IC39-R: What You Don't Know About Distal Radius Fractures

IC39-R: What You Don't Know About

Distal Radius Fractures Moderator(s): Julie E. Adams, MD

Faculty: Juan Manuel Breyer, MD, Ruby Grewal, MD, MSc, FRCS(C), and Jerry I. Huang, MD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

7/16/20

Disclosure The Lost and Found Art of Non-Operative Treatment: Are We too Aggressive w Surgery? • I have no conflicts to Disclose

Ruby Grewal, MD, FRCSC Professor, Division of Orthopedics, University of Western Ontario, London, ON

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Objectives

• Explore DRF treatment trends over last 20 years

• Examine evidence supporting operative vs. non-operative treatment

• Are we operating on too many elderly patients?

• Pearls of Non-Operative Treatment Are We Operating More?

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DRF Treatment Trends: 2005-2014

• Proportion receiving Operative vs. Non-Operative Treatment • Non-Operative: 66.7% 2005 à 64.1% 2014 CR decreased from 82% to 70% • Operative: 33.3% 2005 à 35.9% 2014

• Surgical Trends 2005-2014 • ORIF - increased from 22.7% to 32.2% • Perc pinning - declined from 11.1% to 3.5% ORIF increased from 3% to 16% • Ex fix - declined from 4.5% to 2.1%

JBJS Am 2009 Kakar Hand 2020

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1 7/16/20

Treatment Trends <65 years of age Treatment Trends >65 years of age

Kakar Hand 2020 Kakar Hand 2020

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Age Adjusted Rates per 100 Fractures Treatment Trends

Kakar Hand 2020

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Treatment Trends Treatment Trends

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Decreasing Incidence of Operative Tx in patients >80 years BUT Are We TOO Aggressive?

Hevonkorpi 2018

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Distal Radius Fracture Incidence Proportion of Elderly is Growing

↑ by 17.7% (p=0.01)

↑ by 3.4% (p=0.47) ⎤ ⎥ ↓ ⎦

Kakar et al. Hand 2020

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More Seniors than Children

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3 7/16/20

Falls Very Common in this Age Group “Are we being too aggressive?

• Distal radius fracture incidence increasing

• Proportion of elderly patients is increasing • And they are more active than ever before

• We are operating (ORIF) more

• And we are operating on more elderly w DRF

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AAOS CPG 2009 – Indications for ORIF AAOS Clinical Practice Guidelines - 2009

• post-reduction radial shortening >3mm • dorsal tilt >10 degrees Patients > 55 years • intra-articular displacement or step-off >2mm

• the benefits exceed the harm Moderate • but the strength of the supporting Inconclusive evidence is not as strong • Implications: Practitioners should generally follow a Moderate unable to recommend for or against operative recommendation but remain alert to new information and be treatment for patients older than age 55 with DRF sensitive to patient preferences.

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Are we Operating on too Many DRF’s?

Low Demand Elderly

• No Advantage to operative fixation Decreasing Incidence of • No advantage to Closed Reduction Operative Tx in patients • Operative Rates are Decreasing >80 years Young and Rayan 2000 Chang 2001 Beumer and McQueen 2003 Hevonkorpi 2018 Hevonkorpi 2018

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What’s New?

Egol et al. JBJS 2010 • AAOS Clinical practice guidelines were published in 2009 • Case-control study, unstable DRF >age 65 • Has anything changed since then? • Operative (n=44) vs. Non-operative treatment (n=46)

• Radiographic outcome Better with ORIF • Review of more recent evidence • Wrist Extension 8.5° Better with ORIF at 6 m

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Egol et al. JBJS 2010 Egol et al. JBJS 2010

• At 1 Year • Surgical treatment was not standardized • No Difference DASH, complications • Either ORIF (VLP) or ExFix and pins

• Supination 3.3° advantage ORIF • Selection Bias • Non-operative group offered surgery, but declined • Grip Strength 5 kg advantage ORIF • Did they self select into group that can tolerate malunions?

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Arora et al. JBJS 2011 Arora et al. JBJS 2011

• prospective randomized trial • Inclusion • ORIF with VLP (n=36) • independent living patients • CR + cast (n=37) • without systemic medical conditions • Able to travel on their own to the clinic • Primary outcome: PRWE, DASH • Other outcomes: ROM, complications, x-ray • Excluded patients with low functional demands

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5 7/16/20

Arora et al. JBJS 2011 Arora et al. JBJS 2011

• Radiographic Outcomes better with ORIF • No Difference (at all time points) • Dorsal tilt, radial inclination, radial shortening • Level of pain • Range of motion • More complications with ORIF • 13 vs. 5 (p <0.05)

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Arora et al. JBJS 2011 Arora et al. JBJS 2011 • Grip Strength • PROM’s (DASH and PRWE) • Better with ORIF at all time points • 3.7 kg advantage at 6 months • 3.4 kg at 1 year • Short term à better with ORIF (6w, 12 w)

• Long term à no difference (6m, 1y)

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• Results – comparison between surgical and non-surgical groups

• DASH (6 studies) • No significant difference between the surgical and nonsurgical groups • pooled standard difference in means = −0.08 (95%CI −0.25 - 0.09, p=0.36)

• VAS Pain (3 studies) • No significant difference • pooled standard difference in means = 0.22 (95%CI −0.32 - 0.76, p= 0.42)

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6 7/16/20

• ROM • Grip Strength (4 studies) • No significant difference in extension, pronation, supination, ulnar deviation • no difference in grip strength • More flexion, radial deviation • pooled standard difference in means = 0.23 • 95%CI −0.26 - 0.73, p=0.35

Flexion Radial Deviation

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Martinez-Mendez JHS (E) 2018

• Conclusions • Surgical and Non-Surgical methods produce similar results in the treatment of DRFs in the elderly

• Minor objective functional differences • > age 60 did not impact subjective functional outcome and quality of life. • n = 47 Cast • n = 50 VLP • mean follow-up 29 months

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RCT VLP vs. Casting > 60 years RCT VLP vs. Casting > 60 years

Advantage: VLP

Marginal Advantage: VLP

Martinez-Mendez JHS (E) 2018 Martinez-Mendez JHS (E) 2018

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Alignment was Related to Outcome

• PRWE • was not influenced by age/sex/fracture type • PRWE correlated with RI (r = -0.33), Ulnar variance (r = -0.34), p=0.02

• One of the few studies that show a correlation between • Ages 18-75, median age 58 outcomes and alignment, therefore ORIF better than casting. • 74% female • VLP (n=44) vs. Cast (n=48) • No differentiation between 60-70 vs. over 65 or over 70 • AO type A2 and A3 • 1 year follow-up J Bone J Surg 2019;101(9):787-96 Martinez-Mendez JHS (E) 2018

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DASH Scores – all p<0.05, MCID = 10 PRWE – all p<0.05, MCID: 11-14

60 60 55.8 48.3 50 50

40 40 32.5 29 30 27.5 30 22.5 20 20 ✓ 14.2 20 9.2 11 10 10 6.7 x 5.8 10 ✓ ✓ ✓ 7 ✓ x 2.5 x 4 0 0 6 weeks 3 months 6 months 12months 6 we ek s 3 m on t hs 6 m on t hs 12 mo nt h s

VL P Cast p <0.05 VL P Cast p <0.05

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Saving et al. JBJS 2019 1-year Outcomes à better w VLP

p = 0.03 p = 0.014

• Unstable DRF, dorsally displaced • Age ≥ 70 19.9 17.5 • RCT: n = 72 cast, n = 68 ORIF w VLP 8.3 7.5

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Grip Strength Better w VLP No Difference in Complications

• Major Complications (p=0.606) • 11% in cast (7/63) • 14% in volar locked plate (8/56)

96.8% 80% • Minor Complications (p=0.197) • 11% cast • 20% volar locked plate

p=0.001

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Sirniö et al. Acta Orthopaedica 2019 Sirniö et al. Acta Orthopaedica 2019

• RCT VLP vs. Cast (excluding AO C3) • Age ≥ 55 years DASH Score 14.4 • Acceptable CR achieved (DA <10˚, Ulnar variance <3mm) • n = 38 VLP and n = 42 cast (16 casted patients required surgery) p=0.005 7.2

(Months follow-up)

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Sirniö et al. Acta Orthopaedica 2019 Sirniö et al. Acta Orthopaedica 2019

• Analysis of ≥ 65 years of age • Grip strength comparable

• 2 year DASH Scores – no significant difference • Extension recovery rate faster w early surgery

• 11 (ORIF) vs. 17 (Control) (p=0.2) • At the 2-year follow-up – Advantage VLP • Flexion (71˚ vs 64˚, p=0.002) • Ulnar deviation (28˚ vs 25˚, p=0.009)

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9 7/16/20

Sirniö et al. Acta Orthopaedica 2019 Sirniö et al. Acta Orthopaedica 2019

• As Treated Analysis • Early surgery after CR and casting for physically active patients • If chance of secondary displacement is high 2 Year DASH Scores Early Surgery 7 ± 10 • Make decision between non-operative treatment and delayed p = 0.02 surgery at a very early stage Non-Operative, cross over to ORIF 17 ± 16 Non-Operative 13 ± 12 • Delayed operation avoided in cases of secondary displacement of DRFs in elderly people.

• Early Surgery better than Delayed ORIF (cases of 2˚ displacement)

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Best Evidence – Advantages w Surgery Are Short Term Advantages Relevant?

• Better short-term outcomes • Perhaps these should not be underestimated • DASH and PRWE 6 weeks and 3 months • Possible long term (2 year) outcomes, (clinical vs. statistical significance) • A short-term advantage may be of value for elderly patients who need walking aids. • Possibly a marginal advantage w objective measures (varies w different studies) • Flexion • Independence w ADL’s and mobility may be threatened in cases • Radial deviation of wrist disability. • Extension and supination in some studies • Grip strength in some studies

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Do Malunions Matter?

• Primary surgery better than delayed (Early ORIF advantage)

• Recognize Unstable Fractures

• Recent study shows alignment correlated w PRWE • Likely depends on patient specific factors.

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Recognize Stable vs. Unstable Fractures

• Unstable • >20˚ Dorsal (or volar) angulation on initial x-rays • Displacement of more than 2/3 the width of the shaft in any direction • Metaphyseal comminution • Early Instability • >5mm shortening • Predicted by degree of radial shortening and volar tilt (p<0.05) • Intra-articular component • Dorsal comminution approaching significance (p=0.06) • Associated ulnar fracture • Advanced osteoporosis • Late Failure • Predicted by inclination, age, shortening, volar tilt were predictive (p<0.05) • High risk for secondary displacement in a cast • 1/3 of undisplaced fractures went on to fail • despite acceptable initial reduction and correct plaster techniques • most occurred in patients over the age of 65 years.

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Is Casting a Lost Art? Don’t Use too Much Padding

Bony prominences and cast edges must be well padded More skin irritation from shear stress at skin/padding interface

Too much Loose Loss of Padding Cast Reduction

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3 Point Mold + Casting Well Molded doesn’t mean TIGHT!

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Cast Index 58yo F, FOOSH on Ice

• Cross section of cast – oval not a circle • Sagittal to coronal ratio should be 0.7 (<0.8 in some studies)

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Week 1 Week 1

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Week 2 Features of a Good Cast

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Casting Pitfalls Follow-Up Routine

• Don’t Dimple the cast • Week 1 • Causes high pressure areas under cast • Week 2 • Week 3 • No Direct contact between skin and casting material • Cast change as needed in first 3 weeks • For cast change - suspend unstable fractures in finger traps to prevent • Don’t move the limb position after cast has started to set loss of reduction • Will cause bunching of cast material and increased pressure in flexion • Week 6 crease • Removal of cast

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Prepare for Cosmesis of the Malunion Are we operating on too many DRF’s?

• Warn patients about the ‘look’ of their arm – It may look crooked but will likely • Summary work just fine! • When to Operate? • Consider instability of fracture pattern, risk of secondary displacement • Is the short term advantage in ROM, strength relevant for this patient?

• Consider physiologic vs. chronologic age • and other patient factors – hobbies, hand dominance – Can they tolerate a malunion?

• Pearls of non-operative management • Well molded cast is key • Follow weekly for first 3 weeks, change cast if loose • Prepare older patient for asymptomatic malunion

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13 What you don’t know about distal radius fractures can hurt you Julie E. Adams MD Professor of Orthopedic Surgery

ASSH 2020 Virtual Annual Meeting

[email protected]

Beyond Just the Bone: Decision Making and Avoiding Complications Julie E. Adams MD Professor of Orthopedic Surgery Erlanger Orthopedic Institute/ University of Tennessee College of Medicine - Chattanooga

ASSH 2020 Virtual Annual Meeting

Disclosures

Arthrex Acumed Zimmer Biomet Sonex

3 Introduction

• Hand surgeons are expert in treatment of distal radius fractures • It is easy to be carried away by the routine. • When is that simple distal radius fracture not so simple? What pearls and pitfalls can be shared about distal radius fractures & wrist trauma? • How can we avoid unpleasant surprises? 4

• Pitfall: Failing to put hands on the patient

• Your physical exam is better than Xrays

DORSAL

• Lister’s tubercle •Radius •3rd DEC •SL • Midcarpal joint • Lunate • 4th and 5th DEC •CMCs • Distal ulna 6 • Avoid by immobilizing and repeating films in 1 week….

#1 Occult distal radius fracture

• Avoid by immobilizing and repeating films in 1 week…

Occult distal radius fracture

9 #2 Avoid the temptation of always pursuing operative treatment

• Closed reduction & casting is EFFECTIVE for most patients – Howard JBJS-B 1989: RCT ex fix vs nonop 19/24 excellent results – Arora JOT 2009: RCT CRC vs plating in pts > 70 yo – no difference in functional outcomes

Literature

• AAOS Clinical Practice Guidelines: – 29 recommendations about care – Recommended: “assess post-reduction/final lateral films to ensure DRUJ reduced” – “Due to current limitations, further study is required…regarding surgical vs nonsurgical treatment as preferred treatment of elderly and sedentary patients”.

So, how do you decide on treatment?

• La Fontaine’s criteria… – Risk factors associated with re-displacement of successfully reduced distal radius fractures… if > 3 factors present, high risk of displacement • Dorsal angulation of > 20 degrees • Comminution • Intra-articular involvement • Distal ulna fracture • Age > 60 years – Add: osteoporosis. (Dias, Wray, Jones: osteoporosis is a factor leading to greater progression of deformity following casting)

12 So, how do you decide on treatment?

• Follow weekly with serial xrays x first 3 weeks to ensure displacement does not occur !! • If cast treatment chosen…. – Typically 6 weeks total in SAC – Digital motion encouraged – If they are tentative, therapy (don’t neglect the shoulder) • I accept a lot of deformity in frail/ elderly / infirm patients

Pitfall #3

• Caveats with nonoperative fractures… • Beware EPL rupture

EPL rupture-distal radius fracture

• Nondisplaced DRF • Up to 5% incidence (Roth et al 2012) • Watershed nutritional zone (Hirasawa) • ? Pathophysiology – Fracture fragment – Injury at time of fracture – Vascular phenomenon • Prodromal symptoms may be present Diep & Adams, Fromison, Wolfe, Huang & Strauch. Choi et al.

15 Case: 39 yo woman FOOSH Initial X rays

Case: patient with non displaced DRF

• Immobilized x 6 weeks • Cast removed, very painful

Case: patient with non displaced DRF

• Treated elsewhere with SAC x 6 weeks • Cast removed, very painful

18 Case: patient with non displaced DRF

• Still painful at about 8 weeks post injury • MRI ordered • Referred with “TFCC tear” and “membranous SL tear”

MRI

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27 Case: patient with non displaced DRF

• Exam: WE/WF: 20/20 vs 70/70 on right • Sup/pro 60/60 vs 85/85 • Painful over Lister’s and over EPL • Pain with thumb extension

Case: patient with non displaced DRF

• WALANT release of EPL

• EPL thinned, typical tendinopathy appearance (pale, thinned, nearly translucent)

• Followup at 4 weeks: no pain with EPL, intact EPL function

EPL

Radial wrist extensors

 Proximal Distal 

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#4 Pitfall: having only one arrow in your quiver

Literature

• Koval et al: Fractures of the Distal part of the Radius: The evolution of practice over time. Where’s the evidence? • ABOS part 2 candidates • Open surgical treatment 42% (1999) to 81% (2007) • Largely related to enthusiasm for Volar locked plates • Despite lack of improvement in surgeon-perceived functional outcomes • …Or clear evidence of improved outcomes…

Koval, Harrast, Anglen, Weinstein JBJS 2008 33 Literature

AAOS 2009 34

Pitfall: failing to use that “arrow” appropriately

PROBLEMS • Dorsally prominent screws • Irritation of flexor tendons • Intra-articular screws • Mal-reduction

Arora et al JOT 2007 35

Volar plating cannot treat every fracture

DRUJ- dorsal subluxation of ulna

Volar Subluxation

Volar ulnar fragment Courtesy of MDP 36 Volar plating cannot treat every fracture

Courtesy of MDP 37

Advantages of external fixation

• Maintain axial length • Minimal exposure • No retained Hardware • Quick! (27-36 min in one series) • Acceptable complication rate • Widely available • Easily learned and adaptable • Minimal OR staff education • DRUJ, digits mobile 38

External fixation Perceived barriers to external fixation….

• “Difficult” In Edinburgh study 77% put in by residents • “pin pull out in osteoporotic bone” (none in series of 588 cases) most minor and adequately treated if needed with oral antibiotics • Pin site issues (1%) No higher than with other techniques • Extensor (similartendon incidences issues in ExFix vs Cast vs ORIF-- Kreder et al JOT 2006, McQueen et al) •RSD • Limited number of fractures(60%-McQueen, amenable high percentage -McKee)

McQueen et al 39 Alternative: Spanning internal fixator

• Popularized by Ruch and Hanel • Conceptually neutralize forces on the wrist allowing healing • Advantages: no external hardware • Good for comminuted and osteoporotic or high energy fractures • Remove hardware in 3-4 months • Motion of wrist surprisingly good in published series.

Case

• 62 year old Caucasian slender Female • FOOSH ground level height. Right distal radius fracture, Left radial head fracture • History of Left hip fracture 2 yrs prior • Hep C, hypothyroidism • Smoker

Case

42 Case

Point:

• Don’t forget alternatives to volar plating. • Be vigilant about appropriate technique for volar plating.

• Recognize and promptly treat associated nerve issues

45 Case • 33 yo man bicyclist vs road curb • FOOSH bilaterally • CHI, intoxicated at scene • Bilateral DRF • Back pain

Case

• closed reduction performed on Right • Endorsed N/T bilaterally • First responder documents 2 point pre/post reduction in median nerve on R as “1cm” • Patient admitted to ICU

Case

• Seen daily in ICU • 2 point documented at 1 cm in median nerve • Discharged and told to followup with hand surgeon

• Seen at 12 days post injury

48 Case

• Dense median neuropathy on Right • Digital stiffness, hypersensitivity and pain • Trophic changes • Absent sensibility in median nerve • Absent APB function • Burning dysesthesias

Case

• ORIF Right DRF + CTR – Nerve in continuity • CRIF Left DRF

• Early supervised therapy program • Vitamin C and gabapentin prescribed…. • …..But…

Case

• Seen in followup over next 3 months

• Digital stiffness, hypersensitivity and pain • Trophic changes • Absent sensibility in median nerve • Absent APB function

51 Case

• Still resolving 5 months post injury

• EMG: “likely permanent APB /motor branch changes….little potential for resolution…”

• 2 point > 1 cm in thumb and index, 8 mm in long finger • APB atrophy

• Point: even neurapraxia treated promptly can take time to resolve. • Don’t be part of the “problem” – be part of the “solution” • Compression of nerve can be a source of permanent sequelae and a source of CRPS type 2 • Presence of nerve symptoms that worsen or do not resolve are an indication for surgical release

6 – Don’t forget about “the other bone”

• When is DRUJ instability a problem? • An ulnar styloid fracture is not in itself an indication for treatment, but can be indicative of DRUJ instability

54 Case

• 27 year old RHD woman • Rollerblading FOOSH with grade 1 open DRF • Absent Ulnar nerve sensation and function distally

Case

Closed reduction, no change in ulnar nerve symptoms

57 ORIF

Nerve contused but intact. DRUJ unstable all positions

ORIF

Ulnar nerve symptoms completely resolved…. 3 months after surgery…

Final followup 13 months… Grip R/L 60/60# 60 61

Closed reduction, no change in ulnar nerve symptoms

63 ORIF

Point:

• Ulnar styloid basal fractures and radial translation /increased DRUJ gap may be indicative of postop DRUJ instability • Algorithm: Fix DRF anatomically • Assess DRUJ stability • If unstable – and cannot identify a stable position, must do “something”

• May et al: ulnar styloid base fracture and significant displacement of ulnar styloid fracture increase risk of DRUJ instability

*Contrast: Kim et al JBJS 2010 Showed NO correlation of risk of Instability to displacement of styloid

66 Risk factors for DRUJ instability

• Radial translation is the best predictor of DRUJ instability

• Fujitani et al JHS 2011

#7 There is a big picture. Don’t miss it!

#8 Don’t miss the big picture

69 Don’t miss the big picture • Distal radius fractures are often fragility fractures • A prior fragility fx is the among the best predictors of a future event – Prior low energy fx is a 2-6 fold increased risk of future fracture and risk of significant disability (AAOS) – The orthopedic/plastic/hand surgeon is often the first and or only physician to see these patients. – Interventions include Ca, Vit D, prevention programs or pharmacologic agents to decrease risk by up to 50%

72 Evaluation Bone Mineral Density assessment in: • Women > 65 or men > 70 with or without risk factors • PMP women < 65 or men < 70 with > 1 risk factor – Low body weight –Prior fx – High risk medication use – Disease/condition associated with bone loss • Adults with a fragility fracture • All patients with multiple risk factors ISCD 2013 73

Interventions • Dietary • Exercise • Fall prevention • Medical managements

• You don’t have to initiate TREATMENT…but you do need to start the CONVERSATION. 74

Case

75 Case

T Score of -3.3

#8 Pitfall: not recognizing “host” issues

78 typical American … Sadly, we are overwhelmingly: sedentary overweight (36.5% obesity rate in USA per CDC) adequate (excessive) calories, inadequate nutrition

Be aware of “host” issues!

• Vitamin D deficiency is endemic and epidemic • 1000-2000 IU daily

#8 Be holistic • Serum level of 25(OH) D should be 30-100 ng/ml – 40-60 is “ideal” • Moderate deficiency: 21-29 ng/ml • Deficiency associated with cancers, CV disease, peripartum issues, hypertension, increased mortality, CNS issues, autoimmune disorders, insulin abnormalities, and BONE HEALTH, most issues likely associated with PTH Grober et al:Vitamin D Dermatoendocrinol 2013 81 #8 Be holistic

•> 35th parallel from Oct - Mar, insufficient UV exposure for vitamin D metabolism • UV index of <3, no vitamin D synthesis in skin • i phone app: Dminder.info Grober et al:Vitamin D Dermatoendocrinol 2013 82

#8 Be holistic RX: • All fractures take 2000IU daily empirically • Oral vitamin D2 or D3 is effective • Cumulative dosing is fine (ie, once a week or once a month) • Strategy for grossly deficient: 50,000 IU weekly x 8-12 weeks. Once sufficient, can do 50,000 IU q 2 wk indefinitely without toxity Grober et al:Vitamin D Dermatoendocrinol 2013 83

#8 Be holistic Who gets a vitamin D level tested in my practice? •“at risk” – Autoimmune or absorption issues • DM 1, Celiac, eating disorders, “different” diets – Medically ill or elderly • “intuition”

Grober et al:Vitamin D Dermatoendocrinol 2013 84 #8 Be holistic

• Vitamin C • 500 mg daily x 50 days • CRPS (?)

• Controversial • Based on few studies  AAOS Guidelines • Stay tuned…recent data demonstrates no difference!

#8 Be holistic

• Smoking cessation counseling

• May be linked to your reimbursement / ratings in the future…

#9 Not everything that hurts in the wrist is a fracture….

88 • Derm resident • Foosh off scooter • Pain at base of 5th mc • Pain over wrist • Pain dorsally with Watson’s

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5th MC base fx, SL injury

Detection of “other” injuries Detection

• Rule in/out fracture, ligament injury • Provocative maneuvers • Location of tenderness • Plain film xrays • ? Advanced imaging studies

94 SummarySummary

• Wrist trauma is often straightforward – but not always….

• Careful attention to potential patient/injury/fracture factors as pitfalls

• Have more than one “arrow” in your quiver

Ulnar Neuropathy #10-DecompressionDon’t forget vs. Transpositionyour team –

• They make (us) look good – Hand therapists – Clinic nurses / MA’s / LPNs / RNs, PAs and NPs / Support staff – Administrative assistants

THANK YOU

Thank You !

[email protected]

97 7/27/2020

Spanning the Wrist Internally and Externally: When and How

Jerry I. Huang, MD Associate Processor Dept of Orthopaedics and Sports Med University of Washington Medical Center ASSH 2020 Virtual Meeting ICL 39

Vakshori et al. HAND 2018 “Declining Use of Spanning Wrist Ex‐Fix” • NIS database • 40,000‐50,000/ yr • Ex‐Fix application decline 17% to 5% • More in rural, non‐ teaching hospital

External Fixation Distal Radius

1 7/27/2020

• CR + Cast • No difference at 6 wks, • ORIF + bone graft 3 months, 1 year • External fixation • Negative predictor: Carpal Malalignment • Ex‐Fix w/ early ROM

Indications for External Fixation

• Extra or Simple Intra‐articular DRFx • Comminuted intra‐articular DRFx • Very distal fx or radiocarpal dislocation • Unstable internal fixation • Open fx w/ extensive soft tissue injury

2 7/27/2020

Volar Plating vs. External Fixator

• Roh et al JHS 2015, Rozental et al JBJS 2009 • Volar Plate: ROM and grip strength better at 6 weeks and 3 months • ROM, grip strength, DASH same at 12 mos • Ex‐Fix: Pin infections, SRN neuritis, CRPS

52 yo F s/p MCA 38 yo M s/p MCA

Indications for External Fixation

3 7/27/2020

Technique and Pearls for Ex‐Fix

Pin Placement

• Dorsoradial IF MC • Dorsoradial forearm 8‐ 12 cm proximal to radial styloid, between ECRL and ECRB

Seitz et al J Hand Surg 1990 • Small incisions to avoid complications • Centered placement • Tendon + nerve injury

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Beware Superficial Radial Nerve

• 3.5 mm DCP plate • Originally described by Burke and Singer 1998 • Internal Ex‐Fix

Spanning Bridge Plate vs. Ex‐Fix

• Internal: no pin tract infections and longer duration before hardware removal • Increased length and rigidity for fractures with meta‐diaphyseal extension • Polytrauma or bilateral Fx for early WB and easier bed to chair transfer?

5 7/27/2020

23 yo Male Polytrauma s/p MCA

Spanning Bridge Plate + Repair Volar RC Ligaments

6 Weeks Post‐Op Volar Plating

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Revision ORIF w/ Allograft

56 yo Male s/p FOOSH

Lost to FU: 4 Months Later

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Techniques for Comminuted IA Fx Option #1 • CRPP or Limited ORIF • External Fixator to maintain reduction Option #2 • External Fixator for ligamentotaxis • CRPP + Limited ORIF for articular fragments

69 yo Male Fall Off Ladder

Dorsal Buttress Plate

8 7/27/2020

Bridge Plate: Axial Stability

Must Still Reduce Articular Surface

Intra‐Op Fluoro  3 Months Post‐Op

9 7/27/2020

• Slide plate retrograde under ECRL tendon

• Which Finger is Better? • Index vs. Middle MC

10 7/27/2020

HAND 2015

• 3 plate breakage in middle of plate and 2 distal screw failure • Higher complication rate if hardware > 16 weeks

11 7/27/2020

• 11 pts w/ mean age 72 y/o • Immediate unrestricte WB with affected UE • 2 plate fractures • Recommend plates w/o the central holes 34

Avoid Over‐Distraction

Courtesy, Doug Hanel, MD • Chinese fingertraps at 10# • Set tension with fingers closed • Midcarpal joint space 36

12 7/27/2020

52 yo Female s/p MCA

44 yo Male Mortar Blast Injury

13 7/27/2020

Spanning Bridge Plate: Building Block

Summary • Anatomic reduction and stable fixation is more important than Volar Plate vs Ex‐Fix • Beware SRN and over‐distraction in Ex‐Fix • Spanning bridge plate = Internal Ex‐Fix • Dorsal spanning plate restores length + axial stability, not volar tilt or articular congruity

Bail Out Must Reduce

14 7/27/2020

What About the “Other Bone”? What, If Anything, Do you Do with Associated Ulnar Fractures?

Dr. Juan Manuel Breyer Clínica Alemana ‐ Hospital del Trabajador CHILE

Associated Ulnar Fracture 1

The other bone….

Associated Ulnar Fracture 2

Associated Ulnar Fracture

Styloid Fx Neck Fx 50‐60% 5‐6%

Associated Ulnar Fracture 3

1 7/27/2020

Ulnar Styloid Fracture

• Very common condition – 50‐65% of distal radius fracture Biyani 1995, Souer 2009

• Not so much problem for the wrist • The treatment is still under discussion – Few cases with bad results and complications

Associated Ulnar Fracture 4

Ulnar Styloid Fracture

Level Displacement

Associated Ulnar Fracture 5

Ulnar Styloid Fracture

The effect of USF in the settings of DRF is unclear

Little or no effect on clinical They could be related to some

outcomes Sammer 2009, Lindau 2000 complications May 2002, Oskarsson 1997 1. DRUJ Instability 2. Ulnar pain 3. Worse clinical results

Do we expect different outcomes? Should we fixe it?

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USF ‐ DRUJ Instability

• Ulnar styloid – Insertion of TFCC – Main stabilizer of DRUJ

• DRUJ instability – Level – Displacement

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USF ‐ DRUJ Instability • Many different reports

– Base and displaced USF May 2002, Nakamura 1998

• Base fractures – More risk of fovea and deep TFCC rupture – Base level: not clear defined in literature

• Proximal half Buijze 2010, Zenke 2009

• 75% Souer 2009 • “Full base”

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USF ‐ DRUJ Instability USF can produce Instability

• Cadaver study Pidgeon 2017 – Proximal USF has the potential to cause instability

• May 2002 – 14/130 DRUJ instability – Size and displacement were risk factors

• Stoffelen 2014 – 13/272 with DRUJ instability – USF is related to instability

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USF ‐ DRUJ Instability USF is not related to DRUJ instability

• Kim JBJS 2010 – 138 DRF‐USF – No relation in size/level of USF

• Gogna J Hand Micro 2014 – Prospective 47 DRF‐USF – Similar results

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USF ‐ DRUJ Instability

J Hand Surg 2017

USF is not related to DRUJ instability Associated Ulnar Fracture 11

USF ‐ DRUJ Instability

J Hand Surg 2017

USF Level is not related to DRUJ instability

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USF – Functional Outcomes

Ulnar side pain Wrist Outcomes • Frequent problem • Flexion and extension – 3‐6 month • Pronation and Supination • With and w/o styloid fracture • DASH, PRWE, MHQ – Soft tissue

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USF – Functional Outcomes

• Daneshvar J Hand Sur 2014 ‐ 142 DRF and USF (stable DRUJ) ‐ < 65 y/o ‐ USF: no effect on final outcomes (significant) ‐ Worse results during first 3 month ‐ Base USF: trend to worse results

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USF – Functional Outcomes

• Sammer J Hand Sur 2009 – Prospective study – 144 DRF and stable DRUJ • 12 month, MHQ – USF did not affect outcomes • Level and Displacement

• Kim JBJS 2010 – 138 DRF‐USF – 32 DRUJ with laxity • 4w sugar tong – Similar outcomes • No relation in size/level of USF

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USF – Functional Outcomes

DRF ‐ USF have Similar Outcomes J Hand Surg 2017

DASH

PRWE

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USF – Functional Outcomes

DRF ‐ USF have Similar Outcomes

• 464 studies 6 • 806 DRF • 55% of USF • Some studies had worse results – Pain and wrist flexion

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US Fixation

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US Fixation

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US Fixation Which styloid should be fixed? • Don´t see the level and displacement • Ballotment test after radius fixation – Neutro, Pron and sup – Major DRUJ instability • Good clinical results – Restore the stability Sawada 2016 – Hardware removal • Minor instability 1. Cast 2. Styloid fixation

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US Fixation

68 y/o

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USF Union • Non Union – Frequent finding – 45‐68% • Not always is a “complication” – Pain and instability • The soft tissue can heal – Peripheral TFCC – Capsule • Very low need of – Non union revision Is it a real problem or – Styloid resection complication?

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USF Union

• Daneshvar J Hand Sur 2014 ‐ 142 DRF and USF ‐ 66% non union ‐ Similar results

• Sammer J Hand Sur 2009 – 144 DRF and stable DRUJ – 68% non union – Similar results

• Bujize J Hand 2010 – 54% non union – Similar results The Non Union it´s not a real clinical problem Associated Ulnar Fracture 24

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Associated Ulnar Fracture

Styloid Fx Neck Fx 50‐60% 5‐6%

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Distal Ulnar Fracture • Less frequent than styloid fx

– 5‐6 % Biyani 1995, Lutsky 2018

• Metaphyseal ulnar fracture (last 5 cm Logan 2008) • Typically in the elderly • Tendency to fixation of radius and ulna

– Excellent results w/ surgical treatment Ring 2004, Logan 2008

• Orthopedic treatment is possible too Namba 2009

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Classification

Q System Kim JK 2013

Biyani 1995

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Distal Ulnar Fx – Internal Fixation • Tendency for fixation

• Good results Logan 2008 • Very challenging – Comminution – Thin cortex – Head articular surface – Soft tissue: ECU • Implant removal Is the fixation always necessary?

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Operative Treatment

1. Malalignment Ring 2004, Dennison 2007 – 10° deformity – 3mm of UV change

– 1/3 translation (50% Cha 2012)

2. Instability – Motion with passive rotation – Comminution – Not so easy to evaluate….

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Ulna Fixation • Methods – Screws – Tension band – Intraosseous wire – Plates • Locking • Low profile • Allow early motion • Protect soft tissue

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Ulna Fixation

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Ulna Fixation

• Good clinical results Dennison 2007 – ROM – Pain

66 y/o

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Salvage Procedures

• Darrach or Sauve Kapandji • Not often necessary • Indications – High comminution – Low demand patient

• Good results Ruclelsman 2009, Arora 2014

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Salvage Procedures

72 y/o Severe COPD 1 y DRF, ulna plus New DRF and UF

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Non Op. Ulna Treatment DR plate fixation and non‐op ulna treatment?

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Non Op. Ulna Treatment DR plate fixation and non‐op ulna treatment? • Problems? – Early motion? – Displacement?

– Bad results?Biyani 1995 • Limited evidence….

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– Comparative study • 29 op v/s 32 non‐op Ulna – >65 – DR fracture: plate – Unstable ulna fracture: no fixation • Instability: motion more than 50% • Malalignment: 10° angular deformity – Excellent and similar results

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• Comparative study • 2.968 DR Fx – 172 distal ulna (no styloid) – 5,8% • 70 y/o both groups • Fix and No Fixation • Union Rate – Ulna fixation 72/74 – Ulna no fixation: 91/91 • Good alignment

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Non Op. Ulna Treatment

69 y/o

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Non Op. Ulna Treatment

The Non Op Ulna treatment is a good option

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Surgical Indication

Present Surgical Recommendation

• Major or Gross Lutsky 2018 – Instability – Displacement • 50 y/o Active patients Open Fx – Early rehab. • Open fractures

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Conclusion Ulnar Styloid Fracture • Common injury related to DRF • No major effect in outcomes – Size and displacement are not important • Test the DRUJ stability – Major Inst: Ulna fixation – Minor Inst: Orthopedic treatment

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Conclusion Ulna Neck Fracture • Less common injury • More in elderly • Non operative treatment – Good results • Surgery – Major instability – Active patients

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What About the “Other Bone”? What, If Anything, Do you Do with Associated Ulnar Fractures?

Dr. Juan Manuel Breyer Clínica Alemana ‐ Hospital del Trabajador CHILE

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