DER

Background and Justification

• Fractures of the distal radius are common and result from both high and low energy trauma. The aim of treatment is to optimise functional recovery rather than to achieve specific radiological parameters.
• Assuming the injury is closed, isolated and the limb is NV intact I will follow the BOAST 16 guideline

Principles

• Initial assessment
• Initial management
• Specific management
• Post operative management

Initial assessment

• Document age, MOI, skin integrity, NV status and functional demand
• PA and L views cantering wrist to know the fracture pattern and stability
• Arrange for Regional anaesthesia if CMR is indicated
• If open follow BOAST 4
• Refer to Fracture clinic with in 72 hours

Frykman Classification

• Universal: Extra articular/ IA
• Stable/Unstable

Fernandez: MOI

• Bending
• Shear
• compression
• #D
• combined

Stability

• R: Radial shortening>5mm
• A: Angulation> 20 degree
• D: Dorsal comminution
• I: Intra articular depression>2mm (Jupiter 1986, JBJS am; 100% radiological arthritis with 93% symptomatic)
• U: Ulnar styloid #
• S: Severe displacement

Specific management

• Based on Age, Fracture pattern, stability, NV status and functional demand
• Stable undisplased fracture: Splint , then early mobilisation

• 65, dorsally displaced fracture: Plaster cast 4 weeks

  • Plaster: neutral wrist, 3 point fix
  • No neurology, insignificant deformity
• <65 years, dorsal displaced
  • Look for stability:ulnar variance, IA step, dorsal tilt, patient needs
  • Stable: plaster cast
  • Unstable
    • Reflect on surgical reconstruction
    • K wire if RC joint can be reduced by closed means
    • If not possible Plate
• Volar displaced:
  • Unstable
  • hence operative plate fixation

Timing

• With in 72 hours if IA
• With in a week: Extra articular
• Re displacement following manipulation: <72 hrs

K wire

• 1.6-1.8mm k wires,2 radial styled and 1 dorsal
• If DRUJ unstable use 4th Kwire from radius to ulna
• Should not cross each other at one point

ORIF Volar plate

• Volar henry approach through FCR tendon sheath
• Mindful of watershed area
• A direct volar midline approach including prophylactic carpal tunnel release should not be used due to median nerve problems (Lattmann from Zurich in Hand surgery, 2008)
• CT release - Instead, either a separate incision is made in the proximal palm - or the distal Henry incision is extended across the wrist crease, requiring identification and protection of the palmar cutaneous branch of the median nerve.(Pency from Baltimore, Hand surgery 2010)

Locking plate Interface

• Eliminate screw toggle
• Fixed angle construct maintain reduction
• Takes away load from distal fragment and transfers it to proximal shaft
• Does not rely on frictional force

Structure of LCP

• 2 raws
  • Proximal primary raw:
    • pegs are directed from proximal to distal
    • Support dorsal articular surface and radial styloid
  • Distal raw
    • Distal to proximal
    • supports volar and central part of subchondral bone
    • Neutralises volar displacement forces of proximal raw

DRAFFT

• 12000 patients screened
• inclusion required the fracture to be reduced closed
• 461 were included
• Pragmatic study
• This trial provided no evidence of a clinically important difference between the effect of K-wire fixation and that of locking-plate fixation for patients under or over 50 years or for patients with and without an intra-articular extension of their distal radius fracture.

Post operative management

• Repeat X-ray 1-2 week after manipulation
• Xray at time of plaster removal is not required unless there is clinical concern
• Assess for fall risk and bone health and refer to Fracture Liaison service/fall service
• Information sharing regarding functional recovery, rehab, and return to normal function
• CRPS to be identified and follow the protocol
• Vit C is not recommended