Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_574_Библиотеки_им_академика_М_И_Перельмана.pdf
16. Bickert B, Sauerbier M, Germann G. Scapholunate ligament repair
using the Mitek bone anchor.JHand Surg [Br] 2000; 25(2):188–92.
17. Bloom HT,Freeland AE, Bowen V, et al. The treatment of chronic
scapholunate dissociation: an evidence-based assessmentofthe
literature. Orthopedics 2003; 26(2):195–203 (Quiz 204–5).
18. Lavernia CJ, Cohen MS, Ta leisnik J. Treatment of scapholunate
dissociation by ligamentous repair and capsulodesis. JHand Surg
[Am] 1992; 17(2):354–9.
19. Uhl RL, Williamson SC, Bowman MW,etal. Dorsal capsulodesis
using sutureanchors. Am JOrthop 1997; 26(8):547–8.
20. Szabo RM, Slater RR, Jr., Palumbo CF,etal. Dorsal intercarpal
ligament capsulodesis for chronic, static scapholunate dissociation:
clinical results. JHand Surg [Am] 2002; 27(6):978–84.
21. Wyrick JD, Yo use BD, KiefhaberTR. Scapholunateligament repair
and capsulodesis for the treatment of static scapholunate dissociation. JHand Surg [Br] 1998; 23(6):776–80.
22. Wintman BI, Gelberman RH, Katz JN. Dynamic scapholunate
instability:results of operative treatment with dorsal capsulodesis.
JHand Surg[Am] 1995; 20(6):971–9.
23. Almquist EE, Bach AW,Sack JT,etal. Four-bone ligament
reconstruction for treatment of chroniccomplete scapholunate
separation. JHand Surg [Am] 1991; 16(2):322–7.
24. Glickel SZ, Millender LH. Ligamentous reconstruction for chronic
intercarpal instability.JHand Surg [Am] 1984; 9(4):514–27.
25. Brunelli GA, Brunelli GR. Anew surgical technique for carpal
instability with scapho-lunar dislocation. (Eleven cases). Ann Chir
Main Memb Super 1995; 14(4–5):207–13.
26. VanDen Abbeele KL, Loh YC,Stanley JK, et al. Early results of a
modified Brunelli procedurefor scapholunateinstability.JHand
Surg[Br] 1998; 23(2):258–61.
27. Talwalkar SC, Edwards AT,Hayton MJ, et al. Results of tri-ligament
tenodesis: amodified Brunelli procedureinthe management of
scapholunate instability.JHand Surg [Br] 2006; 31(1):110–7.
28. Watson HK, We inzweig J, Guidera PM, et al. One thousand
intercarpal arthrodeses. JHand Surg [Br] 1999; 24(3):307–15.
29. Rotman MB, Manske PR, Pruitt DL, et al. Scaphocapitolunate
arthrodesis. JHand Surg [Am] 1993; 18(1):26–33.
30. Hom S, Ruby LK. Attempted scapholunatearthrodesis for chronic
scapholunate dissociation. JHand Surg [Am] 1991; 16(2):334–9.
31. Kleinman WB.Management of chronic rotary subluxation of the
scaphoid by scapho-trapezio-trapezoid arthrodesis. Rationale for
the technique, postoperative changes in biomechanics, and results.
Hand Clin 1987; 3(1):113–33.
32. Hastings DE, Silver RL. Intercarpal arthrodesis in the management
of chronic carpal instability after trauma. JHand Surg [Am] 1984;
9(6):834–40.
33. Watson HK, Ashmead D, MakhloufMV. Examination of the
scaphoid. JHand Surg [Am] 1988; 13(5):657–60.
34. Ruby LK, An KN, Linscheid RL, et al. The effect of scapholunate
ligament section on scapholunatemotion.JHand Surg [Am] 1987;
12(5 Pt 1):767–71.
35. Boabighi A, Kuhlmann JN, Kenesi C. The distal ligamentous
complex of the scaphoid and the scapho-lunate ligament. An
anatomic, histological and biomechanical study.JHand Surg [Br]
1993; 18(1):65–9.
36. Mitsuyasu H, Patterson RM, Shah MA, et al. The role of the dorsal
intercarpal ligament in dynamic and static scapholunateinstability.
JHand Surg [Am] 2004; 29(2):279–88.
37. Meade TD ,Schneider LH, Cherry K. Radiographic analysis of
selective ligament sectioning at the carpal scaphoid: acadaver
study.JHand Surg [Am] 1990; 15(6):855–62.
38. Baratz ME, Dunn MJ. Ligamentinjuries and instability of
the carpus: scapholunatejoint. In: Berger RA, Weiss AP,eds.
Hand Surgery.Philadelphia, PA:Lippincott Williams and
Wilkins, 2004:481–94.
39. Cautilli GP,Wehbe MA. Scapho-lunate distance and cortical ring
sign. JHand Surg [Am] 1991; 16(3):501–3.
40. Gilula LA. Carpal injuries: analytic approach and case exercises.
AJR Am JRoentgenol1979; 133(3):503–17.
41. Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of
scaphoid non-union. JBone Joint SurgAm1984; 66(4):504–9.
42. Herbert TJ,Faithfull RG, McCann DJ, et al. Bilateral arthrography
of the wrist. JHand Surg[Br] 1990; 15(2):233–5.
43. Schadel-Hopfner M, Iwinska-Zelder J, Braus T, et al. MRI versus
arthroscopy in the diagnosis of scapholunate ligament injury.
JHand Surg [Br] 2001; 26(1):17–21.
44. Schmitt R, ChristopoulosG,Meier R, et al. Direct MR arthrography
of the wrist in comparison with arthroscopy: aprospective study
on 125 patients. Rofo 2003; 175(7):911–9.
45. Nakamura T, Cooney WP,III, Lui WH,etal. Radial styloidectomy: a
biomechanicalstudy on stability of the wrist joint. JHand Surg
[Am] 2001; 26(1):85–93.
46. Jeffries AO, Craigen MA, Stanley JK. We ar patterns of the articular
cartilage and triangularfibrocartilaginous complex of the wrist: a
cadaveric study.JHand Surg [Br] 1994; 19(3):306–9.
47. Ware JE, Jr.SF-36 health survey update. Spine 2000; 25(24):3130–9.
48. Muermans S, De Smet L, Va nRansbeeck H. Blatt dorsal capsulodesis for scapholunateinstability.Acta Orthop Belg 1999; 65(4):434–9.
49. Cohen MS. Ligamentous injuries of the wrist in the athlete. Clin
Sports Med 1998; 17(3):533–52.
50. Herbert TJ.Acute rotary dislocation of the scaphoid: anew
technique of repair using Herbert screwfixation across the
scapho-lunate joint. World JSurg 1991; 15(4):463–9.
124
&
Goldberg et al.
16
Prosthetic Arthroplasty of Proximal Pole Scaphoid
Nonunions
Christophe L. Mathoulin
Institut de la Main, Clinique Jouvenet, Paris, France
&
INTRODUCTION
Pseudarthrosis andnecrosisofthe proximal pole of the
scaphoid are difficult to treat and the outcome is uncertain,
particularly in elderly people. Eventually,this problem leads to
radioscaphoidarthritis,which progressively spreadstothe
entire wrist and causes carpal collapse, in atypical pattern:
scaphoid nonunion advanced collapse (wrist). In the same way,
scapholunate dislocation rapidly leads to styloscaphoid
arthritis in which the capitate collapses into the scapholunate
space: scapholunate advanced collapse (wrist). Several authors
have previously advocated the replacement of the proximal
pole of the scaphoid. The silicon spacer promoted by Michon (1)
then by Zemel (2) is no longer used and has been replaced by
autologous biological materials proposed by Eaton (3). Jones (4)
proposed aspherical vitallium implant, whereby the prosthesis
was put into acage with the risk of dislocation.
Anovel implant which adapts to the kinematics of the
carpus has recently been proposed (5). The adaptive proximal
scaphoid implant (APSI; Bioprofile, Grenoble, France) is made
of pyrolitic carbon. The total biocompatibility of this material
has been previously proven (6,7). Hard wearing and chemically
inert, it does not wear away the bone. Its friction coefficient is
low when rubbing against bone and cartilage and allows it to
slide between the cartilage and the surrounding ligaments to
findthe position of leastresistanceagainst thedeformable
wallsofits biologic cage.Because it does notadhere to
thesurroundingwalls,itdoesnot applypressuretothe
surrounding bones and does not initiate adislocation.
Its module of elasticity is almost identical to that of bone,
allowing it to be tolerated fully (Young’s module: boneZ 20,
APSIZ 25). This absence of difference between the elasticity
modules avoids wear and tear on the bone.
This implant is distinctive in that its ovoid shape allows
its “adaptive” mobilitywhenthe first row of carpal bones
moves (6).
Frontally,the small radius corresponds to the scaphoid area
of the radius, and from the side view the large radius forms an
ovoid, of which the largecurve is anteroposterior and the small
curve is frontal (Fig. 1). By rotating on these axes during frontal
deviation and flexion–extension movements, the APSI copies
the movements of the proximal scaphoid exactly and becomes
integrated in acorroborating and synchronous way with the
kinematics of the carpal bones. Because of this three-dimensional reorientation during the movements of the wrist, the
implant remains stable in the physiological amplitudes and
does not require any form of fixation to the distal scaphoid or
periprosthetic encapsulation (Fig. 2).
In view of the quality of the reported results with an open
procedure, we decidedtotry placing the implant by
arthroscopy. This report details ourexperiencepositioning
this implant by using wrist arthroscopy.
&
INDICATIONS
This technique is only reserved for replacement of the proximal
pole of the scaphoid in which reconstruction is not possible
(excessivelysmall fragment, an osseous fragment separated
into several small pieces). The surrounding cartilage surfaces
are generally intact without arthrosis. The use of this implant is
avery good salvage procedureinelderly people but could be a
“waiting” therapeutic option in young patients.
Thecontraindicationsinclude toolarge of aproximal
fragment of the scaphoid (waist fracture) and significant chondral changes of the surrounding bones. The presence of styloid
arthritis is not acontraindication because one can perform a
radialstyloidectomyduring thesameoperative procedure.
Furthermore, the minimally invasive technique is better than
open surgery,because with the use of wrist arthroscopy the
surgeon avoids alargeapproach and the normal risk of internal
joint fibrosis.
&
CONSIDERATIONS FOR PREOPERATIVE PLANNING
&
Preoperative Physical Examination
The examination is the same as for all scaphoid nonunions: the
surgeon should document the location of pain, range of motion,
strength, and functional status.The examinationisdone
comparatively to the opposite side.
&
Preoperative Imaging
Simple radiographies(frontal, lateral,and specific scaphoid
view) are most often sufficient. Comparative Xrays of opposite
side are required. CT scan and MRI can be added in order to
check the viability of the proximal fragments and the importanceofchondral changes.Because thewrist continuesto
challenge clinicians with its array of potential diagnoses and
treatments and multiple cartilaginous surfaces, combined with
theintrinsic andextrinsic ligaments, wristarthroscopy has
proven to be auseful adjunct in the diagnosis and planning of
scaphoid nonunions, and is areal part of the treatment.
&
SURGICAL TECHNIQUE
All patients in our series were operated on as outpatients under
local–regional anesthesia using apneumatic tourniquet (8). The
arm is laid flat on an arm table, and axial traction is applied to
the forearm and wrist using awrist tower.The strength of
the traction is usually 5to7kgf. After drawing the different
bone parts on the carpus, the wrist is filled with saline solution
(Fig. 3).
At first, the arthroscopicguide and the arthroscope are
positioned in the radiocarpal joint using 4–5 or 6-R radiocarpal
portal. Explorationofthe jointisperformed,locatingany
possible associated lesions. After locating the proximal pole, a
3–4 radiocarpal portal is performed. This surgical approach is
slightly larger than usual, about 1.5 cm, so that the proximal
pole canbewithdrawn andthe implantput in place. The
arthroscope can easily be positioned in this surgical approach,
allowing direct accesstothe area of nonunion.Aradial
midcarpal surgical approach is used to analyze cartilage and
to monitor the positioning of the implant.
After examining the proximal pole, the remaining cartilage
is analyzed. First, the luno–radial area is analyzed in order to
check that the cartilage between the lunate and radius is sound
(Fig. 4A,B). Second, the quality of the cartilage between the
distal scaphoidand thecapitateisevaluated. It is often
surprising to seegood articular cartilageatthisinterval,
especially in elderly people whereas considering the age of
thelesions onewouldexpecttosee much more extensive
cartilagedegeneration.Finally,the stateofthe cartilage
between the head of the capitate and the distal face of the
lunate is analyzed.
&
Resection of the Proximal Part of the Scaphoid
Proximal pole resectionisarelativelyeasyprocedure,
dependingonhow oldthe lesion is.Incertain cases, it is
necessary to use aburr to resect the proximal pole (Fig. 5).
Sometimes we are faced with asmall, necrosed proximal pole,
weakly attached to the lunate by afew ligament fibers. The
attachments aredividedunder arthroscopiccontrol using
instruments such as asurgical blade and small scissors (Figs.
6and 7A,B). The detached proximal pole is easily withdrawn
with forceps(Fig. 8). Aradial styloid osteotomy is sometimes
recommended to remove apainful contact between the styloid
and the remaining distal part of the scaphoid.
&
Placing the Implant
First, the test implant is tried. There are three sizes:
&
Small: length 16 mm and width 8mm.
FIGURE 1 Position of the APSI in front and side view X-rays. Abbre-
viation:APSI, adaptive proximal scaphoid implant.
(A)
(B)
FIGURE 2 ( A )X-ray of acase with untreatable necrotic proximal pole.
( B )X-ray in ulnar and radial deviation showing the mobility and threedimensional adaptability of the implant.
FIGURE 3 Radiocarpal joint filling.
126
&
Mathoulin
&
Medium: length 17 mm and width 9.1 mm.
&
Large: length 18 mm and width 10 mm.
The size is chosen on the operating table by positioning the
test implants next to the resected proximal pole (Fig. 9). The test
implant is then put into the radiocarpal joint in place of the
proximal pole, and it is very satisfying to see how well this
implant fitsitselfintothe correct position(Fig. 10). After
checking the correctcongruence of the test implant by arthroscopy (Fig. 11A,B), it must be taken out. This is not always easy
and is evidence of the good natural stability of the implant. It is
replaced very easily by the definitive prosthesis, still under
arthroscopic control (Fig. 12). After removing the arthroscope,
forced wrist movements are carried out to confirm that there is
no dislocation of the implant. Arepresentative case with preand postoperative X-rays is seen in Figure 13.
&
Postoperative Care
Only the 3–4 radiocarpal portal is closed by one or two stitches.
As for normal wrist arthroscopy,itisnot necessary to close the
FIGURE 6 Radiocarpal arthroscopic view showing the use of asurgical
blade to perforate the sacpholunate ligament.
FIGURE 5 Diagram showing the 4–5 radiocarpal portal for the arthroscope and the possibility of proximal pole resection through the 3–4
radiocarpalportal using aburr.
(A)
(B)
FIGURE 4 ( A )Arthroscopicmidcarpal view showingarthritis
the position of necrotic proximal pole between the distal scaphoid on
the left and the lunate on the right. ( B )Arthoscopic view showing the
chondralchange of the capitate. The cartilagebetween the lateral side of
the capitate and the medial side of the distal scaphoid is sound.
Prosthetic ArthroplastyofProximal Pole Scaphoid Nonunions
&
127
other portals. Aprotective dressing is put in place for eight
days. Mobility is started immediately,letting the patient choose,
themselves,the movementsheorshe wishes to make
depending on postoperative pain. If necessary,rehabilitation
can start after the thirdweek.
&
COMPLICATIONS
The most important technical point is to remove all fragments of
proximalpoleofthe scaphoid.Itisnecessary to separate
completely the scapholunate ligament attachment in order to
easily remove the several pieces of bone, especially when they
FIGURE 10 Diagram showing aradial midcarpal portal for the arthroscope before placing the test implant.
FIGURE 9 The resected proximal part of the scaphoid compared to the
test and actual implantsinorder to choose the right size.
(A)
(B)
FIGURE 7 ( A , B )Radiocarpal arthroscopic view showing the use of a
scissors to separate the proximal pole and the lunate.
FIGURE 8 Radiocarpal arthroscopic view showing the proximal pole
removal.
128
&
Mathoulin
are small. Nevertheless, we have to take care not to damage the
volar capsule to avoid volar dislocation of the implant in normal
dorsal extension.
We had acase of volar dislocation of the implant postoperatively. It appeared that we createdalittle hole with
scissors when we separated the attached proximal pole to the
lunate. The implant passed by this hole and stayed in volar soft
tissue. We had to replace the implant by aclassic open volar
approach and close the volar capsule perforation but had no
further problems.
&
OUTCOME
We have operated on 18 patients during the period from the
year 2000 to 2004. All wereoperated on as outpatients under
local–regionalanesthesiausing apneumatictourniquet.
The average age was 49 years (range 40–81 years). There were
14 men and 4women. All 18 patients wereavailable for followup examination and radiographs.
The average follow-up time was 28 months (range 12–63
months). In younger people, we needed to place avolar splint in
half of thecases.There werenoimmediate postoperative
complications. We had one case of volar implant dislocation
in the youngest patient, surely in connection with alesion of
volar capsule at the time of proximal pole removal. After intraarticular replacement, suture of the capsule, and cast immobilization for six weeks, the patient finally had avery good result.
We canseparatethese patientsintotwo separate
subgroups. The first series consisted of only elderly people:
six patients. The average age was 76 years (range 72–81 years).
Allpresentedextensive arthritiswithcompletenecrosis of
proximal pole of the scaphoid and disabling pain. None of
oursix elderlypatients hadpostoperative immobilization.
The average follow-up was 39 months (range 25–63 months).
The range of motion increased in all the cases from an average
of 458 to 758 of active flexion–extension. None of these patients
hadpainatthe longest follow-up. We did nothaveany
complications.
The second series consisted of the youngest patients, 10
men and two women. The average age was 44 years (range 40–
61 years). They all had necrotic proximal poles of the scaphoid
in whichthe reconstructionand/orrevascularizationwas
impossibledue to thesmall necroticpieces of scaphoid.
All had no adjacent chondral changes except in front of the
proximal pole. The average follow-up was 23 months (range
12–49 months).
The major complication in this series was the one case of
volar implant dislocation. We had two failures in poor indications (nonunion of the waist scaphoid). This technique should
be reservedonly for the proximal pole nonunions because the
size of the implant is not adapted for replacement of alarge part
of the scaphoid. We performed palliative treatment in these cases
(one four-bone arthrodesis and one proximal row carpectomy).
Except these two cases, all the other cases had excellent to
good result without significant pain based on amodified Mayo
Wristscoringsystemand were completely satisfied. Pain
disappearedcompletely after three months. In all the cases,
(A)
(B)
.entheosweb.com
FIGURE 11 ( A )Diagram showing a3–4 radiocarpal portal for the
arthroscope to check the correct position of the test implant.(B )Radio-
carpal arthroscopic view showing the correct position of the test implant
and the distal part of the distal scaphoid.
FIGURE 12 Midcarpal arthroscopic view showing the correct position of
the implant. It is interestingtocompare this view to the preoperative one
(Fig. 4A) in order to see how the implant fits itself in the right position.
Prosthetic ArthroplastyofProximal Pole Scaphoid Nonunions
&
129
the wrist range of motion improved in the flexion–extension arc
from an average of 508 before surgery to an average of 1008 after
surgery.The incisionsall healed wellwithveryminimal
scarring(Fig. 14).The parameters of radial–ulnar deviation
and grip strength improved markedly after surgery.
&
SUMMARY
The indications are rare and reserved only for necrotic proximal
pole, but when the rules of placement are respected, arthroscopic arthroplasty for proximal pole scaphoid nonunion is a
safe and reliable procedure. It is asimple salvage procedure in
elderly people but could be a“waiting” therapeutic option in
young patients with necrotic proximal pole of the scaphoid.
Brief Indications
Replacement of necrotic, unreconstructable proximal pole of
the scaphoid.
Outcomes
&
Good increase in range of motion.
&
Excellent reduction in pain.
Complications
&
One case of volar implant dislocations.
&
Twofailures in badindications (nonunionofthe waist
scaphoid). These cases required palliative treatment (one
four-bone arthrodesis and one proximal rowcarpectomy).
(A) (B)
(C) (D)
FIGURE 13 ( A , B )Case 1: Front and side view
X-rays of anecroticproximalpole of the
scaphoid. ( C , D )Case 1: Side and front view
X-rays showingthe perfectposition of the
implant postoperatively.
FIGURE 14 Cosmetic appearance without scar.
130
&
Mathoulin
&
REFERENCES
1. Michon J, Merle M, Girod J, et al. Replacement prothetique des os du
carpe. In poignet et medicinedereeducation. Paris: Masson,
1981:255–63.
2. Zemel NP,Stark HH, Ashworth CR, et al. Treatment of selected
patients with ununited fractureofthe proximal part of the scaphoid
by excision of the fragment and insertion of acurved silicone rubber
spacer.JBone Joint Surg 1984; 66:510–7.
3. Eaton RG, Akelman E, Eaton BH. Fascial implant arthroplasty for
treatment of radioscaphoid degenerative disease. JHand Surg 1989;
14:766–74.
4. Jones JK. Replacement of the proximal portion of the scaphoid
withspherical implant for post-traumatic carporadial arthiritis.
JHand Surg 1985; 10:217–26.
5. Pequignot JP,Lussiez B, Allieu Y. Implant adaptatif du scaphoide
proximal. ChirurgeDeLaMain 2000; 2:276–85.
6. Chen L, Vi ncent J, HetheringtonL,etal. Areview of pyrolitic
carbon: application in bone and joint surgery.JFoot Ankle Surg
1993; 32:490–8.
7. Cook SD, BeckenbaughR,Weinstein AM, et al. Pyrolitic carbon
implants in the metacarophalangeal joints of baboons. Orthopedics
1983; 6:952–61.
8. Mathoulin CL. Arthroscopic arthroplasty for proximal
pole of scaphoid nonunion. In: Geissler WB ,ed. Atlas of
Hand Clinics. Philadelphia,PA: W.b. Saunders Company,
2001:341–58.
Prosthetic ArthroplastyofProximal Pole Scaphoid Nonunions
&
131
Part V: Minimally Invasive Procedures for Distal Radius FractureFixation
17
Augmented External Fixation for Distal Radius Fractures
John T. Capo, Kenneth G. Swan,Jr., and Virak Tan
Department of Orthopedics, The New Jersey Medical School, University of Medicine and Dentistry of New Jersey,
Newark, New Jersey, U.S.A.
&
INTRODUCTION
Distal radius fractures are extremely common injuries that are
most frequently seen in children and again later in life in elderly
osteopenic women (1). The majority of distal radius fractures
are simple fractures resulting from afall and impact on an
outstretched hand, and may be treated nonoperatively.Highenergy distal radius fractures are morecommon in younger
adults, and in these patients, the need for operative stabilization
is more likely.Inaddition, some of the osteoporotic low-energy
fractures may be unstable injuries that require operative stabilization. The demands of the elderly patient are increasing as
they become moreactive and physiologically healthier.The use
of external fixators, augmented with pins, screws, or small
plates inserted through percutaneous or minimally invasive
means,isauseful techniqueinthe treatment of distal
radius fractures.
&
INDICATIONS
Atypical injury is abending fracture that is usually seen in an
elderly female. The fracture line is in the metaphysis and may
be comminuted, while the articular surface is often intact. These
fractures are often amenable to external fixation combined with
percutaneous pinning. More high-energy fracturesusually
combine metaphyseal and articular comminution. These fractures demand moreextensive methods of fixation and can be
stabilized with acombination of external fixation and limited
open reduction and internal fixation (ORIF) with pins, screws,
or small plates. Also, open fracturesare particularly suited to
external fixation, as the wound is exposed and easily examined
for postoperative care.
Some fractures can be deemed unstable at presentation. An
unstable distal radius fracturecan be defined by several criteria.
These include articular step-off O 2mm, comminution O 50%
(extending from dorsal to volar), dorsal angulation O 208 ,shortening O 10 mm, ashearing Barton-type fracture pattern, and a
fracturecombined with aradiocarpal dislocation. When any of
thesecriteriaare met, thefractureisusually best treated
operatively.Closed treatment of these injuries has shown poor
results with atendency to redisplace (2). Other indications for
operative treatment are:those patients with lower extremity
injuries who need to weight bear through their upper extremity
and need rigid fixation; other fractures of the ipsilateral upper
extremity that requirestablefixationofthe radiusto
rehabilitatethe armtoachieve functional range of motion
(ROM); andoften open fractures combined with soft-tissue
injury.Inaddition, when combined with ORIF,external fixators
are an excellent method of unloading the carpus to allow small
articular fragments and osteopenic metaphyseal bone to heal
completely (3,4).
&
PREOPERATIVE PLANNING
&
Physical Exam
Adistalradiusfracturetypicallypresents with tenderness,
ecchymosis, and avariable amount of swelling dorsally over
the distal radius. There is often adeformity at the wrist, and it
may assume aposition of apex–volar angulation. Neuorvascular statusmust be completelyexamined.Median nerve
function is critical as distal radius fractures may induce swelling that may create acute carpal tunnel syndrome or,insevere
cases, atrue compartment syndrome. Tendon function needs to
be examined, with attention to the extensor pollicis longus. The
carpusmust be examined fortendernessthatmay indicate
carpal fractures or ligamentous injuries.
&
Imaging
Anterior–posterior (AP)and lateral plainradiographsare
usuallysufficienttocharacterizethe distal radius fracture.
Oblique films with 308 pronation and supination often detect
subtle distal radius fractures. If there is severe shortening or
displacement of the radius or ulna, then an elbow radiograph
should be obtainedtoevaluatefor longitudinal forearm
instability or associatedelbow fractures. Computed
tomographyscans of the radius are occasionally helpfulto
learnmoreabout thearticular involvementofthe radius.
Axial cuts with two-dimensional reconstructions in the frontal
and sagittal planes are helpfultodetectfragment sizeand
displacement. This information may help in planning operative
approaches to achieve better access to the most displaced and
unstable fragments. Triangular fibrocartilage injury may manifest as distal radial–ulnar joint (DRUJ) subluxation, by showing
displacement of the ulna dorsally or volarly.Inatrue lateral X
ray,the pisiform sits between the volar limits of the scaphoid
and volar cortex of the capitate. With this true lateral Xray,the
distal ulna sits in the dorsal half of the radius, with the dorsal
cortices colinear (5).
&
SURGICAL TECHNIQUE
&
Goals and Principles
The goals of treatment of distal radius fracturesinclude: ( i )
restoration of the articular surface, ( ii)realignment of the