Distal Radius Fractures: a Case by Case Approach

OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

Co-Chairs: A. B. Chhabra, MD and Seth D. Dodds, MD

Program Syllabus

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]

OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

An ASSH pre-course geared as much to the on-call hand surgeon as to the skilled wrist surgeon. Twelve master distal radius fracture surgeons will describe their techniques to success using a case by case approach. This pre-course focuses on indications for different types of operative approaches for standard and more complex distal radius fractures. Our panelists will demonstrate concise surgical approaches ranging from volar plating, dorsal plating, fragment-specific approaches about the dorsal, radial and volar-ulnar distal radius, as well as dorsal spanning plate fixation for highly comminuted fractures and for the polytrauma patient. In addition, complex associated injuries to the distal ulna and DRUJ will be addressed to provide thorough treatment of distal radius injuries. Each of our wrist experts will focus on surgical indications and straightforward operative techniques to repair and stabilize difficult scenarios about the wrist. After this pre-course the attendee will have expanded their knowledge of simple and complex distal radius fracture patterns, determined specific repair options for distal radius and distal ulna injuries, and understood clear surgical techniques to achieve definitive stability.

LEARNING OBJECTIVES At the conclusion of this program, the attendee will:

• Understand operative indications for distal radius fractures using appropriate radiological assessment. • Learn various surgical approaches for repair of the distal radius. • Identify specific aspects distal ulna injury that warrant operative intervention. • Determine operative indications for volar plating, dorsal plating, radial styloid internal fixation and dorsal spanning or distraction plating. • Understand complications related to different treatment options and approaches.

CME CREDIT HOURS

The ASSH designates this live activity for a maximum of 4.00 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

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. PRE/POST EVENT – Learner Assessment The Pre-event Assessment was sent electronically to the email you have on file. The Post-event notification will be sent using the same method. Please check your email 24 hours after this course for a message from ASSH with access instructions and information.

You are encouraged to complete the post-event assessment even if you did not participate in the pre-event assessment. If you experience difficulty completing the post-event assessment online please email [email protected] or call (312) 880-1900.

According to standards established by the Accreditation Council for Continuing Medical Education (ACCME), the ASSH is required to assess learning from participation in Continuing Medical Education events. To address these standards, the Hand Society uses pre-and post-tests for all of its courses. These questions are used to evaluate the knowledge of course participants before attending a program and again after the course to see if improvements were made.

DISCLAIMER The material presented in this continuing medical education program is being made available by the American Society for Surgery of the Hand for educational purposes only. This material is not intended to represent the best or only methods or procedures appropriate for the medical situation discussed; rather the material is intended to present an approach, view, statement or opinion of the authors or presenters, which may be helpful, or of interest to other practitioners.

The attendees agree to participate in this medical education program, sponsored by ASSH with full knowledge and awareness that they waive any claim they may have against ASSH for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against the ASSH for injury or other damage that may result in any way from their participation in this program.

All of the proceedings of the 75th Annual Meeting, including the presentation of scientific papers, are intended for limited publication only, and 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. Any sound reproduction, transcript or other use of the material presented at this course without the permission of the speaker or the ASSH is prohibited to the full extent of common-law copyright in such material.

The ASSH is not responsible for expenses incurred by an individual who is not confirmed and for whom space is not available at the meeting. Costs incurred by the registrant such as airline or hotel fees or penalties are the responsibility of the registrant.

The approval of the U.S. Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed and/or demonstrated in or at ASSH educational programs may not yet have received FDA approval.

Claim your CME hours through www.ASSH.org

How to Claim: By viewing on-demand content in the LMS and completing the test questions when prompted, you will automatically be awarded your CME credit and have the ability to download your certificate immediately. No additional steps are needed.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. *Please note that ASSH does not provide Continuing Education for physical therapists. Visit the APTA website for more information.

Questions? Problems? Contact the American Society for Surgery of the Hand at (312) 880-1900 or by email at [email protected].

Conflict of Interest Disclosures for 2020 Program Committee and Course Faculty

Program Faculty & Disclosures The American Society for Surgery of the Hand gratefully acknowledges those who have generously volunteered considerable time and effort to plan, organize and present this CME course. The ASSH appreciates the faculty’s dedication to teaching, their support of the ASSH mission, and their significant contribution to the educational success of this program. The following is a list of disclosures for all participating faculty and program staff.

CONFLICT OF INTEREST POLICY According to the ASSH conflict of interest policy, individuals involved in continuing medical education activities are required to complete a disclosure statement. The ASSH acknowledges this fact solely for the information of the listener. Non-conflicted reviewers have examined, documented and resolved financial relationship disclosures for this course content.

Financial Disclosure – represented by ● Instructors, planners, content reviewers and managers who affect the content of a CME/CE activity are required to disclose financial relationships they have with commercial interests (i.e. any entity producing, marketing, pre-selling, or distribution health care goods or services consumed by, or used on, patients) associated with this activity.

FDA Disclosure – represented by ▲ Some drugs or medical devices demonstrated at this course may have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice.

The ASSH policy provides that “off label” uses of a drug or medical device may be described in the ASSH CME activities so long as the “off label” use of the drug or medical device is also specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device for the described purpose). Any drug or medical device is being used “off label” if the described use is not set forth on the product’s approval label.

Planners 2020 Annual Meeting Program Chairs Dawn M. LaPorte, MD No relevant conflicts of interest to disclose

Ryan P. Calfee, MD, MSc No relevant conflicts of interest to disclose

Session Co-Chairs/Moderators A. B. Chhabra, MD No relevant conflicts of interest to disclose

Seth D. Dodds, MD No relevant conflicts of interest to disclose

Faculty Reid A. Abrams, MD ● Consulting Fees: AO Foundation

Sonya P. Agnew, MD No relevant conflicts of interest to disclose

David G. Dennison, MD ● Speakers Bureau: AO

Scott G. Edwards, MD ● Consulting Fee: Medartis ● Speaker Bureau: Medartis ● Ownership Interest: Mylad Orthopedic Solutions

Felicity Fishman, MD No relevant conflicts of interest to disclose

Aaron M. Freilich, MD No relevant conflicts of interest to disclose

Andrea Halim, MD No relevant conflicts of interest to disclose

Douglas P. Hanel, MD ● Consulting Fee: Aptis, Acumed, Trimed, Skeletal Dynamics ● Speakers Bureau: Aptis, Trimed, Skeletal Dynamics, AONA Guillaume Herzberg, MD, PhD ● Royalty: Groupe Lepine Company

Jonathan E. Isaacs, MD ● Contracted Research: Axogen, Inc., Polyganics, Inc. ● Other: Material transfers from Axogen to our lab

Jesse B. Jupiter, MD ● Intellectual Property: Trimed ● Consulting Fees: AO Foundation ● Speakers Bureau: Trimed, Aptis, DepuySynthes, Acumed ● Non-CME Services: Elsevier ● Ownership Interests: OHK

Robert J. Medoff, MD ● Consulting Fees: TriMed

David S. Ruch, MD ● Royalty: Acumed ● Consulting Fees: Acumed ● Speakers Bureau: Acumed

OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

Co-Chairs: A. B. Chhabra, MD and Seth D. Dodds, MD

Description

Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

Learning Objectives At the conclusion of this program, the attendee will:

Program

10 Minutes Introduction: How Can We Best Tackle Intra-articular Fractures A. B. Chhabra, MD | Seth D. Dodds, MD

15 Minutes Radiographic Assessment of Distal Radius Fractures Robert J. Medoff, MD

15 Minutes Closed Management of Wrist Fractures and When Should I get a CT Scan if I Am Thinking Surgery Aaron M. Freilich, MD

15 Minutes The Volar-FCR Approach: How Can I Make It Better to See the Whole Volar Distal Radius Jonathan E. Isaacs, MD

15 Minutes The Volar Ulnar Corner Sonya P. Agnew, MD

15 Minutes Dorsal Ulnar Corner Fixation from the Volar Side Jesse B. Jupiter, MD

15 Minutes Fragment Specific Fixation, Individualized Repair Techniques for Each Articular Fragment Reid A. Abrams, MD

15 Minutes Extreme Volar Plating Tips and Tricks David G. Dennison, MD

5 Minutes Introduction Seth D. Dodds, MD

15 Minutes Dorsal Spanning Plate Fixation: Bridging Gaps at the Wrist Seth D. Dodds, MD

15 Minutes Spanning Plate Fixation: Can Multitrauma Principles Be Applied to Our Geriatric Patients? Douglas P. Hanel, MD

15 Minutes Dorsal Spanning Plate for Complex Distal Radius: Bone Loss and Nonunion David S. Ruch, MD

15 Minutes The Bridge Plate Debate: 2nd or 3rd Metacarpal Andrea Halim, MD | Felicity Fishman, MD

15 Minutes Ulnar Styloid Fractures and DRUJ Problems Scott G. Edwards, MD

15 Minutes Post-Fracture Management of TFCC Tears and DRUJ Instability Guillaume Herzberg, MD, PhD

15 Minutes Carpal Tunnel Release and Distal Radius Fractures: What Are the Indications and Different Approaches A. B. Chhabra, MD

OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Radiographic Assessment of Distal Radius Fractures

Robert J. Medoff, MD ● Consulting Fees: TriMed

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

8/13/2020

Robert J. Medoff, MD

Consulting Fees: TriMed

Essential radiology of the distal radius

Robert Medoff, MD

1 8/13/2020

The Basics

Motion of sigmoid notch determined by axis of radiocapitellar joint

• DRUJ mostly rotation

• Sloppy joint: some gliding movement

• Radiographic evaluation more difficult – signs can be subtle

2 8/13/2020

Why are x-rays essential?

1. Mechanism

2. Structural components

Mechanisms

(9)

3 8/13/2020

Dorsal bending

Volar bending

Dorsal shear

4 8/13/2020

Volar shear

Radial shear

3 part articular

5 8/13/2020

Complex articular

Carpal avulsion

High energy

6 8/13/2020

Why are x-rays essential?

1. Mechanism

2. Structural components

Are you satisfied with your care? Fragment specific fixation

1. Identify primary fracture components 2. Independent fixation using implants specific to each fracture component 3. Utilize semi‐elastic fixation mechanisms that avoid dependence on thread purchase. 4. Create a load sharing construct.

AO approach Fragment specific approach

1. Thread purchase not effective 1. Not based on thread purchase 2. Large entry holes 2. Minimal hole size 3. Cantilever loaded structure 3. No cantilever loading 4. Bulky, stiff plates 4. Flexible, elastic implants 5. No load sharing 5. Load sharing construct

7 8/13/2020

Essential Landmarks and Parameters

Facet horizon

Carpal facet horizon

Dorsal rim Volar rim

X-ray beam

Medoff R: Essential radiographic evaluation for distal radius fractures. Hand Clin 2005;21(3):279-288. 24

8 8/13/2020

Carpal facet horizon

Volar rim Dorsal rim X-ray beam

Dorsal corner

Which corner?

Volar corner

9 8/13/2020

Teardrop angle

Axial instability pattern

Teardrop

Not always depressed!

Volar instability pattern

10 8/13/2020

Congruency

11 8/13/2020

Congruency

AP distance

Lateral carpal alignment

12 8/13/2020

13 8/13/2020

Lateral carpal alignment

14 8/13/2020

Examples

Missed depressed sigmoid notch

Your intraop C-arm

15 8/13/2020

Coronal malreduction

Widened DRUJ interval (>2mm)

Offset at radial border Destabilizes DRUJ

Coronal malreduction

Destabilizes DRUJ

16 8/13/2020

Carpal avulsion/small volar rim

Sagittal shift, residual dorsal instability

Assessing wrist injuries –

• Radial inclination • Volar tilt • Ulnar variance • Radiocarpal congruency • DRUJ congruency • Teardrop angle • Coronal alignment • Lateral carpal alignment • Intracarpal pathology • Instability mechanism • Fragment stability • Implant placement

17 8/13/2020

18 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Closed Management of Wrist Fractures and When Should I get a CT Scan if I Am Thinking Surgery

Aaron M. Freilich, MD No relevant conflicts of interest to disclose

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

8/13/2020

Aaron M. Freilich, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

Closed Management of Wrist Fractures and When Should I get a CT Scan if I Am Thinking Surgery Aaron M. Freilich, MD

Closed Management of Wrist Fractures and When Should I get a CT Scan

• Understand Normal anatomy as applies to evaluation of DRF • Understand Instability after fracture and decision making • Understand when more imaging is necessary or helpful (i.e. CT Scan)

1 8/13/2020

Normal Parameters Radial Inclination (22°)

Radial Height (11mm) RH RI Radial Tilt (11° volar) uv Ulnar Variance (neutral )

Normal Parameters Radial Inclination (22°)

Radial Height (11mm) RI Radial Tilt (11° volar) Ulnar Variance (neutral ) RT

Closed management Stable or not

• Consider patient factors • Consider Fracture factors

2 8/13/2020

Closed management - Instability

• Lafontaine Criteria (1989) - >3 factors present = unstable • dorsal angulation exceeding 20° at presentation • dorsal comminution; • extension of the fracture into the radiocarpal joint • an associated ulnar fracture • age over 60 years

Closed management - Instability

3 8/13/2020

Closed management -Algorithm

Displaced Nondisplaced VS

Closed management –Algorithm nondisplaced

Closed management –Algorithm displaced

4 8/13/2020

Operative management – Unacceptable Reduction

• AAOS appropriate use criteria (2013)

• Radial Shortening > 3mm • Dorsal tilt > 10 deg • Articular displacement> 2mm

Others – No real consensus

• Dutch National Guidelines for acceptable reduction (2016)

Example

• 60 yo male s/p fall.

5 8/13/2020

Example - Injury

• 60 yo male s/p fall.

Example - Reduction

• 60 yo male s/p fall.

Example- 4 wks

• 60 yo.

6 8/13/2020

What about a CT Scan

• Not typically necessary - Most are obvious with appropriate radiographs

• Reason’s to get one • #1) Experience • #2) Not sure/Can’t see • #3) Subtle Fractures to evaluate articular congruence • #4) Other Carpal fractures • #5) Plan approach or technique

57 yo female

7 8/13/2020

57 yo female

20 yo male

• Reduction films

20 yo male

• Injury films help

8 8/13/2020

20 yo male

• Easier now, but still...

20 yo male

• What about this? • Helpful for other pathology

9 8/13/2020

Conclusion

• Simple Fractures and Stable fractures can be treated nonoperatively • Be mindful of maintenance of reduction on follow up • AP/Lat/Obl radiographs are usually adequate…but • CT Scan can help assess intraarticular reduction or plan approach

10 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

The Volar-FCR Approach: How Can I Make It Better to See the Whole Volar Distal Radius

Jonathan E. Isaacs, MD ● Contracted Research: Axogen, Inc., Polyganics, Inc. ● Other: Material transfers from Axogen to our lab

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

8/13/2020

Jonathan E. Isaacs, MD

Contracted Research: AxoGen, Inc., Polyganics, Inc. Other: Material transfers from AxoGen to our lab

The Volar-FCR Approach: How Can I Make it Better to See the Whole Volar Distal Raidus Precourse 12: Distal Radius Fractures

2020 ASSH Annual Meeting

Jonathan Isaacs, M.D. Herman M. & Vera H. Nachman Distinguished Research Professor Professor and Chief, Division of Hand Surgery Vice Chairman of Research and Education, Department Of Orthopedic Surgery

Disclosures  Contracted research – AxoGen, Inc.  Other partial research support – AxoGen, Inc. – Cook Biotech, Inc. – Neuraptive, Inc.

1 8/13/2020

What’s so great about the volar approach?

 Avoid going dorsal! – Thanks to locking plate technology  Soft tissue envelope  Volar cortex

What’s not so great…

 Neurovascular structures at risk – Primarily median nerve  Complete exposure can be challenging  Some fractures can be difficult to reduce  Can’t visualize articular surface

Three basic options:

 Extended volar approach  Henry approach  FCR approach

Ilyas. HAND 2011

2 8/13/2020

Extended volar approach

 Extended carpal tunnel approach  Median Nerve (and Palmar Cutaneous Branch) at risk – Manipulation/retractors – 31/83 patients with median n dysfunction (Lattmann et al. JHS 2008) . 10% CRPS type I

FCR (Modified Henry)

 Over FCR (8cm long)

 Release FCR sheath (proximally)

3 8/13/2020

 Release FCR sheath floor (proximally)

 Sweep the tendons/median nerve ulnarly  Lift up pronator quadratus

Ilyas. HAND 2011

Extended Carpal Tunnel release  Incision extended distally – Angled across crease – Towards thenar eminence

Orbay et al. Techniques in Hand and Upper Extremity Surgery 2004 12

4 8/13/2020

Pensy et al. JHS 2010

 Follow FCR to insertion

 Identify FPL

 Follow the transverse carpal ligament distally

5 8/13/2020

 Should be able to stick finger in CT  Tendons/nerve retract easily

6 8/13/2020

Caution  PCB branches around 5cm prox wrist crease – Can run in ulnar edge FCR tendon sheath (doesn’t typically cross tendon)  Median Nerve within 5mm of FCR tendon  Radial Artery within 5mm of FCR tendon

Conti Mica, Bindra, Moran J of Orthopaedics 2017

Does improve radial exposure

 At watershed line: 3.3 +/‐ 0.3cm vs 3.1 +/‐ 0.3cm (volar approach)

Jockel et al. JHJS 2013

Easier access to release BR

7 8/13/2020

Allows access to radial column  48yo fell 15 feet from ladder

8 8/13/2020

9 8/13/2020

Can extend proximally…  Subperiosteal elevation of FPL, FDS, PT, Sup  Limited by radial/ulnar arteries proximally  Do have to sacrifice arterial branches  Can expose about 80% of radius

Jockel et al. JHS 2013

10 8/13/2020

FPL weakness

 Innervation proximal third and ulnar  So weakness from elevation

Conti Mica, Bindra, Moran J of Orthopaedics 2017

Pronating the radial shaft

 Release the radial septum

Orbay et al. Tech Hand Surg 2016

 Use a bone clamp to pronate shaft – Can release dorsal periosteum/callus – Dis‐impact depressed articular fragments

Orbay et al. Tech Hand Surg 2016

11 8/13/2020

Final points  I do not repair PQ – Doesn’t cover plate where tendons rub – Often poor quality – No benefit (systematic review:no differences between repair and no repair ) (Mulders et al. Strat Traum Limb Recon 2017)  I do not repair BR

– Minimal biomechanical effect on BR torque (Tirrell et al. JHS 2013)

– No impairment in patient elbow flexion (Kim et al. JHS 2014)

Conclusion

 I start with a standard FCR approach  Release BR prn  Extend distally if struggling  Extend proximally PRN  Rarely need to get to radial column  Rarely need to pronate shaft

Thank You!

12 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

The Volar Ulnar Corner

Sonya P. Agnew, MD No relevant conflicts of interest to disclose

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

Sonya P. Agnew, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

ASSH 2020 Precourse 12 Distal Radius Fractures: A case by case approach

Sonya Agnew, M.D. Assistant Professor Loyola University Medical Center Division of Plastic Surgery, Department of Orthopaedic Surgery Section Chief, Plastic Surgery Hines VAMC

The Lunate Facet is a ….

1 The Lunate Facet: Why do we care?

 Lunate facet accounts for 43% of the contact area of the radiocarpal joint1

•Load pattern is lunate-predominant in most2  52% force transmission

•Most ADLs position the wrist in extension/ulnar deviation

Critical Attachment - SRL

Short radiolunate ligament • Originates from the volar lunate face Lunate • Tethers the carpus – Carpus follows with a palmar subluxated fragment Radius

Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15(6):847-854. 5

Deforming Forces • Ulnolunate ligament complex originating from the palmar margin of the TFCC • Geometry: Precipice – Relies upon tenuous subchondral support

2 Precipitous bone = precipitous fixation

• Extends palmarly compared to scaphoid facet

Paryavi E, Christian M, Eglseder A, Pensy R. Sustentaculum Lunatum: Appreciation of the Palmar Lunate Facet in Management of Complex Intra-Articular Fractures of the Distal Radius. The American Journal of Orthopedics. 2015. E303-307.

CASE EXAMPLES

Good intentions…

Harness N, Jupiter J, Orbay J, Raskin K, Fernandez, P. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. JBJS Volume 860A, 9, Sept 2004

3 Hindsight is 20:20 Recognition of the palmar lunate facet fragment is critical

Case 1 – JK 21 YEAR OLD, MCC

Injury films

4 13

Intraop

One month postop

5 Case 2 - KC 60 YO WOMAN, FALL OFF CHAIR

Case 3 – DZ 48 YO, FALL OFF LADDER (ON PCP)

Case 4 - JN 51 YO FALL INTO A LAKE

6 POST TEST QUESTIONS

Pre/Post test questions 1. Why do we care about the palmar lunate facet? – Provides more than 50% of load in most activities of daily living 2. Why is the palmar lunate facet so tenuous? – Precipitous geometry places it at risk for palmar subluxation due to shear forces and palmar / distal slope compared to scaphoid facet

References

1. Mekhail AO, Ebraheim NA, McCreath WA, Jackson WT, Yeasting RA. Anatomic and x-ray film studies of the distal articular surface of the radius. J Hand Surg Am. 1996;21(4):567-573.

2. Giunta R, Löwer N, Wilhelm K, Keirse R, Rock C, Müller-Gerbl M. Altered patterns of subchondral bone mineralization in Kienböck’s disease. J Hand Surg Br. 1997;22(1):16-20

3. Berger RA, Landsmeer JM. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15(6):847-854.

4. Paryavi E, Christian M, Eglseder A, Pensy R. Sustentaculum Lunatum: Appreciation of the Palmar Lunate Facet in Management of Complex Intra-Articular Fractures of the Distal Radius. The American Journal of Orthopedics. 2015. E303-307.

5. Harness N, Jupiter J, Orbay J, Raskin K, Fernandez, P. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. JBJS Volume 860A, 9, Sept 2004

7 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Dorsal Ulnar Corner Fixation from the Volar Side

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

8/13/2020

Jesse B. Jupiter, MD

Intellectual Property: Trimed Consulting Fees: AO Foundation Speakers Bureau: Trimed, Aptis, Depuy Synthes, Acumed Non-CME Services: Elsevier Ownership Interests: OHK

FIXATIONFIXATION OF A DISPLACED DORSAL LUNATE FACET OF A DISPLACED DORSAL LUNATE FACET THROUGHTHROUGH AN ANTERIOR APPROACH A VOLAR APPROACH

JESSE JESSE B JUPITER MD,MAHANSJOERG PROFESSOR

Disclosures

Intellectual Property: Trimed Consulting Fees: AO Foundation Speakers Bureau: Trimed, Aptis, Depuy Synthes, Acumed Non-CME Services: Elsevier Ownership Interests: OHK

1 8/13/2020

OBJECTIVES

• ASSESS THE ANATOMIC ISSUES

• FIXATION THROUGH ANATOMICALLY SHAPED VOLAR PLATE

• FIXATION USING NEW TECHNOLOGY

• DORSAL FIXATION THROUGH IMPLANT LOCKED INTO VOLAR PLATE

• ADJUVANT USE OF A COMPRESSION CLAMP

OBJECTIVES

• ASSESS THE ANATOMIC ISSUES • FIXATION THROUGH ANATOMICALLY SHAPED VOLAR PLATE • FIXATION USING NEW TECHNOLOGY • DORSAL FIXATION THROUGH IMPLANT LOCKED INTO VOLAR PLATE • ADJUVANT USE OF A COMPRESSION CLAMP

Sigmoid Notch Evaluation

2 8/13/2020

Sigmoid Notch evaluation

3 8/13/2020

OBJECTIVES

• ASSESS THE ANATOMIC ISSUES • FIXATION THROUGH ANATOMICALLY SHAPED VOLAR PLATE

• FIXATION USING NEW TECHNOLOGY

• DORSAL FIXATION THROUGH IMPLANT LOCKED INTO VOLAR PLATE

• ADJUVANT USE OF A COMPRESSION CLAMP

Dorsally displaced lunate facet fragments Treated with a volar locked plate IDEAL SCREW LENGTH 100% or 75%?

IDEAL PLATE POSITION BETTER BONE PURCHASE VS DECREASED FLEXOR TENDON INJURY RISK

Analysis of 10 ICUC cases

ICUC-BASED TRENDS

“Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation.”

Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP.

J Hand Surg Am. 2012 Mar;37(3):446-53. doi: 10.1016/j.jhsa.2011.12.013. Epub 2012 Feb 2. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates.

CONCLUSIONS: Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation. Unicortical distal fixation for extra- articular distal radius fractures should be entertained to avoid extensor tendon injury because this technique does not appear to compromise initial fixation. CLINICAL RELEVANCE: Using unicortical fixation during volar distal radius plating may protect extensor tendons without compromising fixation.

4 8/13/2020

100% 75%

100% Extra-articular fracture

“Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation” Wall LB et al. J Hand Surg 2012

1) “Which is the ideal plate position of a volar plate, distal enough to get a good bone purchase, or not so distal as to avoid flexor tendon problems according to Soong/Kitay criteria?”

100% 75% 2) “Which is the ideal screw length, 100% including dorsal tendon impingement risk, or 75% and a lower bone purchase?”

75% 100%

100 Dorsal ulnar % corner fragment

The question is: is this concept also valid for dorsally displaced dorsal ulnar fragments?

100% 75%

5 8/13/2020

6 8/13/2020

PROTRUDING PLATE

NON PROTRUDING PLATE

223w

PRE

ICUC® Score: FL=0 | P=0

7 8/13/2020

75%

8 8/13/2020

PROTRUDING < PLATE

NON PROTRUDING PLATE

57w

PRE

ICUC® Score: FL=0 | P=0

99w

PRE

ICUC® Score: FL=1 - P=1

9 8/13/2020

IDEAL SCREW LENGTH: 100% or 75%?

IDEAL PLATE POSITION BETTER BONE PURCHASE VS DECREASED FLEXOR TENDON INJURY RISK

OBJECTIVES

• ASSESS THE ANATOMIC ISSUES

• FIXATION THROUGH ANATOMICALLY SHAPED VOLAR PLATE • FIXATION USING NEW TECHNOLOGY • DORSAL FIXATION THROUGH IMPLANT LOCKED INTO VOLAR PLATE

• ADJUVANT USE OF A COMPRESSION CLAMP

10 8/13/2020

Figure 5

The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Journal of Hand Surgery 2020 45361.e1-361.e7DOI: (10.1016/j.jhsa.2019.09.001) Copyright © 2020 American Society for Surgery of the Hand Terms and Conditions

Fixation of dorsal ulnar corner through anterior approach

MARIANE ALVAREZ MD,JESSE B JUPITER MD; ALBERTO FERNANDEZ MD;

11 8/13/2020

Prospective Study

• 61 consecutive patients • All with intraarticular fx with split lunate facet or isolated dorsal lunate facet fracture • All treated surgically within 10 days of injury by Alberto Fernandez MD of Uruguay

Operative Technique

• Standard FCR approach • Fracture reduced by manipulation and ligamentotaxis • Volar VA DPS plate • Dorsal lunate facet and sigmoid notch reduction aided by radiolucent bone reduction clamp

With the wrist in neutral position access is much easier, but fracture reduction might be a problem.

12 8/13/2020

A special forceps helps to overcome this reduction problem.problem.

On the dorsal side the clamp has a thick rubber component which helps to reduce the dorsal aspect of the fracture without putting stress on the tendons or the skin.

With the plate on the volar side, the ball tip in one of the screw holes,…

13 8/13/2020

Case Study 02 - 23-DU-272

14 8/13/2020

Case Study 02 - 23-DU-272

Restoring the volar hinge.

Case Study 02 - 23-DU-272

Volar hinge restored.

Case Study 02 - 23-DU-272

15 8/13/2020

Case Study 02 - 23-DU-272

54w

Radiographic Evaluation

• Each patient had preop and early postop axial and sagittal CT • Two independent observers measured fx gap and intrartic step-off of sigmoid notch and ulnar head subluxation

16 8/13/2020

Sigmoid Notch Evaluation

Sigmoid Notch evaluation

17 8/13/2020

18 8/13/2020

19 8/13/2020

• THANK YOU

20 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Fragment Specific Fixation, Individualized Repair Techniques for Each Articular Fragment

Reid A. Abrams, MD ● Consulting Fees: AO Foundation

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

8/13/2020

Reid A. Abrams, MD

Consulting Fees: AO Foundation

Fragment Specific Fixation, Individualized Repair Techniques for Each Articular Fragment Reid Abrams, MD Chief, Hand Surgery Interim Chair, Department of Orthopedics University of California, San Diego

Disclosures & Acknowledgements:

• Rob Medoff for sharing his knowledge and some of the images used herein • Consulting Fees: AO Foundation

1 8/13/2020

Treatment Goals

• Minimize morbidity • Sensitive to patient needs • Tolerance of treatment

Treatment Goals

• Restore function • Limit pain • Prevent arthritis

What radiographic parameters influence these goals?

1. Radioulnar length

• Restore radial length relative to ulna • <5mm ulnar (+)

2 8/13/2020

2. Articular Congruity

• Restore articular congruity • Step-off or gap <2mm

3. Sagittal Plane Alignment

• Correct sagittal mal-alignment • Associated with adaptive carpal collapse • Mal-orientation of sigmoid notch

4. DRUJ

• Address DRUJ instability/congruity Triquetrum

• Ulnar styloid fx/Palmer 1B TFC injury Palmer 1B Lunate injury • Volar ulnar corner (VUC) • Dorsal ulnar corner (DUC) VUC DUC

Radius Ulna

3 8/13/2020

Fracture Morphology-Column concept (Rikli, Medoff)

• Radial column • Intermediate column • Ulnar column • Pedestal

JAAOS Rhee et al 2017

Fracture Morphology-critical fragments (Medoff)

• Radial styloid • Volar ulnar corner (volar rim) • Dorsal ulnar corner • Central osteochondral Short radiolunate ligament (SRLL)

Volar ulnar corner fragment Volar SRLL Ulnar VRUL

Lunate fossa JAAOS Rhee et al 2017 Dorsal

Determinants of Outcome

• Restoration of bony anatomy • “Soft tissue” • Ligaments, tendons, muscle, nerves, swelling, scar • Patient factors • Comorbidities • Psychosocial • Expectations • Aftercare • Complications

4 8/13/2020

Indications for Surgery

• Clinically significantly better functional outcome anticipated with surgery than nonoperative tx • Need for early stability or mobilization • Assume high chance of success with surgery • Patient able to overcome “collateral damage” of surgery

Fixation Options

• Volar locking plate • Fragment specific fixation • External fixation ± pins • Bridge plate ± pins; augmentation to other fixation

Volar locking plate

• Fixed angle introduced 1990s and 1st reported 2002 JHS 2002 Orbay et al

• Variable angle distal locking screws-versatility Match articular contour, fragmentation pattern

 R Medoff, MD 2005

JHS 2002 Orbay et al

5 8/13/2020

Fragment specific fixation=Match fixation to fracture pattern

 R Medoff, MD 2005 16

Fragment Specific Fixation

• Implants specific to fragment

• Incremental fragment assembly with stable provisional support followed by definitive fixation

• Endeavor for limited soft tissue dissection

• Low profile, multiplanar load sharing

• Strive for early motion

 R Medoff, MD 2005 17

Fixation Sequence

1. Volar ulnar

corner Volar approach 2. Radial styloid

3. Dorso ulnar Combined ? corner approach Dorsal approach 4. Central Dorsal approach osteochondral fragment(s) Combined approach

Volar approach

6 8/13/2020

Surgical Approaches

Volar • FCR • Volar ulnar (extensile)

Pensey et al 2010 Ilyas 2011

Surgical Approaches

Volar • FCR • Volar ulnar (extensile)

Ilyas 2011

Surgical Approaches

Dorsal • Trans EPL (3rd DC) • Dorsoulnar

Berger 1995 in Anakwe 2012 Anakwe 2012

Ilyas 2011

7 8/13/2020

Volar Rim

Type 1 Type 2 • Type 1

• Extension; no RC dislocation

• 2.0 sq cm CSA; 36% artic. surface *

• 14mm volar wall length

• 19mm volar wall width

• Type 2

• Shear; 57% RC dislocation • 1.5 sq cm; 28% artic surface Type 3 • 18mm volar wall length

• 19mm volar wall width

• Type 3

• Avulsion; 100% RC dislocation * • 0.72 sq cm; 12% artic surface

• 8mm volar wall length

• 14mm volar wall width 22

Intermediate column-Volar ulnar corner

• Type 1 • Derotate

8 8/13/2020

Intermediate column-Volar ulnar corner

• Type 2 • Buttress

Intermediate column-Volar ulnar corner

• Type 3 • Capture • Neutralize (?)

9 8/13/2020

Small volar ulnar corner fragment

• “Boutique” FSF devices • “MacGuyver” VUC contoured K-wires

Radial column

• Radial column Plate

Dorsal ulnar corner

• Closed reduction and immobilization • CRPP • ORIF

10 8/13/2020

Dorsal ulnar corner

• ORIF

Central osteochondral fragments

• Dorsal approach • Bone graft • ORIF

Central osteochondral fragments

11 8/13/2020

Cases

70 yo active F, ground level fall while hiking

12 8/13/2020

42 yo RHD mother of 3, endurance athlete, cycling accident

54 yo RHD PMD, L wrist injury cycling accident

13 8/13/2020

62 yo active RHD F MVA with open L wrist injury

14 8/13/2020

62 yo active RHD F MVA with open L wrist injury

15 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Extreme Volar Plating Tips and Tricks

David G. Dennison, MD ● Speakers Bureau: AO

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

David G. Dennison, MD

Speakers Bureau: AO

Volar Plating

• Goals – to help with this question: • I’m fairly good at Volar plating with two part and simple three part distal radius fracture‘s. But how can I get myself into trouble with displaced four and five part distal radius fractures or fx/dislocations when I use a Volar plate?

“Extreme” Volar Plating

David Dennison, MD Rochester, MN

3 Comminuted, Impacted intra-articular fracture Volar Plate?

Courtesy of AONA Lecture Archive: J Fernandez, MD

Wrist Fracture Classification

Three‐ Part Fracture

Courtesy of AONA Lecture Archive: J Fernandez, MD

Wrist Fracture Classification

Four‐ Part Fracture

6 Surgical Technique

FCR volar approach BR tenotomy Cancellous allograft

Volar plating for more complex fractures

• Clearly understand the fx – CT.. • Plan carefully • Be able to image intraop (arthroscope, open, fluoro) • Check stability

Lateral - R-U overlap

9 Radiocarpal and DRUJ Dislocation

Lateral image – Teardrop angle

65-70°

12 AO A B

51 yo male fell out of armored car.

15 CT

• Can direct treatment - based upon fragment size and comminution Katz et al, JHS, 2001

CT – Detect Associated Injuries

CT • Sigmoid Notch • DRUJ alignment

18 Volar Plating - Advantages

• Can see reduction well • Strong volar cortex • Good soft tissue envelope • Potential space for the plate • Preserve dorsal soft tissue

Volar Approach/Plate - Limitations

• No visualization of the articular surface or interosseous ligaments • Distal and ulnar fractures

Volar-Marginal Fragment

Harness NG, Jupiter JB, Orbay JL, Raskin KB and Fernandez DL. Loss of Fixation of the volar lunate facet fragment in fractures of the distal part of the radius. JBJS 2004 Sep;86-A(9):1900-8. 21 Complications

Intra-articular Hardware and Malunion

Volar Plating - Complications

• Intra-articular hardware • Extensor and flexor tendon rupture/irritation

24 Complications following internal fixation of unstable distal radius fracture with a palmar locking plate. Arora, R.; Lutz, M.; Hennerbichler, A.; Krappinger, D.; Espen, D.; and Gabl, M.: J Orthop Trauma, 21(5): 316-322, 2007. • Volar plates are sufficiently stable and have minimal loss of reduction with unstable, dorsally displaced fractures. • Complications: tendon rupture, tendonitis and intra-articular hardware • Single plate and approach may not be suitable for complex fractures.

27 28

30 31

Brachioradialis Z-step cut

Overlap allows repair of BR and Pronator FCR

Brachioradialis Release and the Extended FCR Approach

Removes deforming force

Access to comminuted articular fragments

Courtesy of : Hand Innovations and J Orbay, MD 33 34

LIFT 35

Reduction of the fracture • Anatomic reduction of the distal radius – Translation – Obliquity of the sigmoid notch – “Lift” the metaphysis – Restore tension to DIOL and soft tissue Volar-ulnar corner – Allows reduction of the TFC and ulnar styloid

36 37

Intraoperative Issues

• Plate position Radial or too volar …………… Late rupture or tendonitis • Plate width Should “fit” • Position “lower” than volar lunate facet Proximal to volar lip

Reduction and Fixation

“Lift” the metaphysis • Reduction of volar-ulnar corner • Provisional K-wire fixation • Keep distal screw/peg tips in the bone (-1 or 2 mm) • Don’t drill out the other side 39 Intra-Articular Reduction and Fixation

Partially threaded Reduce and compress dorsal lunate facet -Dorsal exposure if inadequate reduction

Radial Tilt

• Styloid

• Radial Tilt Can see the joint space

Lateral

42 Radial Tilt

45° Pronated Oblique

• Smith et al, JHS, 2004

45° Supinated Oblique

45 Volar tilt

Volar tilt view

Comparison of 4 Fluoroscopic Views for Dorsal Cortex Screw Penetration After Volar Plating of theDistal Radius Kagan Ozer, MD, Jennifer M. Wolf, MD, Bruce Watkins, MD, David J. Hak, MD, MBA

• Dorsal tangential view: 3rd 95% sens. for 1 mm 98% sens. for 2 mm

• Oblique views were needed for 2nd and 4th compartments

48 Intraoperative Imaging of the Distal Radioulnar Joint Using a Modified Skyline View G. Klammer, MD, M. Dietrich, MD, M. Farshad, MD, MPH, L. Iselin, MD, L. Nagy, MD, A. Schweizer, MD

The wrist is extended when evaluating the DRUJ

Intraoperative Imaging of the Distal Radioulnar Joint Using a Modified Skyline View G. Klammer, MD, M. Dietrich, MD, M. Farshad, MD, MPH, L. Iselin, MD, L. Nagy, MD, A. Schweizer, MD

Dorsal Capsular Ligaments and Exposure (Courtesy of RA Berger, MD, PhD)

51 Arthroscopy (or arthrotomy) Arthroscopy (or arthrotomy) Traction Dorsal or volar portals Dry – with small arthrotomy Excellent view, light, magnified

3-4

63 y/o – Surgical Nurse…

54 Cast or Operate?

57 58

Fall down Fire-pole, at work…

60 61

63 One year

Summary of “Current” Treatment • No proof that any one treatment is the best • ORIF = better restoration of anatomy Younger patients have earlier return to activities with ORIF • Volar plating: Lower morbidity than older dorsal plating May have lower morbidity than Ex Fix/Pins • Consider Age and Activity level – Treat the PATIENT, not the Fracture…. • Treat the osteoporosis

• Be prepared to use several techniques • Obtain reduction and stable fixation • Understand how to use fluoro to detect problems Look inside if you need to… • Minimize retraction, overdrilling, long screws and poor plate size/location

66 AKA: Volar-Marginal Fragment

• SEVEN patients treated with volar locked plating LOSS of stabilization of volar lunate facet fragment

69 Intra-articular Hardware and Malunion

Volar Plating - Complications

• Extensor and flexor tendon rupture/irritation

Volar-Marginal Fragment

Surgical Technique: Spring Wire Fixation

Reduce the Fragment

75 LIFT 76

Bend the K-wires

Apply volar plate

78 Methods • NINE patients • 4 Male / 5 Female • Follow up 54 weeks (13-199) • All AO Type C Fractures 5/9 additional hardware 4 - external fixation 3 - K-wires of other fragments 1- dorsal pin plate

Results: Radiographs

• All fractures healed with VMF reduced

Results

81 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Dorsal Spanning Plate Fixation: Bridging Gaps at the Wrist

Seth D. Dodds, MD No relevant conflicts of interest to disclose

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

7/14/2020

Seth D. Dodds, M.D. Dorsal University of Spanning Plate Miami Fixation:

Bridging the Gaps at the Wrist

**Disclosure: Hand and Upper No Relevant Conflicts Extremity Surgery

Distal Radius Spanning Plate Who, What, When, Where, Why? • What is it? – “Bridge” or spanning plate – An internal “external fixator” • Distraction Plating – Synthes-specific plate, but there are others quite similar on the market. – Technique was initially published by Burke and Singer in 1998.

Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Upper Extremity Surg. 1998. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. JBJS Am 2005.

Distal Radius Spanning Plate • What is it? Who, What, When, Where, Why? – Concept is similar to applying a bridge plate to a fracture that you would prefer NOT to expose – Pedi Femur – But crossing the wrist joint itself

Femur Bridge Plate Courtsey of Brian G. Smith, M.D.

1 7/14/2020

Distal Radius Spanning Plate Who, What, When, Where, Why?

• When to use it? – Open fractures – Severe intra-articular comminution • With or without bone loss – Fractures with diaphyseal extension – Multitrauma • Early hand use including limited weight bearing

Distal Radius Spanning Plate Who, What, When, Where, Why? • Why should we use it? – Similar indications for a spanning external fixator • Minimally invasive at fracture site – No external pins or rods • May leave it in place for months rather than weeks – Great alternative to primary fusion

–Eliminates dorsal tilt and translation

Distal Radius Spanning Plate Who, What, When, Where, Why? Why should we use it?

Contraindications to Volar Plating Soft Tissue Issues and Open Wounds

2 7/14/2020

Contraindications to Volar Plating Dorsal Shear

Dorsal Spanning Plate Best Indication: Multitrauma Setting • 31 yo fall from ladder – Pilon fracture – Complex distal radius fx

Dorsal Spanning Plate Multitrauma Setting • 31 yo fall from ladder

Plate and pin removal once he is walking comfortably

3 7/14/2020

Dorsal Spanning Plate Multitrauma Setting • 52 yo car crash: – acetabular fracture, Non‐weight bearing, right elbow, wrist, and scaphoid fx

75 yo female who fell down a flight of stairs: R Elbow Dislocation, Open R DRFx, Closed L DRFx

4 7/14/2020

AP view with Application of the spanning plate to the 5 lbs of traction second metacarpal

AP view with restored radial inclination and articular contour after bone grafting

5 7/14/2020

Dorsal Spanning Plate Can Keep You Out of Trouble Radiocarpal instability and the Volar ulnar corner

– Maintaining the longitudinal alignment of the metacarpal, capitate, lunate, and radius –Prevent late subluxation

Distal Radius Spanning Plate Who, What, When, Where, Why?

Where does it go and how do I put it there?

Application of a spanning plate Axial • Axial traction is critical to maintain reduction Traction during plate placement. – K-wires or screws can also be used to maintain joint reduction • 2 incisions – Dorsal approach to Index metacarpal – Dorsal approach to mid to distal 1/3 of radial shaft • Placement of incisions is guided by fluoro imaging

6 7/14/2020

Application of a spanning plate

• Index metacarpal dissection – Identify and mobilize branches of the radial sensory nerve – Identify and mobilize the EDC to IF and EIP – Plate is placed directly on the periosteum of the index metacarpal

Application of a spanning plate • Dorsal radial shaft dissection – Safe interval between ERCL & ECRB to expose the radius – Radial sensory nerve can be seen radially just dorsal to the brachioradialis as it begins to exit the fascia

Hand Forearm

The plate is inserted deep to the ECRL and ECRB tendons along the floor of the second dorsal compartment

7 7/14/2020

Application of a spanning plate

• Instrumentation – Plate is used as a dissection tool • Beneath the APL and EPB muscles to the thumb. • Between/beneath the ECRL and ECRB tendons – Combination of nonlocking and locking screws (2.4 mm)

Spanning Plate: Post-op Protocol

•Early motion – Fingers and forearm • (depending on DRUJ stability) • May start weight bearing – Immediately WBAT, including a regular walker – Would limit crutch weight bearing until 4 weeks postop

How does the wrist work after plate removal ?

• Plate is removed at 3-6 months, depending on the injury – Gentle manipulation at the time of removal – Wrist tends to move through the midcarpal joint

8 7/14/2020

Dorsal Spanning Plate Function and Mobility after Plate Removal – 24 yo motorcycle collision, spine, chest, and bilateral UE trauma

Left Wrist Right Wrist

Dorsal Spanning Plate Function and Mobility after Plate Removal – 24 yo motorcycle collision, spine, chest, and bilateral UE trauma

Dorsal Spanning Plate Function and Mobility after Plate Removal – Better flexibility on the spanning plate side after removal

9 7/14/2020

Spanning Plate Results

10 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Spanning Plate Fixation: Can Multitrauma Principles Be Applied to Our Geriatric Patients?

Douglas P. Hanel, MD ● Consulting Fee: Aptis, Acumed, Trimed, Skeletal Dynamics ● Speakers Bureau: Aptis, Trimed, Skeletal Dynamics, AONA

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

8/13/2020

PRE COURSE 12 Radius Fracture: Treated with Bridge Plate Doug Hanel, MD Combined Hand Program University of Washington Seattle, WA

DISCLOSURES

Douglas P. Hanel, MD

Consulting Fee: Aptis, Acumed, Trimed Skeletal Dynamics Speakers Bureau: Aptis, Trimed, Skeletal Dynamics, AONA

This Lecture is Level 3, 4 & 5 Evidence

1 8/13/2020

Bridge Plate: Indications

• Multiply Injured Patients Esp. Associated Pelvis Fx Prolonged ICU Need to Use Crutches • Extremely Comminuted Fx’s • Bilateral Fx’s • Limited OR Time • Limited Bone / Elderly

The Next Indication: Salvaging My Mistakes

2 8/13/2020

Case Example 46 Y/O Falls From Bicycle Commuting to Work Full Time Laboratory Technician Part Time Violinist (Juilliard Grad)

Case Example

• Nerves Intact R • Vascular Intact • Head Intact • Body Intact

Splinted & Referred L

LEFT: 2 Days Post Injury

3 8/13/2020

RIGHT: 2 Days Post Injury

Telltale Signs of a Struggle Lateral Carpal Alignment Perfect Stable To Agee Reduction Stress

2 Weeks Post Post Sutures Out Left DRUJ Stable Mobile : SAC Right DRUJ Stiff: Referred to PT

4 Weeks Post Right & Left Improving ROM Playing Violin Riding Bike

4 8/13/2020

5.5 Weeks Post Injury

Right Left

5.5 Weeks Post Injury

Right

5.5 Weeks Post Injury

Right

5 8/13/2020

• Exposure • Reduction • Fixation

Reduction and Implant

6 8/13/2020

Bridge Plate Applied

IN THIS CASE DIRECTION OF INTRODUCTION DOES NOT MATTER

Construct Complete

Distraction Plates Off: 16 Wks These Xrays: 40 Wks Post

Right Left

7 8/13/2020

Results: Alex Lauder JHS2015

Strength Recovery Dominant Side Injured: 95% Non Dominant Side Injured: 80% Wrist Extension Recovery Dominant Side Injured: 96% Non Dominant Side Injured: 75% Wrist Flexion Recovery Dominant Side Injured: 80% Non Dominant Side Injured: 65%

Dominant Side Injuries Recovered Best !

8 yrs Post) Performs With Violin

About As Well As Before Right Rides Bike Everyday

Left

Indications

• Multiply Injured Patients Esp Associated Pelvis Fx Prolonged ICU Need to Use Crutches • Extremely Comminuted Fx’s • Bilateral Fx’s • Limited OR Time • Limited Bone / Elderly

8 8/13/2020

Indications

• Multiply Injured Patients Esp Associated Pelvis Fx Prolonged ICU The Next Indication:Need to Use Crutches • ExtremelySalvaging My Mistakes Comminuted Fx’s • Bilateral Fx’s • Limited OR Time • Limited Bone / Elderly

Thank You

Photo Courtesy Jennifer Brown

9 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Dorsal Spanning Plate for Complex Distal Radius: Bone Loss and Nonunion

David S. Ruch, MD ● Royalty: Acumed ● Consulting Fees: Acumed ● Speakers Bureau: Acumed

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

8/13/2020

David S. Ruch, MD

Royalty: Acumed Consulting Fees: Acumed Speakers Bureau: Acumed

The Use of Spanning Plates for Bone Loss and Non Union in Fractures of the Distal Radius

David S Ruch, MD Professor and Vice Chair Department of Orthopedic Surgery Chief of Division of Hand Surgery Duke University Medical Center

Goal

. To illustrate techniques for management of massive bone loss in distal radius fractures. . With increased trends to ORIF to provide an algorithm for managing complex non unions/infected non unions of the distal radius.

1 8/13/2020

Spanning Plates- open fractures with bone loss

“The Use of Distraction Plating for Salvage of Meta-diaphyseal Fractures” Ruch et al JBJS

. 26 patients(13M/11F) . 50.3y(19-93y) . 9/24 polytrauma Articular (C-2 or C-3) + Diaphyseal extension

Soft Tissue Management

. 9/24 open fxs . 1 STSG . 3 flap closure . Lateral Arm/ Tendon transfer

2 8/13/2020

Lateral Arm Flap Tendon transfers -thumb index

Bone Defect

. 10/24 allograft MRSA post ORIF . 4 Tricortical graft

Bone Defect

. 4 osteomyelitis 6cm bone . 4 antibiotic spacer defect . 4 Tricortical graft

3 8/13/2020

Fracture of the Distal Radius Distraction Plating

. DCP . 5.5 cm Tricortical graft

Fracture of the Distal Radius Bridge Plating

Plate Removal after union (average – 130 days)

Fracture of the Distal Radius Bridge Plating

4 8/13/2020

Expanded Indications

. Elderly . Osteopenic . Open fx . Needs “prolonged fixation and a bone graft”

Expanded Indications

. Distraction . Reduction

5 8/13/2020

2y visit DASH Score 7

Bone Loss-Acute . Frequently associated with open fractures . Stability can allow soft tissue reconstruction . Tendons Nerves and Vessels repaired at appropriate length

6 8/13/2020

Acute bone loss

outcome

7 8/13/2020

Chronic Bone Loss

Chronic bone loss-cement spacer then RIA bone graft

Chronic bone loss

8 8/13/2020

Infected non unions

Delayed union ? infection

Hardware failure

9 8/13/2020

Radial club hand deformity-poor digital excursion

Step 1 Realign Hand on Wrist with aggressive OT for digits

Plate Removal- OT on Wrist

10 8/13/2020

Clinical Outcome

50 yo staph after ORIF

outcome

11 8/13/2020

Salvage of non unions after failed fixation of distal radius fractures Ruch, DS Mithani, S and Richard, MJ JHS2014 . 10 patients 6F 4M . Ave age 62 . Failed fixation . Distal fragement less than 2cm . All with hardware removal and spanning plate . 3month . All united ave arc of motion 55 34

Conclusion

. Numerous options exist for the management of distal radius fractures . Palmar locked plating has supplanted many other techniques . Increased number of surgeries= increased number of surgical complications . Spanning plates may assist in the management of these complications

Thank you

12 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

The Bridge Plate Debate: 2nd or 3rd Metacarpal

Andrea Halim, MD No relevant conflicts of interest to disclose

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

8/13/2020

The Bridge Plate Debate: Second Metacarpal Andrea Halim, MD Asst Professor, Yale Department of Orthopaedics

Disclosures

• No relevant financial or other conflicts • However…

Amazing surgeon and friend

Unfortunately uses the wrong metacarpal for her bridge plates.

Why the second metacarpal?

• No risk to EPL tendon – no third incision required • Maintains mild ulnar deviation ergonomic position • Improved ability to restore radial height/inclination

1 8/13/2020

No Risk to EPL Tendon

• Placement from the 2nd metacarpal to the radial shaft ensures placement beneath EPL tendon • Compare to 3rd metacarpal, in which EPL is trapped beneath plate unless it is retracted

Lewis, JHS 2015

Why not just make a third incision?

• Additional unnecessary scar • Increased surgical / tourniquet time • Need to transpose EPL tendon • And – if plate fatigues/breaks, the sharp edges of the plate put 4th compartment at risk

That ergonomic position

• Ulnar deviation may allow improved ability to perform ADLs • Possibly may allow easier crutch use • Power grip is equal at 0 degrees and 15 degrees of ulnar deviation

Ryu, JHS 1991

2 8/13/2020

Radial height/inclination

• Distracting through second metacarpal pulls radial column • Hypothetically improved radial height and inclination

Thank you!

• The second metacarpal is obviously the correct choice because – • Avoids unnecessary incision / tendon transposition • More ergonomic hand position • Possibly improved radial height/tilt/inclination

3 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

The Bridge Plate Debate: 2nd or 3rd Metacarpal

Felicity Fishman, MD No relevant conflicts of interest to disclose

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

8/13/2020

Spanning Plate Debate: 3rd Metacarpal

Felicity Fishman, MD Associate Professor, Department of Orthopaedics Loyola University Medical Center Shriners Hospital - Chicago

Disclosures • I have no actual or potential conflict of interest in relation to this program/presentation

Is it simply a matter of where you trained?

V.S.

1 8/13/2020

2nd or 3rd?

Why Span to the 3rd? • Stiffer construct

• Direct reduction of articular surface

• Support for Lunate facet

• Equivalent grip strength in neutral

• Similar complication profile

• Dorsal approach over 3rd MC, 3rd extensor compartment and proximal radius

• Identify and protect EPL

• Exposure fracture  reduce articular surface

• K-wires to maintain articular surface

2 8/13/2020

• Plate is adjacent to APL/EPB & Ulnar to ECRL/ECRB • Beneath extensor tendons of fingers

• Can slightly distract to offload lunate facet but check for full passive finger flexion

• Compared 10 matched pair cadaveric specimens

• Unstable extra-articular DRF model

• 2nd vs 3rd MC fixation (3 nonlocking screws distal and proximal)

• Calculated displacement and stiffness with cyclic loading protocol of flexion and extension

• Greater stiffness with fixation to 3rd metacarpal

• No difference in displacement at “fracture” site or other parameters

3 8/13/2020

• Compared fracture displacement with axial load with fixation to 2nd vs 3rd MC

• Intra-articular DRF model

• Evaluated addition of intra-frag bicortical locking screw into lunate facet

• Conclusion: Fixation to 3rd resisted fx displacement more effectively than to 2nd

• Lunate facet screw fixation resulted in further  stability

• Evaluated if radiographic parameters (including height, tilt, inclination, carpal translocation) were restored

• No difference in carpal alignment 2nd vs 3rd

4 8/13/2020

Alignment of Forearm and Hand • Dodds et al (Tech Hand Surg 2013)  span to the 2nd mc to place the hand in a position of power grip

• Pryce (J Biomechanics,1980)  neutral wrist position provided maximum power grip but was not significantly different than 15° of ulnar deviation

Support for Intermediate Column • Die punch lunate facet injuries frequently present as part of the greater injury pattern • Often depressed

• Supports lunate facet and Green’s operative hand surgery, 7th ed, CH 15) offloads articular surface by spanning to 3rd metacarpal

Third Incision: Facilitates Articular Reduction

• Direct visualization of lunate facet for reduction

• Can place bone graft to support depressed joint surface

• Can place intra-fragmentary screw

5 8/13/2020

Risks Risk of complications is essentially equivalent

• 3rd Metacarpal • 2nd Metacarpal • 10° extensor lag • ECRL injury MF • Extensor tendon • Superficial neuritis adhesions • Extensor tendon • Superficial neuritis adhesions

• Cadaveric model • Fixed DRF with spanning plate to 2nd or 3rd MC and then evaluated soft tissue • Used 2 incisions for both techniques

• Showed plating to the 3rd without 3rd incision can entrap extensor tendons

Summary • Fixation to 3rd MC provides increased stiffness

• Can support intermediate column/lunate facet and offload

• Can provide direct articular visualization

• Use a 3rd incision if plating to 3rd to decrease risk of tendon entrapment/injury

• Fracture pattern and surgeon preference may dictate choice

6 8/13/2020

Thank you!

7 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Ulnar Styloid Fractures and DRUJ Problems

Scott G. Edwards, MD ● Consulting Fee: Medartis ● Speaker Bureau: Medartis ● Ownership Interest: Mylad Orthopedic Solutions

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

8/28/2020

Unloved Sibling: Distal Ulna and DRUJ

Scott G. Edwards, M.D. Chief, Hand & Upper Extremity Surgery Director, Hand, Upper Extremity, and Microsurgery Fellowship Program University of Arizona College of Medicine-Phoenix Phoenix, Arizona USA

Disclosures

Major Stockholder – Mylad Orthopedic Solutions Educational Grants – Synthes, Stryker, Arthrex, Integra, Axogen, Medartis, Extremity Medical Research Grants – Medartis, Novadaq Speaker Bureau/Consultant – Medartis, Integra Journal Reviewer – J Bone Joint Surg, J Hand Surg

RADIUS

ulna

1 8/28/2020

Perception vs Reality

DRUJ

2 8/28/2020

3 8/28/2020

Why does this seem to be more prevalent now?

Are we getting more astute? Are we trying to justify our own existence? Are we up-coding?

Yesterday’s Treatments

Immobilization!!!

Today’s Treatments

•Early Motion!!! •Displaces fragments –Dorsal/volar ulna rims of sigmoid notch –Ulnar styloid •Does not allow the TFCC to heal •Does not allow the secondary structures to stabilize the DRUJ

4 8/28/2020

Diagnosis

Acute DRUJ instability

…in the presence of a distal radius fracture

Acute Instability: Distal Radius Fractures

Goal #1:

•Restore normal variance •Tighten ulnar extrinsic ligaments

Acute Instability: Distal Radius Fractures Goal #2: •Reconstitute sigmoid notch –Palmar and dorsal rims

5 8/28/2020

Lunate Facet/Sigmoid Notch Fractures Implications and Significance

DRUJ instability!!

Nana, AD et al. JAAOS 2005; Chen & Jupiter JBJS 2007 16

Acute Instability: Distal Radius Fractures

Beware of the small dorsal or volar ulnar fragments!

Static locking plates?

6 8/28/2020

Polyaxial locking plates?

Dorso-ulnar 19

Fragment Specific Fixation?

Best option to stabilize volar and dorsal ulnar fragments 20

21 21

7 8/28/2020

22 22

You don’t HAVE to use plates

23 23

Lisa L. Lattanza, MD 24 24

8 8/28/2020

Lisa L. Lattanza, MD 25 25

Lisa L. Lattanza, MD 26 26

Clinical Exam

1st 2nd 27

9 8/28/2020

What’s in the literature?

Nothing much Level 5 evidence

• 37 Pages • 37 Figures • 101 References

Intraoperative Exam

•Three-position shuck –Supination –Pronation –Neutral •Normal tightening in supination •General laxity •Compare to contralateral side ***

10 8/28/2020

No magical measurement Rather, look for asymmetric laxity = Instability!

What now?

Styloid or no Styloid?

If sizable ulnar styloid fracture present…. – Fix the styloid, re‐assess – Allow early motion

Styloid Assortment of fixation methods

11 8/28/2020

Styloid •Goal: stabilize DRUJ

•Allow soft tissues to heal (more important than bony healing)

Styloid •Nonunion –Common (63%) –Symptomatic (14%) •Incompetent TFCC •Impingement with ECU •Abutment with carpus •Irritating loose body –Treatment •Excision (if stable) •Stabilization procedure (if unstable) •Difficult to achieve union

The Critics

We don’t fix ulna styloids

12 8/28/2020

Misguided by literature?

Souer JS, Ring D, et al. (JBJS, 2009) • Repairing ulna styloid showed no advantage over not repairing it.

“We did not evaluate the stability of the distal radioulnar joint”

If there is no styloid fracture….

Find position of stability, and immobilize for 6 weeks

If no position of stability?…

Departure of thought

Reduce and Pin DRUJ Repair TFCC Two pins Primary stabilizer Proximal to DRUJ IF contracture release is Penetrate all 4 cortices required, stability will be maintained

13 8/28/2020

Fracture Types

Head and Anatomic Neck

•Rare •Fifteen cases reported

Head and Anatomic Neck

•Headless compression screws •Fixed angle plate •Tenuous fixation •Mobilize cautiously

14 8/28/2020

Head and Anatomic Neck: Comminuted

•Hemiarthoplasty •If adequate fixation is not possible Better than any fixation! 43

Surgical Neck •Avoid pinning! •violates TFCC •Irritating to soft-tissues •Pin site infection •Not rigid •lacks rotational control •high incidence of nonunion

Surgical Neck

•Pinning •Narrow indication •Pediatric open physes

15 8/28/2020

Surgical Neck •Rigid fixation –Allow early motion –Compliments distal radius fixation •Locking plate –Controls torque forces better –Buttress the reduction

Surgical Neck: Comminuted

•Excision –Instability is common –Impingement is inevitable

Radioulnar Impingement

Big Problem! 48

16 8/28/2020

Surgical Neck: Comminuted •Full resection arthroplasty •Traditionally, poor outcomes •Unstable •Not the best option in the trauma setting

Surgical Neck: Comminuted Constrained total DRUJ arthroplasty

•Early results promising •Very difficult to revise •Prefer to begin with Darrach and convert to implant (not vice-versa)

Shaft Avoid pinning! •violates TFCC •Irritating to soft-tissues •Pin tract infection •Not rigid •lacks rotational control •high incidence of nonunion

17 8/28/2020

Shaft

•Plate fixation –Treat the same way you would treat a ulna mid-shaft fracture –Makes no sense to rigidly fix one bone and not the other

Shaft •Lower profile •Custom contoured •Prefer anterior placement

“Take Home Points” • Scrutinize the sigmoid notch • Do not ignore the distal ulna • Have a high index of suspicion for instability • DRUJ instability is a subjective clinical diagnosis • Match the treatment for the distal ulna to the treatment for the distal radius • Treat aggressively, but know when to cut your losses

18 8/28/2020

Thank You

19 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Post-Fracture Management of TFCC Tears and DRUJ Instability

Guillaume Herzberg, MD, PhD ● Royalty: Groupe Lepine Company

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

Management of Acute Distal Radius Fractures with TFCC Tears & DRUJ Instability

Guillaume Herzberg MD PhD

(royalties Groupe Lepine)

Speaker has no financial relationships with commercial interests related to present topic to disclose

ASSH Precourse 12 – Distal Radius Fractures: A Case by Case Approach - 2020 Management of Acute Distal Radius Fractures with TFCC Tears & DRUJ Instability

Guillaume Herzberg, Marion Burnier, LYON, FRANCE

3 1  Introduction

 Patient

 Diagnosis

 Our Management

TFCC Injuries with DRF

49% to 78%

Lindau 1997 Mehta 2000 Fernandez 2004 Kim 2008 Gradl 2013 Mrkonjic 2015

No Evidence, No Guidelines for Management

Clinical Relevance +++

Case: 42 Y-Old Lady, Sports ++,

Incapacitating Wrist Pain 6 Mo after DRF

6 2 Poor Initial Management:

- Non-Anatomic Reduction of Distal Radius Fracture

- Neglected Combined Foveal TFCC Avulsion

 Introduction

 Patient

 Diagnosis

 Management

New DRF Clasification System Based on

P: Patient’s General Health & Fuctional Needs,

A: « Accident » (Energy of Injury)

F: Fracture Type (AO)

Herzberg 2010 9 3 Patient Health Status Functional Needs Gender - Age By Interview

1. Dependent 1. Minimum

2. Comorbidities 2. Intermediate

3. Normal 3. Maximum

> Patients / « 1- 1 » / « 2 -2 » / « 3 -3 » / Other Combinations

A Complete Extra-Articular

C Complete Articular

B Partial Articular

Relevant X-Ray Parameters

 Scaphoid Fract.  Possible SL Tear

 Volar / Dorsal Displacement  Comminution Dorsal Volar Circumferential  DRUJ diastasis  Distal Fracture Line  Possible TFCC Tear  Radial Coronal shift  Ulnar Neck / Head Fractures  Impaction  Cartilage defect  Loose bodies  Irreparable

12 4 Relevant X-Ray Parameters

 Scaphoid Fract.  Possible SL Tear

Compared with Current Classifications

More Homogeneous DRF Groups

Logical Workups

More Logical Treatment Options First Based on Patient’s Status

1 - 1 2 - 2 3 - 3 n=1485 DependentComorbidities Normal TFCC (2017) Independent DRUJ AO « A » 3% 10% 18% 85 Y. 77 Y. 45 Y. 95% Females 86% Females 64% Females AO « C » 3% 19% 40% Relevance ? 82 Y. 75 Y. 45 Y. 95% Females 84% Females 46% Females AO « B » ------7% ------34 Y. 88% Males

15 5 1 - 1 2 - 2 3 - 3 n=1485 DependentComorbidities Normal TFCC (2017) Independent DRUJ AO « A » 3% 10% 18% 85 Y. 77 Y. 45 Y. 95% Females 86% Females 64% Females AO « C » 3% 19% 40% 82 Y. 75 Y. 45 Y. 95% Females 84% Females 46% Females AO « B » ------7% ------34 Y. 88% Males

Most Often no Clinical Impairement

1 - 1 2 - 2 3 - 3 n=1485 DependentComorbidities Normal TFCC (2017) Independent DRUJ AO « A » 3% 10% 18% 85 Y. 77 Y. 45 Y. 95% Females 86% Females 64% Females AO « C » 3% 19% 40% 82 Y. 75 Y. 45 Y. 95% Females 84% Females 46% Females AO « B » ------7% ------34 Y. 88% Males

Most Often no Clinical Impairement May be Very Incapacitating

 Introduction

 Patient

 Diagnosis

 Our Management

18 6 XR suspicion of Combined DRF and TFCC

KELIDJIAN Virginie

55-year-old female Acute DRF

2014 J Wrist Surg

IWIW 2015

DRUJ Instability Testing

After Anatomic DRF Fixation

21 7 Use of Arthroscopy

LB L bruneel TFCC S STEP-OFF

GAP

Use of Arthroscopy

 Introduction

 Patient

 Diagnosis

 Our Management

24 8 DRUJ Instability after 1 - 1 2 - 2 3 - 3 Anatomic Fixation of DRF DependentComorbidities Normal Independent AO « A »

AO « C »

AO « B » ------

DRUJ Instability after 1 - 1 2 - 2 3 - 3 Anatomic Fixation of DRF DependentComorbidities Normal Independent AO « A »

AO « C »

AO « B » ------

Skillfull Neglect or Elbow Immobilization Neutral 3 Weeks

DRUJ Instability after 1 - 1 2 - 2 3 - 3 Anatomic Fixation of DRF DependentComorbidities Normal Independent AO « A »

AO « C »

AO « B » ------

Skillfull Neglect or Arthroscopic TFCC Reinsertion Elbow Immobilization Neutral 3 Weeks

27 9 28

Dry Arthroscopy (Del Pinal) + Automatic Wash-Outs

30 10 31

18 y-old Male, Judo Accident .

GULLOTTO Johan

33 11 GULLOTTO Johan

Lyon Wrist 2017 D5-3

GULLOTTO Johan

Summary DRUJ Instability after 1 - 1 2 - 2 3 - 3 Anatomic Fixation of DRF PAF DependentComorbidities Normal Independent AO « A »

AO « C »

AO « B » ------

Skillfull Neglect or Arthroscopic TFCC Reinsertion Elbow Immobilization Neutral 3 Weeks Ulnar Styloid Fixation when Necessary 36 12 ASSH Precourse 12 – Distal Radius Fractures: A Case by Case Approach - 2020 Management of Acute Distal Radius Fractures with TFCC Tears & DRUJ Instability

Guillaume Herzberg, Thank You Marion Burnier 37

According to the current literature, the Incidence of TFCC injuries combined with Acute Distal Radius Fractures is :

A More than 40% B About 5% C About 20% D About 25% E Less than 5%

In a Young Actve Patient presenting with an Acute Distal Radius Fracture and a high radiological suspicion of DRUJ Instability:

A DRUJ instability testing should be made before DRF reduction + fixation B The TFCC will heal provided that the Elbow is immobilized after Surgery C Arthroscopy may be useful to diagnose and fix the TFCC D If arthroscopy is used, wet technique should always be preferred E Open fixation of the TFCC is the most reliable technique

39 13 OnDemand Precourse 12: Distal Radius Fractures: A Case by Case Approach

15 Minutes

Carpal Tunnel Release and Distal Radius Fractures: What Are the Indications and Different Approaches

A. B. Chhabra, MD No relevant conflicts of interest to disclose

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

8/13/2020

Hybrid Extended FCR Approach for ORIF of the Distal Radius and Concurrent Carpal Tunnel Release

My 20 Year Experience and Why I Still Do It

Bobby Chhabra, MD

Disclosures

No Conflicts with this Presentation

University of Virginia Orthopaedic Surgery 2

Introduction

• Acute CTS in 5.4 to 8.6% of distal radius fractures

University of Virginia Orthopaedic Surgery 3

1 8/13/2020

Introduction

• Acute CTS in 5.4 to 8.6% of distal radius fractures • Etiology includes fracture displacement, hematoma or edema in the carpal tunnel

University of Virginia Orthopaedic Surgery 4

Introduction

• Acute CTS in 5.4 to 8.6% of distal radius fractures • Etiology includes fracture displacement, hematoma or edema in the carpal tunnel • Median nerve contusion similar presentation • non-progressive symptoms

University of Virginia Orthopaedic Surgery 5

Introduction

University of Virginia Orthopaedic Surgery 6

2 8/13/2020

Carpal Tunnel Release

• Indicated for progressive symptoms • Transverse carpal ligament is divided to release compression on median nerve

University of Virginia Orthopaedic Surgery 7

Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 8

Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 9

3 8/13/2020

Carpal Tunnel Release

• Indicated for progressive symptoms • Transverse carpal ligament is divided to release compression on median nerve • Techniques • conventional carpal tunnel release with separate palmar incision • extended volar incision across wrist crease • endoscopic

University of Virginia Orthopaedic Surgery 10

Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 11

Volar Plating of Distal Radius

• Trend toward volar plating of certain distal radius fractures

University of Virginia Orthopaedic Surgery 12

4 8/13/2020

Volar Plating of Distal Radius

• Trend toward volar plating of certain distal radius fractures • Is it justifiable to perform routine CTR during volar fixation in patients without symptoms of acute carpal tunnel syndrome?

University of Virginia Orthopaedic Surgery 13

Prophylactic carpal tunnel release

University of Virginia Orthopaedic Surgery 14

Prophylactic carpal tunnel release

• n = 69 • standard ORIF (45) vs. ORIF with prophylactic CTR (24) • CTR: extended distal Henry approach across wrist crease • reported prophylactic CTR results in 2x risk of CTS • “We conclude that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may increase post‐operative morbidity.”

University of Virginia Orthopaedic Surgery 15

5 8/13/2020

Prophylactic carpal tunnel release

University of Virginia Orthopaedic Surgery 16

Prophylactic carpal tunnel release

• n = 174 • standard distal Henry approach (91) vs. direct volar approach with prophylactic CTR (83) • CTS in none of standard group vs. four in prophylactic CTR group • “The direct volar approach to the distal radius with routine CTR should be abandoned because it was associated with an increased rate of temporary and persistent median nerve irritation…” University of Virginia Orthopaedic Surgery 17

Prophylactic carpal tunnel release

University of Virginia Orthopaedic Surgery 18

6 8/13/2020

Prophylactic carpal tunnel release

• Surgical approaches in these two studies may have contributed to post‐op median nerve dysfunction • Odumala: “an extended incision to the ulnar side of the thenar eminence for patients who had carpal tunnel decompression…” • Lattman: “a longitudinal midline incision ulnar to the flexor tendons and median nerve crossing the wrist flexion creases in a Z‐shape… the median nerve was mobilized and carefully retracted radially…”

University of Virginia Orthopaedic Surgery 19

Prophylactic carpal tunnel release

University of Virginia Orthopaedic Surgery 20

Prophylactic carpal tunnel release

• Surgical approaches in these two studies may have contributed to post‐op median nerve dysfunction • Lattman: “Direct nerve manipulation and retractor‐related nerve irritation are the most plausible causes of this problem.”

University of Virginia Orthopaedic Surgery 21

7 8/13/2020

Concurrent CTR with ORIF

• Is it justifiable to perform routine CTR during volar fixation in patients without symptoms of acute carpal tunnel syndrome? • Can carpal tunnel be safely released through a volar approach?

University of Virginia Orthopaedic Surgery 22

FCR Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 23

FCR Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 24

8 8/13/2020

FCR Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 25

FCR Carpal Tunnel Release

BEFORE FCR RELEASE AFTER FCR RELEASE

University of Virginia Orthopaedic Surgery 26

FCR Carpal Tunnel Release

University of Virginia Orthopaedic Surgery 27

9 8/13/2020

FCR Carpal Tunnel Release

Median Nerve CTR Incision

University of Virginia Orthopaedic Surgery 28

FCR Carpal Tunnel Release

• n = 87 • complete or partial relief of preoperative carpal tunnel syndrome symptoms in 91% • “The FCR approach to carpal tunnel release couples the advantages of direct visualization of the carpal canal contents with the decreased disruption of palmar skin and soft tissues, thereby reducing pillar pain without increasing the risk of surgical complications.

University of Virginia Orthopaedic Surgery 29

Hybrid volar approach with FCR CTR

FCR Approach to FCR Carpal Tunnel Release Distal Radius

Weber and Sanders, 1997

Orbay et al., 2001

University of Virginia Orthopaedic Surgery 30

10 8/13/2020

Hybrid volar approach with FCR CTR

• Incision made over the FCR tendon proximal to wrist crease

University of Virginia Orthopaedic Surgery 31

Hybrid volar approach with FCR CTR

• Incision made over the FCR tendon proximal to wrist crease • FCR tendon exposed and mobilized

University of Virginia Orthopaedic Surgery 32

Hybrid volar approach with FCR CTR

University of Virginia Orthopaedic Surgery 33

11 8/13/2020

Hybrid volar approach with FCR CTR

University of Virginia Orthopaedic Surgery 34

Hybrid volar approach with FCR CTR

• Incision made over the FCR tendon proximal to wrist crease • FCR tendon exposed and mobilized • Superficial limb of the TCL divided sharply near its insertion at the trapezial ridge • FPL retracted ulnarly to expose deep limb of the TCL which is divided under direct visualization • Digital palpation confirms complete division of the TCL from its radial attachment

University of Virginia Orthopaedic Surgery 35

Hybrid volar approach with FCR CTR

University of Virginia Orthopaedic Surgery 36

12 8/13/2020

JHS Article #1

University of Virginia Orthopaedic Surgery 37

Hybrid volar approach with FCR CTR

• Standard FCR approach vs. Hybrid approach with FCR‐ CTR • Statistically significant reduction in carpal tunnel pressures

University of Virginia Orthopaedic Surgery 38

Hybrid volar approach with FCR CTR

• Standard FCR approach vs. Hybrid approach with FCR‐CTR • Statistically significant reduction in carpal tunnel pressures • Recurrent motor branch average 11 mm from distal edge of TCL

University of Virginia Orthopaedic Surgery 39

13 8/13/2020

JHS Article # 2

• Retrospective study of 68 patients who underwent distal radius ORIF with concurrent FCR‐CTR • No cases of recurrent or palmar cutaneous branch injury • No cases of tendon injury • 2 cases (2.9%) of delayed median nerve symptoms occuring >3 months after surgery – all resolved

University of Virginia Orthopaedic Surgery 40

JHS Article # 3

• Purpose: To determine the relative benefits of an eFCR approach for ORIF distal radius fractures with prophylactic release of the carpal tunnel to a traditional Henry approach. Cohort study comparison

• The symptom severity score improved to statistical significance at 6 weeks in the eFCR group compared to 3 months for the volar henry approach group

• CONCLUSIONS: eFCR found to be safe and efficacious with no increased surgical morbidity. Can be used safely for all patients undergoing ORIF of distal radius fractures and not just in cases with concurrent carpal tunnel syndrome

University of Virginia Orthopaedic Surgery 41

JHS Article # 4 (in review)

“Relative Increase in Distal Radius Exposure with extension of the FCR Approach”

San Antonio Hand Center & UVA Hand Center ‐ Cadaver Study 1) Henry Approach, 2) Extended FCR Approach (Orbay) , 3) Hybrid FCR Approach with CTR (Chhabra) ‐ Computer Analysis of surface area of volar radius exposed with each approach ‐ Hybrid FCR Approach with CTR far superior in volar radius exposure, particularly the volar ulnar radius/facet – statistically significant difference ‐ 61% exposure Henry approach, 73% exposure with Extended FCR approach, 87% exposure of distal radius with Hybrid FCR approach with CTR (better exposure of radial styloid and volar ulnar facet) ‐ Better exposure and less tension on median nerve with retraction of tendons because of radial sided release of Carpal Tunnel

University of Virginia Orthopaedic Surgery 42

14 8/13/2020

Concurrent CTR with ORIF

• Median nerve dysfunction from contusion vs. CTS

University of Virginia Orthopaedic Surgery 43

Concurrent CTR with ORIF

• Median nerve dysfunction from contusion vs. CTS • For certain fracture patterns – High energy, significant displacement, comminution, volar fracture fragments

University of Virginia Orthopaedic Surgery 44

Concurrent CTR with ORIF

University of Virginia Orthopaedic Surgery 45

15 8/13/2020

Concurrent CTR with ORIF

• Median nerve dysfunction from contusion vs. CTS • For certain fracture patterns – High energy, significant displacement, comminution, volar fracture fragments • Multi‐trauma / Head‐injured pts • Regional anesthesia • ALLOWS ME TO SLEEP AT NIGHT!

University of Virginia Orthopaedic Surgery 46

Concurrent CTR with ORIF

University of Virginia Orthopaedic Surgery 47

Conclusion

• I have tried to show ease of approach, efficacy, safety, better exposure of distal radius retrospective data, a cohort prospective study that shows faster return to activities, but….. • Prospective multi‐center randomized trial comparing volar plating of distal radius fractures with and without FCR carpal tunnel release is necessary before universal acceptance and the approach becomes the standard of care.

University of Virginia Orthopaedic Surgery 48

16 8/13/2020

Thank You

University of Virginia Orthopaedic Surgery 49