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
FIGURE 5 Fixation of radial and dorsal intermediate columns with 3.5 and 4.0 mm screws accomplished
through minimal incisions. Source:Courtesy of Dr Diego L. Fernandez; From Ref. 5.
FIGURE 6 Radial column buttressed with aradial plate. Source:Courtesy of Dr Robert J. Medoff.
FIGURE 7 ( A )Axial loads transmittedcan result in afour-part fracture with the lunate fossa split into avolar and a
dorsal piece. ( B )Inthis model, the radial styloid fragmenthas been stabilized with Kirschner wires. ( C )The volar
lunate facet is stabilized with aplate. ( D )The dorsal lunate fragmentisstabilized with aKirschner wire. ( E )The
distal radioulnarjoint should then be evaluated for instability, especially when the ulnar styloid has been fractured
through its base. Source:Adapted from Ref. 6.
184
&
Nolla and Jupiter
FIGURE 8 Radial styloid and dorsal ulnar fragments stabilized with columnar pin plates. Source:Courtesy of Dr Robert J.
Medoff.
FIGURE 9 Volar ulnar approachbetween the ulnar artery/nerve and flexor tendons. Source:Adapted from Ref. 7.
Open Reduction and Internal Fixation of Distal Radius Fractures
&
185
FIGURE 10 Small volar ulnar fragmentfixed with 24-gauge wire. Source:From Ref. 8.
FIGURE 11 Split lunate facet with large volar fragment.
186
&
Nolla and Jupiter
good andexcellent results(11). In theirtreatment of 74
fractures, of which 58 were severely comminuted, they were
able to effectively treatthemusing dual dorsal titanium
plates. In their earlyexperiencetheyhad fivecases of
tendonrupture, whichdid notoccur again once they
stopped cutting the distal extent of their plates. Similarly,in
their treatment of 12 patients with mini-fragment titanium
plates, Martinez and colleagues obtained 11 excellent results
and one good result according to the Gartland and Werley
Scale(12).Theyhad no casesoftendonirritationatan
average follow-up of 18 months.
&
SUMMARY
Recent improvements in the understanding of distal radius
fracture patterns, design of fragment-specific implants, and
developments in implant technology have revolutionized the
care of this injury.Itisnow possible to specifically tailor
incisions to fit specific fracture patterns with small implants
that minimize soft-tissue irritation. These implants provide
strong fixation, whichcan withstandearly motion.Asa
result,excellent outcomes canbeattainedwith minimal
complications.
(A)
(B)
FIGURE 12 Fracture from Figure 11. ( A )The volar fragment has been
buttressed with aplate and the radial styloid has been stabilized with
Kirschner wires. ( B )X-rays 1year after surgery.
FIGURE 13 Clinical result for fracture in Figure 11 six months after surgery.
Open Reduction and Internal Fixation of Distal Radius Fractures
&
187
&
SUMMATION POINTS
Indications
&
Intra-articular AO type Bfractures including fractures of
the radial column involving the radial styloid, intermediate
column including the volar and/or dorsal lun ate facets,
and the ulnar column, specifically,the ulnar styloid fracture.
&
Moreextensile approaches are needed for those with severe
shortening and those with extensive intra-articular involvement (AO groupC), especially if theyextendintothe
diaphysis.
Outcomes
&
Excellent to good results can be expected as long as articular
alignment is obtained and maintained.
&
Use of newer,low profile dorsal implants and avoidance of
plate cutting, minimizes the incidence of tendon irritation
and/or rupture
Complications
&
Wound necrosis is best avoided by allowing the soft tissues
to stabilize from the initial trauma prior to embarking on
surgical treatment.
&
An early motion protocol can minimize the incidence of
peritendinous adhesions.
&
Dorsalinstrumentation shouldnot be cut and should
be covere dwithperiosteumtominimizeextensor
tendon irritation.
FIGURE 14 Ulnar styloid stabilized with tension-band construct.
FIGURE 15 Ulnar styloid fracture stabilized with pin plate. Source:Courtesy of Dr Robert J. Medoff.
188
&
Nolla and Jupiter
&
REFERENCES
1. Rikli DA, Regazzoni P. Fractures of the distal end of the radius
treated by internal fixation and early function. Apreliminary
report of 20 cases. JBone Joint Surg Br 1996; 78(4):588–92.
2. Fernandez DL, Jupiter JB. Fractures of the Distal Radius. New
York: Springer,1995.
3. Jiuliano JA, Jupiter JB. Distal radius fractures. In: Trumble T,
Cornwall R, BudoffJ,eds. CoreKnowledgeinOrthopedics:
Hand, Elbow and Shoulder. Philadelphia,PA: C.V.Mosby,2005:87.
4. Fernandez DL, Jupiter JB. Fractures of the Distal Radius. New
York: Springer,1995:70.
5. Jupiter JB, Ring DC. Wr ist—distal radius. AO Manual of Fracture
Management:Hand and Wrist. New Yo rk: AO Publishing, 2005:251.
6. Fernandez DL, Jupiter JB. Fractures of the Distal Radius. New
York: Springer,1995:97.
7. Fernandez DL, Jupiter JB. Fractures of the Distal Radius. New
York: Springer,1995:79.
8. Jupiter JB, Ring DC. Wr ist—distal radius. AO Manual of Fracture
Management: Hand and Wr ist. New York: AO Publishing, 2005:215.
9. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
radius in young adults. JBone Joint Surg Am 1986; 68(5):647–59.
10. Slutsky DJ. Predicting the outcome of distal radius fractures. Hand
Clin 2005; 21(3):289–94.
11.Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius
treated by internal fixation and early function. Aprospective study
of 73 consecutive patients. JBone Joint Surg Br 2000; 82(3):340–4.
12. Martinez AA, Canales V, Cuenca J, Herrera A. Minifragment
plating for fractures of the distal radius. Acta Orthop Belg 2004;
70(4):311–4.
Open Reduction and Internal Fixation of Distal Radius Fractures
&
189
24
Repair of Distal Radial Malunions
with an Intramedullary Nail
John T. Capo, Damon Ng, 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
Fractures of the distal radius are oneofthe most common
fracturesthatare treatedbyorthopedic surgeons. They
account for up to 20% of all fractures seen in the emergency
department (1,2). There is abimodal age distribution, occurring
most commonly between the ages of 5to14and 60 and 69 years.
Within the second age group, there is apredominance of female
patients with aratio of approximately 4:1. Also within this age
group, the fracture is usually the result of alow energy injury;
typically the patient presents after afall on an outstretched
hand. Theaccelerating body weig ht produces abending
moment on th edistalforearm,and thedistalradiusfails
through the softer metaphyseal bone. The result usually is a
displaced,extraarticularmetaphysealfractureofthe distal
radius. Extraarticular distal radius fractureswithout significant
comminution typically prove to be stable after closed reduction
and are usually amenable to cast immobilization.
This was historically thought to be so often the case, that in
1814 Abraham Colles suggested, “the limb will at some remote
period enjoyperfect freedominall of its motions and be
completelyexemptfrompain” (3). However,withfurther
understanding of the anatomy surrounding the distal radius
and the increased physical demands of patients, the effect of
distal radial malunions have received increased attention in the
past several decades. Malunion is actually the most common
complication following adistal radius fracture (4). Distal radial
malunions can result from inappropriate initial treatment or
failureofappropriate treatment due to osteopenia or fracture
comminution. The clinical result from amalunion is variable as
X-ray findings do not always correlate with patient symptoms
and function (5). Often patients with malunions can be plagued
by pain,limitedrangeofmotion(ROM), decreased grip
strength, and poor cosmesis.
Corrective osteotomy for distal radial malunions has been
described as early as the 1930s by Ghormley and Mroz(6). As
osteosynthesis techniquesevolved,sodid the treatment for
distal radial malunions.Currently,the “gold-standard” of
surgical intervention for malunions is osteotomy followed by
internal fixationasdescribed by DiegoFernandez (5). The
osteotomy is carefully planned to correct the deformity,the
resultingdefect is replac ed with bone graft, and the final
position is stabilized rigidly with plates and screws. Tr adition-
ally for dorsally displaced malunions, adirect approach with
dorsal plating has providedexcellent results (7). With the
advent of locked plates, avolar approach has also been utilized
(8–10). These locked plates placed on the volar surface have a
theoretical advantage of less tendon irritation. However,direct
visualization of thecorrectioncannot be achieved andan
external plate still needs to be applied. Elevation and stripping
of the pronator quadratus is required and there is apotential
for decreasing vascularity to the region.
Intramedullary (IM) nail fixation for distal radius fractures
has recently been described with promising results (11,12). The
IM nail is inserted through the radial styloid, spans the length of
the fracture, and is fixed proximally and distally.Aswith all
locked IM implants, it acts as aload sharing device rather than
load bearing. Fixed angle interlocking screws stabilize the distal
fragment while locking bolts proximally provide length stability.Also, like other IM devices, alimited approach is used to
deploy the device with very little soft tissue being disrupted. By
definition an IM device rests within the confines of the bone.
Therefore, thereisnoexternalhardwaretocause tendon
irritation and attrition. In the case of distal radial malunions,
the correction is directly visualized dorsally and the nail is
deployed into thebonethrough alimitedapproach at the
radial styloid.
&
INDICATIONS
Classic radiographic anatomic criteria for acceptable healing in
the distal radius is: radial shortening of ! 3to5mm, radial
inclination O 158 ,sagittal tilt on the lateral projection between
108 dorsaltilt and20 8 volartilt, andincongruity of intraarticular fractures ! 1to2mm at the radiocarpal joint (13).
Distal radial fractures that heal outside of these parameters and
that presentwithclinical defo rmitiesare candidatesfor
osteotomy,bone grafting and fixation with an IM nail.
From the perspective of functional limitation, adistal radial
malunion disrupts the normal mechanics of the wrist including
ROM, load distribution, andforce couplingbetween the
forearm, wrist, andhand (14–16).Inthe case of adorsal
malunion, as thedistalradialartic ular surface is directed
dorsally,the amount of wrist flexion decreases and extension
motion increases. This altered anatomy disrupts the pull of the
wrist flexors and extensors. As the deformity worsens, compensatory midcarpal instability ensues. The midcarpal joint creates
adorsal intercalated segmental instability pattern to compensate for the extended position of the distal radius and proximal
carpal row.
In addition, load profile between the carpus and the distal
radius is altered. The load is shifted dorsally with the distal
radius being point loaded. With distal radial deformity,the
distal radial–ulnar joint (DRUJ) can become subluxated and is
subjected to altered load forces.Inhis study,Palmer demonstrated that the load transmittedthroughthe distal ulna
increasedfrom 21%to67% as thevolar angulation of the
distal radius increasedfrompalmar tilt of 108 to adorsal tilt
of 458 (17,18). As the distal radius is shortened, it brings with it
the triangular fibrocartilagecomplex(TFCC); this abnormal
tensioning of the TFCC blocks normal sweep of the TFCC over
the head of the ulna which in turn can limit normal motion of
the DRUJ (1,5). Clinically,these altered load profiles, instability
and sites of possible arthrosis can be manifested as pain and
functional limitations.
Osteotomy and fixation with an IM device is ideally suited
for malunitedextraarticular distal radius fractures which
are either dorsally or volarly angulated. The patient typically
has pain in the dorsal or ulnar wrist and is unhappy with
the cosmesis of the extremity.Issues of bony defects do not
represent significant problems as bone graft or bone substitute
can be placed at the site of the osteotomy.Incases of distal
radiusfractures with limited extensionintothe articular
surface, osteotomyand fixationwithanIMdevicecan be
utilized if the articular surface can be stabilized first.
In thecasewhere thereissignificant arthrosis and
deformity as aresult of along standing established malunion,
corrective osteotomy and fixation with an IM nail is not
indicated. In theselate stagesituations,the extraarticular
alignmentisnolongerthe main issue. Salvageprocedures
such as arthrodesis and arthroplasty should be considered.
&
CONSIDERATION FOR PREOPERATIVE PLANNING
&
Preoperative Evaluation
The first step in evaluating apatientwith adistal radial
malunion is acompletehistory and physical exam.One
must elucidate thedetails surroundingthe injury including
mechanismofinjury and importantly thetime sinceindex
injury in order to determine the chronicity of the malunion
(19). Patient related factors such as general health, associated
medical problems, hand dominance, occupation and level of
activitymus tbeevaluated.Assessmentofthe post injury
wristmust includedegreeoffunctional limitation in daily
andvocational activities,and thefrequency,durationand
quality of pain in the wrist (including narcotic and analgesic
requirement).
Careful exam of both theaff ected and the unaffected
extremityisimperative. Thelocationofthe pain must be
clearly identified. Examination must include palpation directly
at the fracture site, in the DRUJ, the radial-carpal joint and the
ulnar-carpal joint. The following provocative maneuvers should
be performed: axially loading on the ulnarly deviated wrist,
palpation of the scapholunate interval and evaluation of stability
of the carpus and DRUJ. The ROM in flexion, extension, pronation, supination, radial, and ulnar deviation should be recorded.
(A)
(B)
FIGURE 1 ( A )Anteroposterior and ( B )lateral views of an established
distal radial malunion. The alignment shows that the radius is short,
dorsally angulated and that theinclinationisdecreased. Source:
Courtesy of John T. Capo, MD.
(A)
(B)
FIGURE 2 ( A )Two centimeter radialsided incisioncenteredove r
radial styloid and ( B )the interval betweenthe first and second dorsal
compartments has been used. The tendons and superficial radial nerve
areretracted to expose theradial styl oid. Source:Courtesyof
John T. Capo, MD.
192
&
Capo et al.
Grip stre ngthmeasure mentsmustbemade.Motor and
sensory exam of the wrist and hand is critical, as median nerve
compressionfromaseverely dorsally angulatedmalunion
can occur.
&
Preoperative Imaging
Straight anterior–posterior,oblique and true lateral views of the
affected wrist need to be obtained. Asimilar series of the
contralateral wrist helps with planning the degree of correction.
The radiocarpal and midcarpal joints should be examined for
arthrosis. Shortening of the distal radius produces abnormal
loading of the carpus on the distal ulna, so careful attention
must be made towardthe ulnacarpal articulation. There may be
cysts in the distal ulna or proximal lunate with ulnarcarpal
impaction. Acomputed tomography scan is an adjunct that can
be employed but is not always necessary.Situations in which it
can be best utilized include evaluation of DRUJ for arthrosis and
congruence, and three dimensional visualization of the distal
radial deformity.
FIGURE 3 Dorsal incision for exposure of the malunion and placement
of the proximal locking bolts. The proximal hash marks represent the
limits of the incision for screw insertion only, as in an acute fracture.
Source:Courtesy of John T. Capo, MD.
(A)
(B)
FIGURE 4 ( A )The second and fourth dorsal
compartments are elevatedinasubperiosteal
manner andthe malunion is exposed. The
extensor pollicis longus muscle belly can be
seen proximally and ( B )the malunionisfound
and then opened with an osteotome. Source:
Courtesy of John T. Capo, MD.
Repair of Distal Radial Malunions with an Intramedullary Nail
&
193