Fractures of distal radius apleys 2013 feb
Transcript of Fractures of distal radius apleys 2013 feb
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FRACTURES OF THE DISTAL RADIUS
IN ADULTS
Dr. D. N. Bid
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• The distal end of the radius is subject to many different types of fracture, depending on factors such as age, transfer of energy, mechanism of injury and bone quality.
• With any of these fractures, the wrist also can suffer substantial ligamentous injury causing instability to the carpus or distal radio-ulnar joint.
• These injuries are easily missed because the x-rays may
look normal.
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COLLES’ FRACTURE
• The injury that Abraham Colles described in 1814 is a transverse fracture of the radius just above the wrist, with dorsal displacement of the distal fragment.
• It is the most common of all fractures in older people, the high incidence being related to the onset of post-menopausal osteoporosis.
• Thus the patient is usually an older woman who gives a history of falling on her outstretched hand.
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Mechanism of injury and pathological anatomy
• Force is applied in the length of the forearm with the wrist in extension.
• The bone fractures at the cortico-cancellous junction and the distal fragment collapses into extension, dorsal displacement, radial tilt and shortening.
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Clinical features
• We can recognize this fracture (as Colles did long before radiography was invented) by the ‘dinner-fork’ deformity, with prominence on the back of the wrist and a depression in front.
• In patients with less deformity there may only be local tenderness and pain on wrist movements.
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• X-ray There is a transverse fracture of the radius at the corticocancellous junction, and often the ulnar styloid process is broken off.
• The radial fragment is impacted into radial and backward tilt.
• Sometimes there is an intra-articular fracture; sometimes it is severely comminuted.
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Treatment
• UNDISPLACED FRACTURES• If the fracture is undisplaced (or only very slightly
displaced), a dorsal splint is applied for a day or two until the swelling has resolved, then the cast is completed.
• An x-ray is taken at 10–14 days to ensure that the fracture has not slipped; if it has, surgery may be required; if not, the cast can usually be removed after four weeks to allow mobilization.
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• DISPLACED FRACTURES• Displaced fractures must be reduced under anaesthesia
(haematoma block, Bier’s block or axillary block).
• The hand is grasped and traction is applied in the length of the bone (sometimes with extension of the wrist to disimpact the fragments); the distal fragment is then pushed into place by pressing on the dorsum while manipulating the wrist into flexion, ulnar deviation and pronation.
• The position is then checked by x-ray.
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• If it is satisfactory, a dorsal plaster slab is applied, extending from just below the elbow to the metacarpal necks and two-thirds of the way round the circumference of the wrist.
• It is held in position by a crepe bandage.
• Extreme positions of flexion and ulnar deviation must be avoided; 20 degrees in each direction is adequate.
• The arm is kept elevated for the next day or two; shoulder and finger exercises are started as soon as possible.
• If the fingers become swollen, cyanosed or painful, there should be no hesitation in splitting the bandage.
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• At 7–10 days fresh x-rays are taken; redisplacement is not uncommon and should be treated, if the patient’s functional demands are high, by re-manipulation and internal fixation.
• However, in some elderly patients with low functional demands, modest degrees of displacement should be accepted because – (a) out-come in these patients is not so dependent upon
anatomical perfection, and – (b) fixation of the fragile bone can be very difficult.
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• The fracture unites in about 6 weeks and, even in the absence of radiological proof of union, the slab may safely be discarded and exercises begun.
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• IMPACTED OR COMMINUTED COLLES’ FRACTURES
• With substantial impaction or comminution in osteoporotic bone, manipulation and plaster immobilization alone may be insufficient.
• The fracture can some-times be reduced and held with percutaneous wires, but if impaction is severe even this may not be enough to maintain length; in that case, an external fixator is used to neutralize the compressive force of the 25 tendons crossing the wrist, and bone graft or bone substitute is placed into the gap.
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• The fixator is attached to the dis-tal radius and the second metacarpal shaft.
• It should be used only as a neutralizing device; too much distraction will lead to stiffness.
• The fixation is removed after 5–6 weeks and exercises begun.
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• Plate fixation is increasingly being used for some Colles’ fractures.
• The so-called ‘volar locking plate’ is applied to the front of the radius through the bed of flexor carpi radialis.
• The screws are fixed to the plate itself and are passed into the relatively stronger subchondral bone distally.
• These devices, which are flourishing in the orthopaedic marketplace, allow stable fixation and thus early mobilization of the forearm.
• Other devices, such as a locked intramedullary nail or crossed K-wires, are also suitable for the distal radius.
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Outcome
• As Colles himself recognized, the outcome of these fractures in an older age group with lower functional demands is usually good, regardless of the cosmetic or the radiographic appearance.
• Poor outcomes can often be improved by performing a corrective osteotomy.
• The amount of displacement that can be accepted depends on patient factors such as age, co-morbidity, functional demands, handedness, and quality of bone, and treatment factors such as surgical skill and implants available.
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• As a rule, shortening of more than 2 mm at the distal radio-ulnar joint, dorsal tilt of more than 10 degrees and dorsal translation of more than 30 per cent are likely to lead to a poor outcome and early correction should be considered.
• This advice applies to older osteopaenic fractures; in younger patients the tolerances are far less!
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Complications• EARLY
• Circulatory problems The circulation in the fingers must be checked; the bandage holding the slab may need to be split or loosened.
• Nerve injury Direct injury is rare, but compression of the median nerve in the carpal tunnel is fairly common.
• If it occurs soon after injury and the symptoms are mild, they may resolve with release of the dressings and elevation.
• If symptoms are severe or persistent, the transverse ligament should be divided.
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• Reflex sympathetic dystrophy This condition is probably quite common, but fortunately it seldom progresses to the full-blown picture of Sudeck’s atrophy.
• There may be swelling and tenderness of the finger joints, a warning not to neglect the daily exercises.
• In about 5 per cent of cases, by the time the plaster is removed the hand is stiff and painful and there are signs of vasomotor instability.
• X-rays show osteoporosis and there is increased activity on the bone scan.
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• TFCC injury
TFCC injury is more common than is generally appreciated.
As the distal radius displaces dorsally, the TFCC is damaged; the ulnar styloid fracture which commonly accompanies a Colles’ fracture illustrates the forces which are transmitted to the TFCC, which attaches in part to it.
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• LATE• Malunion Malunion is common, either because reduction
was not complete or because displacement within the plaster was overlooked. The appearance is ugly, and weakness and loss of rotation may persist.
• In most cases treatment is not necessary.
• Where the disability is severe and the patient relatively young, the lower 1.5 cm of the ulna may be excised to restore rotation, and the radial deformity corrected by osteotomy.
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• Delayed union and non-union Non-union of the radius is rare, but the ulnar styloid process often joins by fibrous tissue only and remains painful and tender for several months.
• Stiffness Stiffness of the shoulder, elbow and fingers from neglect is a common complication.
• Stiffness of the wrist may follow prolonged splintage.
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• Tendon rupture Rupture of extensor pollicis longus occasionally occurs a few weeks after an apparently trivial undisplaced fracture of the lower radius.
• The patient should be warned of the possibility and told that operative treatment is available.
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Wrist Fractures video
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Wrist Fracture Repair video
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Distal Radius fracturevid
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SMITH’S FRACTURE• Smith (a Dubliner, like Colles) described a
similar fracture about 20 years later.
• However, in this injury the distal fragment is displaced anteriorly (which is why it is sometimes called a ‘reversed Colles’).
• It is caused by a fall on the back of the hand.
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Clinical features
• The patient presents with a wrist injury, but there is no dinner-fork deformity. Instead, there is a ‘garden spade’ deformity.
• X-ray There is a fracture through the distal radial metaphysis; a lateral view shows that the distal fragment is displaced and tilted anteriorly – the opposite of a Colles’ fracture.
• The entire metaphysis can be fractured, or there can be an oblique fracture exiting at the dorsal or volar rim of the radius.
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Treatment
• The fracture is reduced by traction, supination and extension of the wrist, and the forearm is immobilized in a cast for 6 weeks.
• X-rays should be taken at 7–10 days to ensure the fracture has not slipped.
• Unstable fractures should be fixed with percutaneous wires or a plate.
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Thank You……