Fractures of the Distal Radius - Punjab Orthopaedic Association

Pb Journal of Orthopaedics Vol-X, No. 1, 2008
Fractures of the Distal Radius: Current Concepts
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unstable fractures. The development of angular stable
fixation techniques with use of implants designed specifically
for the anatomy of the distal end of the radius improves our
ability to manage these problems. In these implants, stability
is not achieved by the creation of friction between the plate
and bone as in traditional screw-plate fixation, but rather
mechanical bridging of the bone and load-bearing are allowed
through the locked screw-plate construct (Fig 6). Lockinghead
screws do not rely on the bone thread for purchase; and
screws that lock into the plate prevent loosening within the
implant, so early failure of fixation with an angular stable
implant will occur only if the entire screw-plate construct
pulls out from the bone or there is material failure of the
implant.
stopped, but before the hematoma has consolidated. The
greatest value of arthroscopy may be an improved ability to
assess how successful articular restoration has been because it
is becoming increasingly clear that plain radiographs and
fluoroscopy are not always reliable in assessing small
displacements.
Bone graft
During the healing process, collapse of the distal fragments
into the cancellous defects in the metaphyseal and
subchondral regions can lead to secondary displacement and
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loss of reduction .
Bone graft or bone substitutes are frequently used to fill
the metaphyseal void for added support of the articular
surface during healing. Autogenous bone graft is the gold
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standard , however morbidity associated with harvesting of
this, has led to use of allograft and various bone substitutes.
This area of molecular orthopaedics is burgeoning, and
further objective, comparative and longer term studies are
required to assist in decision making and finding the optimum
bone substitute.
Fig. 6
Biomechanical studies have emphasized the need for
placement of the distal most screws or pegs just beneath the
subchondral bone of the articular surface to achieve the
maximum benefit of volar fixed-angle plate fixation.
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Arthroscopic assisted reduction
Advances in arthroscopic technique have added
significantly to our armamentarium for the treatment of distal
radius fracture. Arthroscopic visualization and reduction
techniques are particularly helpful, for example, in restoring
an incongruous joint surface in the setting of a single, large,
depressed, radial, styloid fragment. Arthroscopically assisted
reduction and fixation require traction and adequate
visualization. It is advisable; therefore, to use this technique
between 4 and 7 days after fracture when bleeding has
5
High energy injuries
High energy trauma to distal radius results in usually a
comminuted fracture pattern and may require a combined
dorsal and volar approach, needing expertise care. These
injuries may result in open fractures and are dealt with
aggressive debridement and stabilization with internal or
external fixation. Ideally soft tissue coverage should be
restored within 1 week of injury and bone grafting is done
when soft tissues have healed.
In case of closed fractures associated with significant
swelling, it is prudent to wait for the swelling to subside and to
delay the procedure.
5, 8-9
Associated Injuries
Injuries to distal radioulnar joint (DRUJ) and fracture of
ulnar styloid are frequently associated with distal radius
fractures. Evaluating the stability of DRUJ is essential in the
treatment of wrist fractures. If the DRUJ is stable, the ulnar
head is reduced and is stabilized with K –wires. Associated
fractures of ulna also need stabilization. Small avulsion
fractures of the ulnar styloid process do not necessitate
additional treatment. However, fractures near the base of the
ulnar styloid process include the entire insertion of the ulnar
border of the triangular fibrocartilage complex and need
fixation. Options for fixation include K wires, tension band