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6.3.3 Distal Radius and Wrist

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6.3.3 Distal Radius and Wrist 6 Specific fractures 6.3 Forearm and hand 6.3.3 Distal radius and wrist 1 Assessment 657 1.1 Biomechanics 657 1.2 Pathomechanics and classification 657 1.3 Imaging 658 1.4 Associated lesions 659 1.5 Decision making 659 2 Surgical anatomy 660 2.1 Anatomy 660 2.2 Radiographic anatomy 660 2.3 Preoperative planning 661 2.4 Surgical approaches 662 2.4.1 Dorsal approach 2.4.2 Palmar approach 3 Management and surgical treatment 665 3.1 Type A—extraarticular fractures 665 3.2 Type B—partial articular fractures 667 3.3 Type C—complete articular fractures 668 3.4 Ulnar column lesions 672 3.4.1 Ulnar styloid fractures 3.4.2 Ulnar head, neck, and distal shaft fractures 3.5 Postoperative care 674 3.6 Complications 676 3.7 Results 676 4 Bibliography 677 5 Acknowledgment 677 656 PFxM2_Section_6_I.indb 656 9/19/11 2:45:49 PM Authors Daniel A Rikli, Doug A Campbell 6.3.3 Distal radius and wrist of this stable pivot. The TFCC allows independent flexion/ 1 Assessment extension, radial/ulnar deviation, and pronation/supination of the wrist. It therefore plays a crucial role in the stability of 1.1 Biomechanics the carpus and forearm. Significant forces are transmitted across the ulnar column, especially while making a tight fist. The three-column concept (Fig 6.3.3-1) [1] is a helpful bio- mechanical model for understanding the pathomechanics of 1.2 Pathomechanics and classification wrist fractures. The radial column includes the radial styloid and scaphoid fossa, the intermediate column consists of the Virtually all types of distal radial fractures, with the exception lunate fossa and sigmoid notch (distal radioulnar joint, DRUJ), of dorsal rim avulsion fractures, can be produced by hyper- and the ulnar column comprises the distal ulna (DRUJ) with extension forces [2]. Various forces act on the wrist depending the triangular fibrocartilaginous complex (TFCC). on the position of the hand at the time of impact. In a low- energy fall, bending forces lead to dorsally displaced extra- or The radial styloid is an important stabilizer of the wrist provid- intraarticular fractures. Shear forces lead to partial displace- ing a bony buttress and attachment for the extrinsic carpal ment of the palmar joint surface and produce unstable inju- ligaments. Under normal physiological conditions, only a mi- ries. Compression forces are predominant in high-energy, nor amount of load is transmitted along the radial column. A axial loading injuries and lead to impaction of articular frag- large proportion of load is transmitted across the lunate fossa ments. Avulsion is the main mechanism in fracture disloca- to the intermediate column. The ulna is the stable partner in tions and the avulsed fragments often represent the bony forearm rotation. The radius swings around the ulna and the attachments of a ligament. two bones are firmly linked together by ligaments, at the level of the proximal and distal radioulnar joint, and by the interos- Numerous classification systems are available for wrist frac- seous membrane. The ulnar column represents the distal end tures. These include the Müller AO Classification( Fig 6.3.3-2), 1 2 3 RC IC UC Fig 6.3.3-1 The three-column concept. 1 Radial column (RC). 23-B1 23-B2 23-B3 2 Intermediate column (IC). 3 Ulnar column (UC). Fig 6.3.3-2 Müller AO Classification—partial articular fractures. 657 PFxM2_Section_6_I.indb 657 9/19/11 2:45:51 PM 6 Specific fractures 6.3 Forearm and hand Type I which has an anatomical basis and the Fernandez classifi ca- Bending fracture of the tion [3] that is based upon the pathomechanics described above metaphysis (Tab 6.3.3-1). 1.3 Imaging Type II Radiological investigations allow a more precise understand- ing of the fracture pattern and associated injuries. Shearing fracture of the joint surface Plain x-rays Plain anteroposterior (AP) and lateral x-rays must be taken for all radial fractures. Oblique views may be helpful. Normal ra- diological parameters should be known and a comparative view of the other wrist can be helpful. Type III Areas of collapse of metaphyseal bone (and therefore effective Compression fracture of the bone loss) can be predicted from the position of fracture frag- joint surface ments, particularly on the lateral view. This indicates potential instability, which is the single most important radiological guide to treatment. Type IV The important criteria for the radiographic assessment of instability [4] are: Avulsion fractures, radiocar- signifi cant comminution; pal fracture, dislocation angular deformity > 10°; shortening > 5 mm; articular displacement > 2 mm. Type V Most of the information required for planning treatment can be obtained from plain x-rays. However, CT scan is helpful in Combined fractures more complex cases. (I, II, III, IV); high-velocity injury Computed tomography (CT) CT scans provide extremely accurate information about fracture fragment position and size and articular congruity. Tab 6.3.3-1 The Fernandez classifi cation. 658 PFxM2_Section_6_I.indb 658 9/19/11 2:45:52 PM 6.3.3 Distal radius and wrist The sigmoid notch is especially well visualized by CT scan (and CT scans) should carefully be reviewed for widening of (Fig 6.3.3-3). This information is almost impossible to gain by the scapholunate interval (Fig 6.3.3-5), interruption of Gilula’s any other mode. 3-D reconstruction CT, with digital subtrac- lines, fractures that separate the scaphoid and lunate fossa, tion of the carpus and ulna (Fig 6.3.3-4), can give an uninter- and evidence of carpal instability with dorsal angulation of rupted view of the fracture pattern and may be helpful in the scaphoid. High-energy injuries may have associated frac- some cases. tures of the scaphoid waist. 1.4 Associated lesions 1.5 Decision making All wrist fractures must be assessed for open wounds (usually Decision making depends upon the “personality” of the in- on the ulna side) and injury to the median or ulnar nerve. jury, including patient, soft-tissue and fracture factors. A distal Compartment syndrome may develop in high-energy inju- radial compression fracture in the osteopenic elderly behaves ries. very differently from the high-energy fracture dislocation seen in young adults. It is crucial to educate the patient on Lesions of the proximal carpal row and TFCC their responsibilities prior to surgery and to stress that the out- Distal radial fractures may be associated with injuries to the come depends upon a team: the surgeon, the physical thera- TFCC and carpal ligaments, particularly the scapholunate or pist, and—most importantly— the patient. If all members of lunotriquetral. These injuries are seen in extraarticular frac- the team are motivated and dedicated, the best possible out- tures but are more common with articular fractures [5]. X-rays come will be achieved. Fig 6.3.3-3 CT showing displaced sigmoid Fig 6.3.3-4 3-D CT reconstruction. Fig 6.3.3-5 Widening of the scapho- notch. The four main articular fragments of lunate interval due to carpal insta- the distal radius are well demon- bility with associated radial styloid strated. fracture. 659 PFxM2_Section_6_I.indb 659 9/19/11 2:45:53 PM 6 Specific fractures 6.3 Forearm and hand Clear goals must be set prior to devising a plan of treatment. It Ulnar variance: a measurement of the relative lengths of must be established whether the fragments already are in an radius and ulna at the wrist. The distance between two acceptable position. This decision will vary with the personal parallel lines drawn perpendicular to the long axis of the situation of the patient, although certain guidelines exist. For radius at the distal articular surface of the ulna and the instance, the presence of an intraarticular step greater than ulnar corner of the sigmoid notch of the radius. 2 mm demands reduction—unless the patient already has es- 60% of the population are ulnar neutral. tablished radiocarpal arthrosis. Radial length is thought to be another important radiological parameter and this should Lateral view (Fig 6.3.3-7) form a keystone in decision making. Palmar inclination: the angle between two lines—one drawn perpendicular to the long axis of the radius and the other between the dorsal and palmar lips of the distal ra- dial articular surface. 2 Surgical anatomy Average = 12°. Scapholunate angle: the angle between the axis of the 2.1 Anatomy scaphoid (a line joining palmar limits of proximal and dis- tal poles) and the axis of the lunate (a line perpendicular A thorough knowledge of the anatomy around the wrist and to the line joining dorsal and palmar lips of the lunate). carpus is essential if surgical intervention is planned. The fol- Average = 30–80°. This will vary depending on the position lowing sections describe the anatomy relevant to both radiog- of the wrist. raphy and surgical approaches. 2.2 Radiographic anatomy Standard radiographic parameters are used to assess the distal Radial inclination = 23° radius. Radial height = 12 mm AP view (Fig 6.3.3-6) Ulnar variance Radial height: the distance between two parallel lines drawn perpendicular to the long axis of the radial shaft— one from the tip of the radial styloid and the other from the ulnar corner of the lunate fossa. Average = 12 mm. Radial inclination: the angle between two lines—one drawn perpendicular to the long axis of the radius at the ulnar corner of the lunate fossa and the other between that point in the lunate fossa and the tip of the radial styloid. Fig 6.3.3-6 Normal x-ray anatomy.
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