lateral to lister’s tubercle ; pin is placed
b/w the tendons of EPL and tendons of EPB & APL
• Posteromedial incision: in the 4 th extensor compartment , usually b/w the
extensors of the ring and little finger

62. • Pins are introduced perpendicularly in the line of fracture and then inclined
obliquely upwards thus buttressing cortex of the distal fragment.
• The pin is then driven into the opposite cortex of the radius
• Post procedure : short arm cast or varying periods upto 6 weeks

65. COMPLICATIONS
• Damage of superficial branch of radial nerve : placement of pin should be
under direct visualisation using small skin incisions and blunt disection down to
the bone. care should be taken while removing the pin,that the incisions are
large enough to ensure protection of the nerve
• Pin tract infecton : major or minor . burial of pins s/c to avaoid pin tract infection

66. EXTERNAL FIXATION
• Ligamentotaxis :principle of tension on the ligaments and capsules inorder for
reduction
• Bridging / spanning external fixation
• Nonbridging/ nonspanning external fixation

67. BRIDGING EXTERNAL FIXATOR
• Uses pin in the second metacarpal and radial shaft thus bridging radiocarpel
,intercarpel and carpometacarpal joints
• Indication
-actual or predicted instability in dorsally displaced extra articular or minimal
articular fractures of the distal radius
-can also be used for severe articular fractures and open injuries

69. THE TECHINIQUE
• Patient – supine
• Arm ,abducted to 90 degrees
• Tourniquet in the upper arm
• Either 1 or 2 incisions may be used and are placed on the lateral side of the
metacarpal in the gap between extensor tendon and first dorsal interosseus
muscle
• 2 pins are placed in the second metacarpal ,proximal of which should be close
to the second carpometacarpel joint, which can easily be palpated
• Proximal pins are placed in the radial diaphysis
• Augmentation: percutaneous k wires, limited ORIF with plaster, bone graft or
bone substitute

70. • Postoperative care
-regular dressings: changed twice weekly
-hand,elbow,and shoulder physiotherapy – if any stiffness is detected
• Fixator is usually removed at 6 weeks

71. NONBRIDGING EXTERNAL FIXATOR
• There must be sufficient space in the distal fragment to site the pins : usually 1
cm of the intact volar cortex
• Indication
-distal end radial fracture with predicted or actual instability which are extra
articular / have an articular extension which is undisplaced or reducible closed
-displaced fractures if there is sufficient space after reduction of the joint surface
-distal radial osteotomy for dorsal malunion

73. • Patient supine
• Arms abducted to 90 degrees
• Torniquet in the upper arm
• Marker is placed on the skin at the estimated point of entry of the pin to the distal
fragment
• With forearm in lateral position, an image is obtained
• ulnar pin is introduced first ,on the ulnar side of listers tubercle,in the ulnar corner
of radius
• 1 cm longitudinal incision at appropriate point in the skin ,deepened till the
extensor retinaculam is visualised
• Longitudinal incision in the retinaculam avoiding injury to extensor tendons
• A pin is placed on the bone halfway between fracture and the radiocarpel joint in
the lateral view parallel to the same joint
• It is inserted by hand without predrilling to the distal fragment
• The pin should penetrate the volar cortex

74. • Forearm is then rotated ,to confirm free rotation and exclude injury to distal
radioulnar joint
• Another pin is introduced in the same manner in the radial side of listers
tubercle
• Two proximal pins are then placed in the radius ,proximal to fracture in a
similer fasion to that used for bridging external fixators
• Once the skin and subcutaneous tissue are opened ,the interval between the
ECRL and ECRB can be seen,which is develeped and radius is exposed

75. • Fixator is then assembled , maintaining adequate space between the clamp
and the skin to allow access for pin tract dressing
• The fracture is reduced by using the distal pins as a joystick to control the
position of the distal fragment
• Avoid overreduction- can lead to volar comminution
• Sutures are not used as it can lea to pin tract infection

76. POST OPERATIVE CARE
• Pintract care
• No immobilisation
• Encouraged to move hands ,wrist and elbow
• Physiotherapy is stiffness develops
• Fixator is removed after 5 – 6 weeks

78. COMPLICATIONS
• Pintract infection- major/minor
- Minor : antibiotics , increased frequency of dressing
- Major : demands removal of the fixator , and added surgical procedure
• Pin tract fracture : resite the pin
• Pin fall out : occur rarely
• Skin adherence : can occur after healing of pin tracts
-surgical correction can be done with local anaesthesia
• Joint distraction : when excessive force is applied in an attempt to reduce
fracture in bridging ex fixators

79. PLATING : VOLAR,DORSAL
• Volar locked plating
- For stabilising extra articular or minimal articular fracture of distal radius
- For volar displaced fractures in elderly ,osteoporotic patients
- Correction osteotomy of malunion distal radius
- Must have sufficient space for pins in the distal fragments

80. patient was treated with volar locking plate fixation
technique for unstable distal radius fracture.

81. • Patient – supine
• Arms abducted to 90 degree
• Hand supinated , placed on an arm table
• Tourniquet in upper arm
• Approach : modified henry’s approach / trans flexor carpi radialis approach
• A longitudinal skin incision is made in line with the FCR tendon,length of which
depends up on the plate size
• The fascia is released to expose the flexor tendon
• Tendon is then retracted in an ulnar direction and an incision is made in the
floor of the tendon sheath which exposes the FPL muscle belly which is swept
to ulnar side by blunt dissection

82. • Transverse muscle fibers of pronater quadratus are released from the radial
side side of the radius
• If there is intra articular fracture in the volar ulnar corner , it is mandatory to
take that fragment also with the plate
• In such cases , incision is made more ulnar ,over the ulnar border of palmaris
longus
• Flexor tendons are mobilised in radial direction ,ulnar neurovascular bundle in
ulnar direction ; pronator quadratus is incised at its attachment to ulna and
elevated radially
• Give easy access to carpel tunnel , for median nerve release

83. PLATE APPLICATION
• Reduce fracture fragments
• Apply the plate secured on to the radial shaft
• Position of plate should not be distal to the watershed line (FPL rupture)
• Screws are placed distally parallel to the joint surface in lateral view ,taking
care not to penetrate the dorsal cortex
• The proximal limit of the plate is then pushed gently on to the shaft : ‘Lift
technique’ and fixed in plane
• Take the length of central screws 2 mm less than the measured length to avoid
penetration to the dorsal cortex and to reduce the tendon rupture
• Augment by either bone substitute / grafting ,to prevent migration of the screws
to the radiocarpel joint as well as collapse

84. POST OPERATIVE CARE
• Plaster or splint x few weeks
• Finger moton after 3-4 weeks

85. COMPLICATIONS
1. Screw penetration into the radiocarpel joint and DRUJ (in collapse or in
metaphyseal comminution) : remove the metal work
2. Tendon complications :
- Rupture /irritation :
Extensor side : due to screw prominence on the dorsal surface , measured length of
screw should be reduced by < 2 mm ; at the symptoms of tenosynovitis ,hard ware
is removed
Flexor side : usually FPL tendon due to prominence of plate distal to ( abt 2 mm)
watershed line :elective removal

87. PITFALLS OF VOLAR PLATING

88. DORSAL PLATING
• Used prior to the introduction of volar plating
• for extra articular or minimally articular distal radius fractures
• Limited use due to the concerns abt collapse and tendon irritation / rupture

90. INTRAMEDULLARY NAILING
• For extra articular / minimally articular of distal radius
• Rqs closed rdn of fracture,provisional fixation with percutaneous wires
• Entry point ; radial styloid b/w first and second dorsal compartment

91. preoperative (A), postoperative (B), and latest follow-up
(C) X-ray findings for Micronail.
Preoperative (A), postoperative (B), and latest follow-up
(C) X-ray finding

92. DISPLACED INTRA ARTICULAR FRACTURES
• Displacement > 2 mm in : fit and active patients – rqs surgery
:frail, elderly : cast fo comfort
1. Closed or percutaneous rdn of articular fracture surface with bridging
externalfixation
2. ORIF -using single plate ( volar single plate )
- fragment or column specific approach with multiple plates

93. ROLE OF ARTHROSCOPY
• Direct visualisation of articular surfeces
• Allows confirmation of joint rdn
• Exclusion of an inadvertently placed intra articular implants
• Disadvantage : longer,more difficult,needs greater experience ,long learning
curve ,risk of fliud extravasation : a/c compartment syndrome

94. SALVAGE PROCEDURES
when articular congruity or metaphyseal alignment can not be achieved due to
severe comminution
1. DISTRACTION PLATING : internal fixation : using plate from 3 rd metacarpal
distally and to the radial diaphysis proximal to the fracture
- a 12 to 14 holed plate is passed from distal to proximal and distraction force
is applied to the fracture
- plate is then clamped to the proximal radius
-3 screws are used proximally and distally after rdn
- rdn is confirmed by fluoroscopy
-k wires,screws,bone graft, can be used

95. • Double sandwich plating -In cases with both volar and dorsal comminutiuon
-Use of single plate may lead to loss of alighment in the opposite direction
• Arthrodesis – used rarely,when severe bone losss or articular incongruity
-early radiocarpel or complete wrist arthrodesis
-radiocarpel : some motion occur at carpometacarpal and
midcarpal joints
-complete wrist fusion : midcarpal,carpometacarpal and
radiocarpel joints are fused
Fusion in 10 – 20 degree extension with slight ulnar deviation

96. PARTIAL ARTICULAR FRACTURES
• Volar shearing/volar lip / volar bartoin’s
• Dorsal shearing /dorsal lip /dorsal barton’s
• Radial styloid /chauffer’s
• Usually occur from impaction of scaphoid- lunate complex to distal radius

97. VOLAR SHEARING FRACTURES
• AO type B3 fractures ,unstable
• Nonoperative treatment for elderly fragile patient or undisplaced fractures
• Operative treatment : palmar buttress plate with emphasis on rdn of articular
surface
• Place the plate sufficiently ulnar to support an ulnar sided volar lip fracture

98. DORSAL LIP FRACTURES
• Result of high energy injuries ,tend to occur in young patien
• Treatment : surgery with dorsal or volar or combined approach

99. RADIAL STYLOID FRACTURE
• Commonest type of partial articular fracture
• Occur in isolation or in ass with scaphoid fracture ,scapholunate injury
,radiocarpel dislocation ,or more complex distal radial fracture
• ISOLATED RADIAL STYLOID FRCATURE
Usually undisplaced or generally benigh
Careful examination of scaphoid to rule out fracture ,carpel ligamentous injury

100. • Treatment : undisplaced : cast or splint for pain relief
• Significant articular step or gap : surgery is needed
-percutaneous with manipulative rdn and fixation with pin / screws
Open rdn with radial buttress plating if percutaneous approach is not possible

104. COMPLICATIONS
• Nerve injury
• Tendon injury
• Malunion
• Nonunion
• Complex regional pain syndrome

105. NERVE INJURY
• Median nerve : most common nerve affected in distal radial fractures
- presents as CTS
Causes : Early CTS – swelling and haematoma extending to carpel tunnel/deep to the fascia at
the level of fracture
- direct nerve contusion
-cotton loder position
Late CTS : Callus formation and malunion
Acute – with in 1 week of fracture : in young ,high energy injuries,AO Type C injuries
Subacute – from 1 week to 12 weeks
Delayed - > 12 weeks older women,low energy injuries,extra articular
fractures
Treatment :decompression

106. • Ulnar nerve : less common
• Risk factors : DRUJ instability
open fractures
high energy injury
severe fracture displacement
Most cases : neuropraxia
In complete ulnar nerve palsy , with an open wound or concurrent acute CTS
- exploration

107. TENDON INJURIES
• Commonest tendon involved : EPL
• CAUSES : hardware related : volar or dorsal plating
: fracture related : mechanical or biologic causes ,occur early ,rarely
because of pronater quadratus being present b/w tendon and bone
: attritional causes : an intact extensor retinaculam holds the tendon
in the spike of a sharp bone ,a roughened area of distal radius ,non-union of
lister tubercle ,occur late
:vascular cause : narrowing of the third extensor compartment and
mechanical obstruction
Treatment : tendon transfer ,with extensor indicis proprius

108. MALUNION
• Symptoms
: pain - ulnar sided
- carpel : altered mechanics of a malalighened carpus
- radiocarpel : articular malalignment or intra articular osteoarthritis
- DRUJ : due to incongruency of the sigmoid notch because of the tilt of
radius ,intraarticular malunion ,damage to the cartilage of the ulnar head
: weakness of grip : pain or mechanical disadvantage
: reduced range of movement ,esp rotation
: demormity
: reduced range of movement : Due to malalignment or incongruity of DRUJ ,
wrist flexion is affected in dorsal malunion ,wrist extension limited in volar
malunion
: CTS

110. TREATMENT
• Fit ,independent patient ;for symptomatic malunion : surgery
• Dorsal extra articular malunion : closing or opening wedge osteotomy
fixation : by dorsal plating ,volar locked plating ,nonbridging external fixation
,per cutaneous pinning ,intramedullary nailing
• Volar extra articular malunion : less common ,plating is treatment of choice
:if there is little angular deformity ,oblique sliding osteotomy
:if angular deformity is (+) : open wedge osteotomy and bone graft

112. • Intra articular malunion
-has serious consequenceses with early onset degenerative arthritis
Indications for surgery : residual step off of > 2 mm esp if ass with extraarticular
malunion or joint subluxation
The procedure : original fracture line is recreatd using an osteotome
: fixation by small plates or wires
: bone grafting for residual metaphyseal defect

113. ULNAR SIDED PROCEDURES
• Indications : persistent pain ,rotational contracture ,instability of DRUJ ,
BOWER ‘S PROCEDURE :
- Hemiresection interposition arthroplasty of DRUJ
- ie excision of substantial portion of ulnar head leaving ulnar styloid , TFCC ,
ulnar column of cortex
SAUVE – KAPANDJI PROCEDURE :
- A segment of the ulna is excised at the level of ulnar neck
DARRACH ‘ S PROCEDURE :
-excision of distal end of ulna ,at the proximal end of sigmoid notch

115. Ulnarshortening :
• Indicated in symmptomatic ulnocarpel impingement after distal radius fract
Ulnar head replacement
• salvage procedure ,in painful radioulnar impingement following failed darrach
or sauve kapandnji procedure

117. NONUNION
• Rare
• May occur in the presence of extensive metaphyseal comminuton
• Diagonosis : increasing pain and increasing deformity
• Treatment : plating and bone grafting : wrist fusion in failed cases

118. COMPLEX REGIONAL PAIN SYNDROME
• Multisystem multi symptom disorder usually affecting one or more extremities
but may affect vitually any part of the body
• Symptoms : pain out of proportion to the insiting cause
vasomotor instability
trophic skin changes
regional osteoporosis
functional impairment

119. • Treatment
medical management of oain : NSAIDS ,tramadol,opioids
surgical management : sympathetic block
regional block
spinal cord stimulation

120. T
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