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Balloon Reduction and Grafting of Distal Radius Fractures
Jose´M. Nolla
Department of Hand and Upper Extremity Surgery, Massachusetts General Hospital, Harvard Medical School,
Boston, Massachusetts, U.S.A.
Jesse B. Jupiter
Orthopedic Hand Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,
U.S.A.
&
INTRODUCTION
The concept of “cementing” fractures became areality with the
development of polymethylmethacrylate bone cement in the
1960s (1). Schmalholz in 1988 described the use of polymethylmethacrylate in the management of distal radius fractures (2).
This approach has been further supported by severalother
investigators (3–5). By the same token, problems with polymethylmethacrylate havelimitedits application. These
difficulties include its curing with an exothermic reaction, its
inability to be incorporated with the host bone, and its requirement for wide exposureofthe fracturesite.
The advent of injectable cements like Norian SRS (Synthes
Corp., We st Chester,Pennsylvania, U.S.A.) has brought again to
the forefront the potential for cementing fractures through a
minimallyinvasiveapproach.Norian SRSand othernew
biologic cements are biocompatible and have ahigher compressive strength than cancellous bone (6). Norian SRS cures at a
physiologic pH and temperature to form an osteoconductive
carbonated apatite with properties very similar to the mineral
phase of bone (3,6). Several prospective studies have demonstrated the efficacy of Norian SRS over conventional treatments
such as cast, pins, and/or external fixation (3,5). One difficulty
that was recognized in attempting to apply the Norian SRS
percutaneously was the observation that the viscous cement did
not always fill the metaphyseal defect following manipulative
reduction. This proved to be theresultofcancellous bony
spicules blocking the flow of the Norian cement. As aresult, it
became evident that it was necessary to compact the metaphyseal bone to accommodatethe cement.Thistaskcan be
accomplished through an open approach where tamps and
elevators would be used to create ametaphyseal void.
Recently,inflatable balloons for “vertebroplasty” have been
developedfor spine surgery.Thistechniquehas also been
evaluated in the management of fractures involving metaphyseal bone suchasfractures of thecalcaneus, tibial plateau,
femoral condyles, and distal radius (4). Such aballoon combines
the potential of creating ametaphyseal void with its ability to
assist with fracture reduction.
&
INDICATIONS
Balloon reduction and minimally invasive bone grafting techniques are appropriate for active osteoporotic patients with
reducible unstable and/or displaceddistalradiusfractures
resulting from low-energy impact.These shouldbeextraarticular (AO type A2 or A3) or simple articular fractures(AO
type C1 or C2) without extension into the diaphysis (Fig. 1). The
techniqueisnot applicable to shearing fractures (Barton’s),
volardisplacementfractures (Smith’s),highl ycomminuted
fractures, high-energy injuries, or nascent malunions, which
aremoreamenabletoopentechniques.Activeinfectio n,
severe medicalillness, and patient unreliability alsoare
contraindications.
&
CONSIDERATIONS FOR PREOPERATIVE PLANNING
Careful evaluation of the patient as awhole is important prior to
embarking on surgery.Itisimportant to note their activity level,
functional independence, reliability,and comorbid medical
conditions. Prior to any intervention, it is essential to perform
adetailed exam of the involved extremity.Acareful examination of the skin and neurovascular status may drastically
change the timing of intervention. In the presence of median
nerve symptoms, which persist following provisional fracture
reduction, acarpal tunnel release should be considered simultaneously with fracturefixation. When the hand and wrist are
very swollen, it is beneficial to elevate the limb afew days to
allow the soft tissues to heal from the initial injury.
Standard posteroanterior,lateral, and oblique radiographs
are often sufficienttodelineate the fracture pattern. Xrays
obtained after longitudinal traction is applied will add further
clarity to the fracture definition. Computed tomography may be
needed when determining if an articular component is sufficiently displaced to negate balloon-assisted treatment. While
examining radiographic studies, it is also important to note the
carpal alignment and any distal radioulnar joint involvement.
It is our perception that balloon-assisted reduction and
void creationare optimally combined with percutaneous
cement infusion as opposed to the use of other bone substitutes,
such as allograft or autogenous graft, which must be applied
through more extensile exposures.
&
SURGICAL TECHNIQUE
Regional block anesthesia is preferredunlessmedical conditionspreclude this approach. Preoperativeantibiotics are
given for prophylaxis. The patient is placed in supine position
with the extremity placed on aradiolucent hand table with a
pneumatic tourniquet applied. Fluoroscopy is required. Supplemental fixation in the form of Kirschner (K) wiresoranexternal
fixator should also be available. Traction fingertraps can help
when extra assistance is not available.
The procedurebegins with amanipulative reduction of the
fracture (Fig. 2) (8). To insert the balloon cannula, a1.5–2 cm
incision is made between the first and second extensor compartmentswithcaution to avoidinjury to theoverlyingradial
sensory nerves. The incision should also be placed over the
metaphyseal fracture zone. Usinga3.5 mm drill bit with a
protective drill sleeve, an opening is createdfor insertion of
the balloon cannula. Using fluoroscopic guidance, the vertebroplasty cannula is centered in the metaphyseal defect with the
opening directed distally (Fig. 3). Progressive inflation of the
balloon with saline will accomplish two things: ( i )creation of a
metaphyseal void and ( ii)fracture reduction. To maintain the
reduction following balloon deflation, atemporary transfixing
K-wire is placed between the distal ulna and the radius distal
to the metaphyseal defect.Alternatively,anobliqueK-wire
canbepassedacrossthe fracture site throughthe radial
styloid (Figs. 4and 5).
The Norian SRS is mixed by hand and injected through a
separate cannula directly into the defect under fluoroscopic
guidance until complete fill of the defect is observed (Figs. 6
and 7). Whenever possible, cement extravasations are to be
avoided. The fracture is not to be manipulated for aminimum
of 10 minutes to permit the Norian SRS to set properly.
&
Postoperative Management
Postoperatively,the patient should be placed in awell-molded
splint for two weeks. The patient is then placed in aremovable
splint for four weeks while motion is initiated. If an external
fixator was utilized to supplement the phosphate cement, it can
A
B
C
A1
B1
C1
A2
B2
C2
A3
B3
C3
FIGURE 1 AO/ASIF classification of distal radius fractures. Source:From Ref. 7.
FIGURE 2 Fluoroscopy-assisted closed reduction.
Source:Courtesy of Dr Mark Cohen.
176
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Nolla and Jupiter
be discontinued at two weeks, followed by aremovable splint
for four weeks. From the first postoperative day,all patients
should work on digital rangeofmotionand elevation to
minimize edema. Occupational therapy should be started two
weeksafter surgerystressing wristand fo rearmrange
of motion.
&
COMPLICATIONS AND THEIR MANAGEMENT
The most common complication of using Norian SRS is the
loss of fracturereduction. In aprospective study by Cassidy
and colleagues, this was observed in 46 out of 161 (29%)
patientsofwhich 9patients required secondarytreatment
(3). In the series by Sanchez-Sotelo and colleagues, this was
observed in 10 out of 55 patients treated with Norian SRS (5).
In aseriesof12patients treated by Reileywith balloon
reductionand cementation, 4patients showed mild subsidence(4).Another potentialcomplicat ionispin site
infections. These are often seen with K-wiresand external
fixators. They can often be treated with local wound care and
oral antibiotics. More severe cases may requirepin removal
and operative debridement.
The superficial radial sensory nerve and its branches are at
risk during this approach. These are best avoided by the use of
protective drill sleeves and avoiding multiple penetrations of
the skin in the same area with the K-wires.
Extraosseous cement can be seen in as many as 70% of
patients (3). It is best avoided by meticulous application of the
Norian SRS. While it dissolves in most with time, it can be
associated with other complications including fracturesettling,
FIGURE 3 The fracture is reduced and the metaphyseal defect is prepared by compacting the cancellous bone
with an inflatable balloon. The opening in the cannula should open distally to assist in fracture reduction.
FIGURE 4 Supplemental fixation. K-wiresare used to
supplement stability in unstable fractures. Source:Courtesy
of Dr Mark Cohen.
Balloon Reduction and Grafting of Distal Radius Fractures
&
177
carpal tunnel syndrome, and tendon attrition. Intra-articular
cement is usually not substantial enough to cause any symptoms,but there is onereported case of symptomatic intraarticular cement requiring surgical excision (5).
&
OUTCOMES
Whilelittle hasbeen published combining balloon-assisted
reductionwithNorianSRS, otherreports utilizing with
Norian SRS offer favorable results. In aprospective study of
323 patientstreatedwith closed reductionand Norian SRS
cement compared to thosetreated with external fixation
and/or percutaneous pinning, those treated with Norian
showed an earlier return of function. However,the difference
disappearedat12months (3). Similarly,inaprospective study
of 110patients randomized to treatment with closed reduction
and Norian SRScement versus closedreductionalone also
showed an earlierreturnoffunctioninthose treated with
cement. Thedifferencenormalizedover12months. In this
series, the incidence of fracture settling was significantly less
in thosetreated with closed reductionand Norian cement
compared to those treated with closed reduction alone (5).
&
SUMMARY
Recent improvements in bone graft substitutes are making it
possible to treat distal radius fractures with less invasive and
more reliable techniques.Through percutaneous methods
using aballoon it is now possible to reduce the fracture and
create awell-demarcated metaphyseal void. This void can then
FIGURE 5 Atemporary transfixing Kirschner wire is used to maintain the reduction after the balloon is deflated.
FIGURE 6 The phosphate cement is injected while the temporary Kirschner wire holds the reduction.
178
&
Nolla and Jupiter
be filledwith biologic cementsinorder to attainstable
fracturefixation.
&
SUMMATION POINTS
Indications
&
Osteoporotic patient with extra-articular or simple intraarticular low-energyfracture.
Outcomes
&
Patients treatedwithcalcium phosphate cementcan be
expected to have aquicker functional recovery.
&
Basedonavailable data,fractures supplemented with
calcium phosphate cement seem to be less likely to develop
settlingand/or arelesslikelytorequire surgic al
intervention.
Complications
&
Observefor significantsettling, sincemalunions can
become symptomatic.
&
Extraosseous cement is avoided by meticulous technique.
This significantly reduces the incidence and extent. Still, a
small amount is commonly observed. This dissolves with
time and is rarely symptomatic.
&
Supplemental fixation techniques like external fixators and
K-wires have inherent risks like neurovascularinjury upon
applicationand late pinsiteinfec tions. Theseare best
avoided by careful technique.
&
Digital motion loss due to adhesions should be avoided by
carefulwireplacement and an earlyrangeofmotion
program.
&
REFERENCES
1. Hartigan BJ, Cohen MS. Use of bone graft substitutes and bioactive
materials in treatment of distal radius fractures. Hand Clin 2005;
21(3):449–54.
2. Schmalholz A, Alberts KA. Ascintimetric study of Colles’ fracture.
Comparison between cementation and closed treatment. Acta
Radiol 1988; 29(6):715–7.
3. Cassidy C, Jupiter JB, Cohen M, et al. Norian SRS cement compared
with conventional fixation in distal radial fractures. Arandomized
study.JBone Joint Surg Am 2003; 85-A(11):2127–37.
4. Reiley MA. Percutaneous balloon-plasty technique and results for
tibial plateau, distal radius and femoral condylar,and calcaneus
fractures. In: Poster in Orthopedic Tr auma Association Meeting.
Toronto, ON, October 11–13, 2002.
5. Sanchez-Sotelo J, MunueraL,Madero R. Treatment of fractures of
the distal radius with aremodellable bone cement: aprospective,
randomised study using Norian SRS. JBone Joint SurgBr2000;
82(6):856–63.
6. Constantz BR, Ison IC, Fulmer MT,etal. Skeletal repair by in situ
formation of the mineral phase of bone. Science 1995;
267(5205):1796–9.
7. Jiuliano JA, Jupiter JB. Distal radius fractures. In: Trumble T,
Cornwall R, BudoffJ,eds. CoreKnowledge in Orthopedics: Hand,
Elbow and Shoulder.Philadelphia,PA: C.V.Mosby,2005:87.
8. Fernandez DL. Closed manipulation and casting of distal radius
fractures. Hand Clin 2005; 21(3):307–16.
FIGURE 7 Radiographic appearance one year after surgery. Source:Courtesy of Dr Mark Cohen.
Balloon Reduction and Grafting of Distal Radius Fractures
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23
Limited Approach Open Reduction and Internal Fixation
of Distal Radius Fractures
Jose´M. Nolla
Department of Hand and Upper Extremity Surgery, Massachusetts General Hospital, Harvard Medical School,
Boston, Massachusetts, U.S.A.
Jesse B. Jupiter
Orthopedic Hand Service, Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts, U.S.A.
&
INTRODUCTION
Thetreat ment of distal radius fractures hasundergonea
number of changes in recent years. These have been the result
of better understanding of fracturepatterns, design of implants,
and developments in implant technology.The comprehensive
AO classification,aswellaswork by Fernandez, andthe
column theory advocated by Rikli and Regazzoni and Medoff
have brought light to key components in distal radius fractures
(1,2).
Understanding of the key components in the structural
support of the distal radius articular surface has allowed the
development of implants that provide the needed support in
casesofcompromised stability.The keycomponents as
describedbyRikli andRegazzoni include amedial(ulnar)
column, which consists of the distal ulna, triangular fibrocartilage complex (TFCC), and distal radioulnar joint (DRUJ) (Fig. 1)
(2). The intermediate column consists of the medial aspect of
the radius including the lunate fossa and sigmoid notch. The
lateral(radial)columnconsistsofthe scaphoid fossa and
radial styloid.
Studies of force transmission across the wrist have demon-
stratedmoreforcestransmittedthrough theintermediate
column than previously thought. When looking at the lunate
facet of the distal radius, the axial forces vary between 29% and
44% of the total axial force (Rikli DA, personal communication).
Onecan therefore view therole of theradialcolumnasa
stability column, providing abony buttress for the carpus and
the origin for the stabilizing capsular ligaments. In contrast, the
intermediate column functions in load transmission and serves
as the “keystone” to the radiocarpal joint. The ulnar column
serves both for load transmission and stability acting as a“pivot
point” for wrist mobility.
With aclearer understanding of the structural anatomy and
biomechanics of the distal radius, radiocarpal, and distal radioulnar joints, fragment-specific fracture treatment with limited
surgicalapproac hesisapplicablefor avariety of fracture
patterns.
&
INDICATIONS FOR LIMITED APPROACH OPEN
REDUCTION AND INTERNAL FIXATION
Anumber of specific fracture patterns are amenable to limited
exposures for internal fixation. These include fracturesofthe
radial column involving the radial styloid, intermediate column
including the volar and/or dorsal lunate facets, and the ulnar
column, specifically,the ulnar styloid fracture.
&
CONSIDERATIONS FOR PREOPERATIVE
PLANNING
Adistal radius fracturecan affect anyone and therefore it is
essential to have aclear understanding of the patient’s activity
level, co-morbid medical conditions, independence level, and
reliability.During the physical examination it is important to
note the neurovascular status of the hand as well as the status of
the skin. Excessive skin swelling without median nerve symptoms benefitsfromaperiod of elevation to facilitate softtissue management.
Radiographic examination should include standard anteroposterior,lateral, and oblique views. In cases of extensive
collapse,longitudinaltractionfilmsunder hematomablock
anesthesiaare extremely helpful. Computed tomography,
with reconstructions in the coronal and sagittal planes as well
as three-dimensional reconstructions,ishelpfultoelucidate
specific fragments (Fig. 2). During examination of the radiographs it is important to note any evidenceofcarpal
malalignment or derangement.
Other pieces of information to obtain from the radiographs
are fracture fragment recognition and fracture classification. It is
essential to recognize radial styloid fragments, lip fragments,
volar- and dorsal-ulnar fragments, and ulnar styloid fragments.
This knowledge will guide the therapeutic approach. The last
piece of information to get from the radiographs is classification
as this assists with communication, treatment decisions, and
prognosis. Themostthoroughclassi fication system is the
AO/ASIF system. It takes into consideration the severity of
the skeletal and articular injury.Inthis system the fracturesare
divided into extra-articular (type A), partial articular (type B),
and complete articular (type C). Each is then subdivided in
increasing order of severity (Fig. 3).
&
SURGICAL TECHNIQUE
Regional block anesthesia is preferred. Preoperative antibiotics
aregivenfor prophylaxis.The patientisplaced in the
supine positionwiththe extremity on aradiolucenthand
table. Apneumatic tourniquet is applied. Fluoroscopy will
be required. One should have available avariety of fixation
options includingstainlesssteel wire,Kirschnerwires,
external fixation,and anatomicallyshaped pl ates or wire
forms. Anumber of limited extensile exposures are available
to approach either dorsalorvolar fracture components
(Fig. 4).
&
Radial Column Fractures
Shearing fractures of the radial column are classified within the
AO/ASIF GroupasB1fractures. The subgroup B1.1 is avertical
shearing-type fracture, whileB1.2repre sentsamulti -fragmented radial styloid fracture.These fractures may be isolated
injuries as aresult of afall on the outstretched hand with the
wrist forced into extension and radial deviation. The scaphoid
directly transmits the force of impact onto the radial styloid.
Styloid fractures can also be seen in association with perilunate
dislocations of the carpus. Smaller avulsion fractureswill have
the radial capsule attached while larger ones will additionally
have the origin of the radioscaphocapitate ligaments. Anatomic
reductionand stableinternal fixation of these fractures will
restoreboth alignment of the radial column’s buttress as well
as the integrity of the supporting ligaments of the wrist.
An attempt should be made to achieve aclosed manipulative reduction and percutaneous Kirschner wireorscrew
fixation.Whenaclosed reductionisnot successful, open
reduction is recommended. Asmall dorsoradial incision will
provide excellent exposureofthe fracture and if necessary,the
radiocarpal joint (Fig. 4). Stable fixation most often will require
one or two screws,but in some instances, asmall radial column
platewillhelpbuttressalargeverticallysheared styloid
fracture (Figs. 5and 6).
&
Intermediate Column Fractures
Whilethe vast majority of thesefractures are duetoaxial
compression of the lunate against the lunate facet, there is a
unique fracture pattern involving the dorsal lunate facet characterized by avertical shear pattern classified as subgroup B1.3.
Dorsal lunate facetcompression fractures are most often a
componentofathree-part articular injuryorafo ur-part
pattern characterized by asplit of the lunate facet with both
dorsal and volar components (Fig. 7). In some instances, the
dorsal lunate facet fracture can be reduced through asmall
incision and manipulated into place with an elevator,tamp, or
pointed awl. Stabilityisachievedwitheitherstrategically
placed Kirschner wires or asmall plate or wire-form (Figs. 7
and 8).
Volar lunate facet displacement is less amenable to percutaneous manipulation and Kirschner wire fixation. Alimited
volar incision is made creating an interval between the ulnar
artery and nerve, and the flexor tendons (Fig. 9). By elevating
FIGURE 1 Rikli and Regazzoni’s division of the distal radius into three
columns (medial, intermediate, and lateral).
FIGURE 2 Computed tomographyscan canassist in
elucidatingthe involved columns in complexfractures.
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Nolla and Jupiter
the distal ulnar corner of the pronator quadratus, the volar
lunate facet is readily exposed. Internal fixation can be accomplished either with atension wire technique or asmall plate or
wire-form (Figs. 7, 9–12).
&
Ulnar Column
There are instances in which the stability of the distal radioulnar
joint will require stable fixation of the ulnar styloid. Following
stable fixation of the distal radius fractures, passive forearm
rotation will definethe presence of distal radioulnar joint
instability.Inthese instances, especially when there is alarge
ulnar styloidfracture, fixation of theulnar styloidis
recommended.
The ulnar styloid lies relatively anterior to the longitudinal
axis of the ulna, thus the surgical approach should be through a
small incision over the styloid itself. If done with the forearm
supinated, thestyloid will rest in amoredorsalposition,
facilitating exposure and internal fixation. The fixation of the
ulnar styloid will depend in part upon its size. Small screws,
headless screws,ortension band wire or wire-forms are all
applicable (Figs. 14 and 15).
&
COMPLICATIONS AND THEIR MANAGEMENT
Open approaches are at risk of wound healing problems, the
most severe being wound necrosis. Prevention is best treatment
in these situations. The surgeon should be cautious and not
proceed with the surgery until the soft tissues have recovered
from the initial soft-tissue trauma.
Complex fractures at times cannot be securely fixed with
internal hardwareonly.Inthese cases, it is useful to have an
external fixator available. The fixator can help not only with the
fracture reduction, but also with maintenance of the reduction.
In this situation, the fixator is kept in place for at least three
weeks. Bone graft can also be used to supplement fixation,
particularly for support of articular fragments. Bone graft will
also assist in fracturehealing.
The median nerve and the sensory branches of the radial
nerveare at risk during some approaches to thewrist.
Excessive retraction of the median nerve can lead to significant motor and sensory disturbances. Minimizing the use of
self-retaining retractors and frequent changing of their
positions during volar approaches minimizes the incidence
of neuropathies. Careful dorsal dissection minimizes damage
to the superficial sensory branches of the radial nerve.
Peritendinous adhesions can severely limit digital motion.
This complication is best avoided by covering dorsal and volar
hardware with periosteum and/or muscle and by promptly
starting adigital and wrist motion protocol soon after surgery.
Severe cases that have failed to improve with range of motion
exercisesand splintingmay requireoperative tenolysis
and capsulotomies.
Dorsal instrumentation places the extensor tendons at risk
for complications, namely,tenosynovitis and tendon rupture.
Whereas this risk was significant with prior implants, newer
implants have been designed with the goal of minimizing
tendon irritation. If tenosynovitis is still encountered, it is
best addressedbyplate removal. Tendon ruptureisbest
addressedwith plate remo valand an appropriate
tendon transfer.
&
OUTCOMES
The important aspect in obtainingagood result in these
fracturesisattaining and maintaining an adequate articular
alignment (9,10). Work by Jakob and colleagues using the
same principles outlined above revealed greater than 95%
A
B
C
A1
B1
C1
A2
B2
C2
A3
B3
C3
FIGURE 3 AO/ASIF classification of distal radius fractures. Source:
From Ref. 3.
FIGURE 4 Dorsal approaches to the wrist. 1, between the first and
second extensor compartments; 2, through the third compartment; 3,
betweenthe fourth and fifth compartments; 4, between the fifth and sixth
compartments. Source:Adapted from Ref. 4.
Open Reduction and Internal Fixation of Distal Radius Fractures
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