Case Conference

Terdthai Malapetch

Instructions for use

• Case– ผปวยหญงไทยคอาย 67 ป

• Chief Complaint– หกลมขอมอซายยนพน 3 hr PTA

• Present illness– 3 hr PTA ผปวยหกลมแลวใชมอซายยนพน ตอมามขอ

มอซายบวม ผดรป ขยบไดนอยลง ปวด ไมมอาการชา

Primary survey

• A : normal speaking,no tender at C-spine• B : no dyspnea,RR18• C : pulse full ,BP 130/85 • D : E4V5M6 ,pupil 3mm RTLBE• E : Left wrist swelling and deformity

Secondary survey

• A : No drug allergy• M : No current medication• P : No underlying disease• L : Last meal 7 hr PTA• E : ขณะเดนผปวยหกลมแลวใชมอซายยนพน ตอมามขอ

มอซายบวม ผดรป ขยบไดนอยลง ปวด ไมมอาการชา ไมมบาดแผล ไมมศรษะกระแทกพน ขณะลมผปวยรสก

ตวด

• Left wrist swelling and deformity• Limit range of motion due to pain • Capillary refill < 2 sec• Neurovascular intact

Investigation

• Film Lt. wrist AP,Lat

Diagnosis

• Close Fx at Left distal end radius

Distal Radius Fractures

Distal Radius Fractures

• Most common orthopaedic injury– younger patients - high energy– older patients - low energy / falls

• 50% intra-articular• Associated injuries– DRUJ injuries must be evaluated – radial styloid fx - indication of higher energy

• Osteoporosis– high incidence of distal radius fractures in women >50

• History of trauma • Clinical examination look for other injury injury should be evaluated for:-• open/closed• degree of soft tissue injury• neurovascular injury- median nerve injury

common• Tendon injury• Imaging Wrist PA, Lat, and oblique CTscan-intrarticular

Diagnosis

Classification

• Ideal system should describe– Type of injury– Severity– Evaluation– Treatment– Prognosis

Common Classification

• 1. Gartland & Werley• 2. Frykman (radiocarpal & radioulnar)• 3. AO• 4. Melone (Impaction of lunate)• 5. Fernandez (Mechanism)

Classification – Fernandez (1997)

I. Bending-metaphysis fails under tensile stress (Colles, Smith)

• extraarticular

II. Shearing-fractures of joint surface • Intra articular(Barton, radial styloid)

importance of mechanism and energy level of injury

Classification – Fernandez (1997)III. Compression - intraarticular fracture

with impaction of subchondral and metaphyseal bone (die-punch)

• Complex articular fracture & radial pilon fracture

IV. Avulsion- fractures of ligament attachments (ulna, radial styloid)

V. Combined complex - high velocity injuries

Options for TreatmentCasting

– Long arm vs. short armExternal Fixation

– Joint-spanning– Non bridging

Percutaneous pinningInternal Fixation

– Dorsal plating– Volar plating– Combined dorsal/volar plating– focal (fracture specific) plating

Indications for Closed Treatment

Low-energy fractureLow-demand patientMedical co-morbiditiesMinimal displacement- acceptable

alignment

Closed Treatment of Distal Radial Fractures

Obtaining and then maintaining an acceptable reduction

Acceptable reduction :

Immobilization: – long arm (cast for high demand)– short arm adequate for elderly patients

Frequent follow-up necessary in order to diagnose re-displacement.

Normal Parameter• Radial inclination = 23°• Radial length = 12mm• Palmar tilt = 10°• Scapholunate angle = 60° +/- 15°

Technique of Closed ReductionAnesthesia (pain relief & decrease muscle spasm)

– Hematoma block– Intravenous sedation

Traction: finger traps and weightsReduction Maneuver (dorsally angulated fracture):

– hyperextension of the distal fragment, – Correct radial tilt– Maintain weighted traction and reduce the distal to the proximal

fragment with pressure applied to the distal radius.

Do check X-ray to confirm the acceptable reduction.

After-treatment

Watch for median nerve symptoms – parasthesias common but should diminish over few hours– If persist release pressure on cast, take wrist out of flexion– Acute carpal tunnel: symptoms progress; CTR required

Follow-up x-rays needed in 1-2 weeks to evaluate reduction.

Change to short-arm cast after 2-3 weeks, continue until fracture healing.

Prediction of Instability1. Age > 802. Initial displacement of fracture (esp Radial shortening)3. Extent of metaphyseal comminution4. Displacement following closed reduction

Management of Redisplacement

• Repeat reduction and casting – high rate of failure

• Repeat reduction and percutaneous pinning• External Fixation• ORIF

Indications for Surgical Treatment

1. High-energy injury with instability2. Comminuted displaced intraarticular fracture3. Open injury4. Radial inclination < 15°5. Articular step-off, or gap > 2mm6. Dorsal tilt > 10 °7. DRUJ incongruity

Treatment Options• Type I

– Mostly non operative– Few by external fixation

• Type II– ORIF with buttress plate

• Type III– Fixation with multiple K wires & plates with cancellous bone grafting– Open & closed techniques in combination

• Type IV– Secure reduction of carpus to distal radius by K wires

• Type V– Combination of percutaneous pinning & external fixation

Operative Management of Distal Radius Fractures

Percutaneous Pins

Pins & plaster traction

Distraction plate fixation

Plan of Management

• Pain control : MO 3 mg iv stat• Close reduction with long arm AP slab• Home medication– Paracetamol(500) 1 tab oral prn q 6 hr– Tramol(50) 1 x 2 oral PC– CaCO3(1000) 1 x 1 oral PC

• Follow up 1 wk

References

• Orthopaedics for medical student วทยาลยแพทยศาสตรพระมงกฎเกลา

• เวชปฏบตทางออรโธปดกส ภาควชาออรโธปดกสโรงพยาบาลมหาราชนครราชสมา

• http://www.orthobullets.com/trauma/1027/distal-radius-fractures

Thank You