Manual of Fracture Management - Wrist 3132428418, 9783132428416

Citation preview

Je sse B Jupite r | Douglas A Cam pbe ll | Fie sky Nuñe z

Manual of Fracture Management Wrist

Includ e s the e bo ok an d o n line con te nt via QR co d e s

Je sse B Jupite r | Douglas A Cam pbe ll | Fie sky Nuñe z

Manual of Fracture Management Wrist

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Je sse B Jupite r | Douglas A Cam pbe ll | Fie sky Nuñe z

Manual of Fracture Management Wrist

Close to 2 ,0 0 0 illustrations and im age s and 15 vide os

Library of Congre ss Cataloging-in-Publication Data is available from the publishe r.

Ha z a rd s Gre at care has be e n take n to m aintain the accuracy of the inform ation containe d in this publication. Howe ve r, the publishe r, and/ or the distributor, and/ or the e ditors, and/ or the authors cannot be he ld re sponsible for e rrors or any conse que nce s arising from the use of the inform ation containe d in this publication. Contributions publishe d unde r the nam e of individual authors are state m e nts and opinions sole ly of said authors and not of the publishe r, and/ or the distributor, and/ or the AO Group. The products, procedures, and therapies described in this work are hazardous and are the re fore only to be applie d by ce rti e d and traine d m e dical profe ssionals in e nvironm e nts spe cially de signe d for such proce dure s. No sugge ste d te st or procedure should be carried out unless, in the user‘s professional judgment, its risk is justi e d. Whoe ve r applie s products, proce dure s, and the rapie s shown or de scribe d in this work will do this at the ir own risk. Be cause of rapid advances in the medical sciences, AO recommends that independent veri cation of diagnosis, the rapie s, drugs, dosage s, and ope ration m e thods should be m ade be fore any action is take n. Although all adve rtising m ate rial which m ay be inse rte d into the work is e xpe cte d to conform to e thical (m e dical) standards, inclusion in this publication doe s not constitute a guarante e or e ndorse m e nt by the publishe r re garding quality or value of such product or of the claim s m ade of it by its m anufacture r.

Le g a l re s trictio n s This work was produce d by AO Foundation, Switze rland. All rights re se rve d by AO Foundation. This publication, including all parts the re of, is le gally prote cte d by copyright. Any use , e xploitation or com m e rcialization outside the narrow lim its se t forth by copyright le gislation and the re strictions on use laid out be low, without the publisher‘s consent, is illegal and liable to prosecution. This applies in particular to photostat re production, copying, scanning or duplication of any kind, translation, pre paration of m icro lm s, e le ctronic data proce ssing, and storage such as m aking this publication available on Intrane t or Inte rne t. Som e of the products, nam e s, instrum e nts, tre atm e nts, logos, de signs, e tc re fe rre d to in this publication are also prote cte d by pate nts and trade m arks or by othe r inte lle ctual prope rty prote ction laws (e g, “AO”, “ASIF”, “AO/ ASIF”, “TRIANGLE/ GLOBE Logo” are re giste re d trade m arks) e ve n though spe ci c re fe re nce to this fact is not always m ade in the te xt. The re fore , the appe arance of a nam e , instrum e nt, e tc without de signation as proprie tary is not to be construe d as a re pre se ntation by the publishe r that it is in the public dom ain. Re strictions on use : The rightful owne r of an authorize d copy of this work m ay use it for educational and research purposes only. Single images or illustrations m ay be copie d for re se arch or e ducational purpose s only. The im age s or illustrations m ay not be alte re d in any way and ne e d to carry the following state m e nt of origin ”Copyright by AO Foundation, Switze rland”. Che ck hazards and le gal re strictions on www.aofoundation.org/ le gal

Copyright © 2019 by AO Foundation, Clavade le rstrasse 8 , 7 270 Davos Platz, Switze rland Distribution by Ge org Thie m e Ve rlag, Rüdige rstrasse 14, 70 4 69 Stuttgart, Ge rm any, and Thie m e Ne w York, 333 Se ve nth Ave nue , Ne w York, NY 10 0 01, USA

ISBN: 978 3132428 416 E-book: 978 3132428 42 3

IV

1 2 3 4 5 6

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Fore word

Foreword Thomas J Fischer, MD, FAOA, ASSH, AAOS, AOTK Hand Expert Group Clinical Associate Professor Indiana University School of Medicine Department of OrthopedicSurgery Section Chief Hand Surgery Ascension St Vincent, Indianapolis Indiana Hand to Shoulder Center 8501 Harcourt Rd Indianapolis, IN 46260 USA

We are n ow in ou r 60th year o celebratin g th e su rgeon s th at cam e be ore u s an d started a u n iqu e organ ization or “workin g grou p” th e Arbeitsgem ein sch a t ü r Osteosyn th ese ragen , th e AO. Th e AO h ad at its core an organ ization al stru ctu re th at worked to develop edu cation al program s, docu m en tation o ractu re care, research , an d in stru m en tation to m ake th eir prin ciples applicable to th e variety o ractu res.

In th e spirit an d in n ovation th at ch aracterized th e ou n ders o th e AO, th ese skilled su rgeon s h ave approach ed th is task with a passion to per orm better an d to teach better in a world wh ere on lin e edu cation is th e n orm . Th ey h ave u sed th e written text as an an ch or an d plat orm to work rom an d go back to in order to u n derstan d th e com plex repairs o th is w on der u lly m ade join t. In reality, th e w rist is a series o m u ltiple join ts workin g in h arm on y to place ou r h an d in space. Th ey h ave broken down th e workin g com pon en ts an d th e com m on in ju ries to sh ow u s th e operative an d n on operative treatm en t th at covers th e m u ltitu de o in tern al deran gem en ts th at can occu r. Th ese su rgeon s are m y valu ed colleagu es an d I am h on ored th at th ey asked m e to set th e stage or th is Manual of Fracture Management— Wrist. It is th e logical ou tgrowth o all th e learn in g an d developm en t th at h as taken place sin ce th e rst developm en t o volar platin g or sh earin g ractu res an d extern al xation with pin xation or wildly m u lti ragm en ted ractu res. It covers th e “lay o th e lan d” qu ite well an d gives u s th e m ap we n eed or li elon g learn in g in wrist trau m a care.

It was ou t o th is grou p a text was created, som e 30 years ago, called th e Manual of Internal Fixation. Th is was th e con sen su s an d widely con sidered tech n ical m an u al o its tim e in developin g tech n iqu es or ractu re xation . It provided a ram ework or su rgeon s to approach broken bon es an d disru pted join ts. It provided th e in tegration o th ou gh t to per orm th e docu m en tation , in stru m en tation , an d edu cation o su rgeon s arou n d th e world, th u s u l llin g th e aim s o th e organ ization . Now several decades an d th ou san ds o operation s later we n d ou rselves im m ersed in a m ou n tain o im plan ts with h igh ly adapted tech n iqu es th at ocu s n ely on a u n iqu e piece o h u m an real estate, th e wrist. Drs Cam pbell, Ju piter, an d Nu n ez, th ree li elon g su rgeon edu cators, h ave tackled th is n ely ocu sed application o th e prin ciples o ractu re care an d h ave given u s a well-docu m en ted an d organ ized text. Th e text lin ks electron ic m edia with th e written word to organ ize th e su rgical approach es to prim ary ractu re m an agem en t an d clearly docu m en ts th e eviden ce th at h elps u s ch oose ou r su rgical m eth ods an d ou r su rgical im plan ts. Bu t th eir work does n ot stop with th e prim ary care o th e ractu re. Th e book’s h ybrid approach to diagram s, case presen tation s, an d eviden ce-based decision m akin g can also be applied to th e described com plication s an d posttrau m atic con dition s th at plagu e ou r patien ts.

V

Pre face

Preface A con siderably greater u n derstan din g o trau m atic an d recon stru ctive problem s abou t th e wrist led u s to th e decision to revise th e in itial AO Manual of Hand and Wrist in to two distin ct texts. Followin g com pletion an d pu blication o th e 2 n d edition o th e h an d ractu res volu m e (n ow titled Manual of Fracture Management— Hand) in 2016, we n ow o er you th e n ew an d expan ded Manual of Fracture Management— Wrist. Th e orm at o th e m an u al is en tirely case based, w h ich h as proven to be so su ccess u l or both train ees as w ell as season ed su rgeon s in h elpin g to approach an d treat both sim ple an d com plex in ju ries. As w ith th e recen t h an d m an u al, w e h ave en h an ced ou r clin ical case presen tation s w ith illu stration s taken rom th e expan sive library o th e AO Fou n dation on lin e edu cation site, AO Su rgery Re eren ce, or u sed th e exception al skills an d resou rces o th e m edical illu stration an d graph ic design team s at AO Su rgery Re eren ce an d th e AO Edu cation In stitu te. Recogn izin g th e su bstan tial advan cem en ts in th e u n derstan din g o th e com plex an atom y o th e w rist, expan ded su rgical approach es, an d tech n ological im provem en ts in im plan ts speci c to a variety o an atom ical sh apes an d in ju ry pattern s, th is volu m e covers a wide ran ge o in orm ation an d is divided in to ve speci c section s. Section on e o ers th e reader ten di eren t su rgical approach es to th e distal radiu s, carpu s, an d distal u ln a. Section tw o exam in es ractu res an d ractu re dislocation s o th e carpu s in clu din g sim ple an d m u lti ragm en tary ractu res o th e scaph oid, n on u n ion s, an d even th e u se o vascu lar pedicle gra tin g. Th e th ird section ocu ses on problem s o th e distal u ln a an d distal radiou ln ar join t w h ile th e ou rth section covers a w ide variety o ractu re pattern s an d m eth ods o in tern al xation o th e distal radiu s, w ith

VI

som e ascin atin g clin ical cases in volvin g severe m u lti ragm en tation an d de orm ity. Th e n al section provides th e reader w ith illu strated cases o variou s recon stru ctive problem s in clu din g n on u n ion an d m alu n ion s o th e distal radiu s as w ell as posttrau m atic con dition s o th e radiocarpal an d in tercarpal join ts. Th is w rist m an u al also ref ects th e experien ce an d expertise o m an y teach in g acu lty th at h ave tau gh t in AO Fou n dation h an d an d w rist cou rses, over m an y years, an d th rou gh ou t th e w orld. Th eir con cepts as w ell as clin ical exam ples h ave assisted an d in f u en ced th e editors th rou gh ou t its produ ction . We w ish to especially ackn ow ledge th e ollow in g su rgeon s or th eir con tribu tion s: Drs Diego Fern an dez, Ren ato Fricker, Fiesky Nu ñ ez Jr, Zh on g yu Li, Th om as Fisch er, an d Ju an Del Pin o, all o w h om con tribu ted u n iqu e treatm en ts o speci c problem s th at are illu strated w ith in th e m an u al. As w e rst iden ti ed in ou r origin ally pu blish ed AO Manual of Hand and Wrist, an d again em ph asized w ith th e recen t Manual of Fracture Management— Hand, th is w rist pu blication prim arily en com passes several exam ples o operative treatm en t. It sh ou ld n ot be con stru ed to be th e on ly w ay n or even n ecessarily th e best w ay to approach th e in dividu al problem s presen ted. Likew ise it is n ot in ten ded to be an exh au stive text on th e su bject. Still, w e h ope you w ill n d m an y h ou rs o learn in g an d pleasu re in th is text in retu rn or th e m an y h ou rs w e an d oth ers h ave dedicated in providin g th is book to you . Jesse B Ju piter Dou glas A Cam pbell Fiesky Nu ñ ez

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Acknowle dgme nts

Acknowledgments We are w ell aw are th at it w ou ld n ot be possible to produ ce an d pu blish th e Manual of Fracture Management— Wrist, n or an y o th e n e AO Fou n dation book pu blication s you see today, w ith ou t th e dedication an d assistan ce o a large n u m ber o con tribu tors. Th e com radery sh ow n by ellow AO m em bers to sh are resou rces, im ages, an d cases, an d th e h ou rs o edu cation w ork previou sly u n dertaken by w rist su rgeon colleagu es, plu s ad h oc in volvem en t o ou r ow n clin ical sta m ean s th at th ere tru ly is a lon g list o people to th an k. Bu t w h ile th ere h ave been cou n tless people in volved in som e w ay in th e developm en t o th is book, w e w ou ld like to especially m en tion th e ollow in g in dividu als, com m ittees, an d grou ps: • Mem bers o th e AOTrau m a Edu cation Com m ission , or providin g th e opportu n ity to develop both th is w ork an d th e partn er pu blication th e Manual of Fracture Management— Hand • Urs Rü etsch i an d Robin Green e, rom th e AO Edu cation In stitu te, or providin g access to th e resou rces an d AOEI sta requ ired to brin g th is pu blication to ru ition

• Ren ato Fricker, or h is con tribu tion s both as an editor o th e Manual of Fracture Management— Hand an d as an au th or o th is w ork • Diego Fern an dez an d Ladislav Nagy or th eir previou s con tribu tion s to h an d an d wrist edu cation at AO Fou n dation an d con tribu tion s an d assistan ce with th is pu blication • Pro Tom Fisch er or kin dly providin g h is Forew ord • Carl Lau , Man ager Pu blish in g, an d Mich ael Gleeson , Project Man ager or both h an d an d w rist pu blication s, plu s th e en tire team o graph ic design an d m edical illu stration sta an d con su ltan ts th at h elped brin g h an d draw n sketch es an d verbal ideas in to reality • Lars Veu m , Man ager AO Su rgery Re eren ce, an d th e team s o cu rren t an d orm er project m an agers, su rgeon au th ors an d editors, an d illu strators or th eir editorial an d illu stration w ork developin g th e AO Su rgery Re eren ce carpal an d distal radiu s m odu les • Fion a Hen derson an d An dreas Sch abert rom AO Fou n dation ’s pu blish in g partn er Th iem e • An d last bu t n ot least to ou r partn ers an d am ily or th eir con tin u in g an d n ever-en din g su pport or ou r in volvem en t w ith th e AO Fou n dation ’s w orld-class books, cou rses, an d on lin e edu cation activities an d even ts.

VII

Contributors

Contributors Ed it o rs

Jesse B Jupiter, MD

Douglas A Campbell, ChM, FRCS Ed, FRCS(Orth),

Fiesky A Nuñez Sr, MD

Hansjorg Wyss/AO Professor of Orthopaedic Surgery

FFSEM(UK)

Associate Professor

Harvard Medical School

Consultant Hand and Wrist Surgeon

Department of Orthopaedic Surgery

Massachusetts General Hospital

Leeds General Infirmary

Wake Forest School of Medicine

Yawkey Center, Suite 2100

Great George St

Medical Center Boulevard

55 Fruit Street

Leeds LS1 3EX

Winston-Salem NC 27157-1010

Boston MA02114

United Kingdom

USA

Douglas A Campbell, ChM, FRCS Ed, FRCS(Orth),

Diego L Fernández, MD

Thomas J Fischer, MD, FAOA, ASSH, AAOS, AOTK

FFSEM(UK)

Professor of Orthopaedic Surgery

Hand Expert Group

Consultant Hand and Wrist Surgeon

University of Bern

Clinical Associate Professor

Leeds General Infirmary

Orthopedic Surgeon

Indiana University School of Medicine

Great George St

Consultant, Hand and Upper Extremity Surgery

Department of Orthopedic Surgery

Leeds LS1 3EX

Ch. de la Côte du Bas 12

Section Chief Hand Surgery

United Kingdom

CH-1588 Cudrefin

Ascension St Vincent, Indianapolis

Switzerland

Indiana Hand to Shoulder Center

USA

Au t h o rs

8501 Harcourt Rd Indianapolis, IN 46260 USA

VIII

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Contributors

Renato Fricker, MD

Jesse B Jupiter, MD

Fiesky A Nuñez Jr, MD, PhD

Member AOTauma Europe, Swiss and American

Hansjorg Wyss/AO Professor of Orthopaedic Surgery

Hand Surgeon

Societies for Hand Surgery, German speaking Working

Harvard Medical School

Bon Secours Mercy Health

Group for Surgery of the Hand

Massachusetts General Hospital

Piedmont Orthopedic Associates

Specialist in Hand Surgery FMH

Yawkey Center, Suite 2100

35 International Drive

Senior Consultant Hand, Wrist, Elbow Surgery

55 Fruit Street

Greenville, SC 29615

Orthopedic and Trauma Surgeons

Boston MA02114

USA

Hirslanden Clinic Birshof

USA Fiesky A Nuñez Sr, MD

Reinacherstrasse 28 CH4142 Münchenstein

Zhongyu Li, MD, PhD, FAOA, FAAOS, ASSH, ASPN

Associate Professor

Switzerland

ABOS Board Certified in Orthopaedic Surgery and

Department of Orthopaedic Surgery

Hand Surgery

Wake Forest School of Medicine

Juan González del Pino, MD, PhD

Professor

Medical Center Boulevard

Member Spanish Society for Hand Surgery

Department of Orthopaedic Surgery

Winston-Salem NC 27157-1010

Member Spanish Society for Orthopaedic Surgery

Department of Vascular and Endovascular Surgery

USA

Former member AOTKHand Expert Group

Wake Forest School of Medicine

Former Editor-in-Chief Spanish Journal of

Medical Center Boulevard

Orthopaedic Surgery

Winston-Salem NC 27157-1070

Former President Spanish Society for Microsurgery

USA

Founder and Head The Institute of the Hand Nuestra Señora del Rosario Hospital 80 Castelló St 28006 Madrid Spain

IX

Abbre viations

Abbreviations A PL CH CMC D CP D RUJ ECRB ECRL ECU ED C ED M EIP EPB EPL FCR FCU FPL LC-D CP LCP PIP SL SLA C SN A C TFCC TFC VA VCP

X

abdu ctor pollicis lon gu s capitate h ead carpom etacarpal dyn am ic com pression plate distal radiou ln ar join t exten sor carpi radialis brevis exten sor carpi radialis lon gu s exten sor carpi u ln aris exten sor digitoru m com m u n is exten sor digiti m in im i exten sor in dicis propriu s exten sor pollicis brevis exten sor pollicis lon gu s f exor carpi radialis f exor carpi u ln aris f exor pollicis lon gu s lim ited con tact dyn am ic com pression plate lockin g com pression plate proxim al in terph alan geal scaph olu n ate scaph olu n ate advan ced collapse scaph oid n on u n ion advan ced collapse trian gu lar brocartilage com plex trian gu lar brocartilage disc variable an gle volar colu m n plate

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Online book content

Online book content Usin g a QR code scan n er on a m obile device, readers w ill be able to access th e approach an d dem on stration videos featu red in th is book. Th e QR code on th is page w ill also brin g you to addition al on lin e edu cation al con ten t related to th is book. ht t ps://wrist .aoeducation.org/asset s.ht m l

XI

Table of conte nts

Pa rt I Surgical approach

Front matter

Fore word Pre face Acknowle dgm e nts Contributors Abbre viations Online book conte nt

XII

1

Approache s

3

V

1.1

Palm ar approach to the scaphoid

5

VI

1.2

Dorsal approach to the scaphoid

13

VII

1.3

Com bine d approach to the lunate and pe rilunate injurie s

21

VIII

1.4

Radiopalm ar approach to the thum b base

31

X

1.5

Dorsoradial approach to the distal radius

37

XI

1.6

Modifie d He nry palm ar approach to the distal radius

41

1.7

Ulnar palm ar approach to the distal radius

49

1.8

Dorsal approach to the distal radius

55

1.9

Exte nde d dorsal approach to the distal radius

65

1.10

Ulnar approach to the distal ulna

77

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Table of conte nts

Pa rt II Case s 2

Carpals

83

4

Radius

2 .1

Scaphoid—nondisplace d fracture tre ate d pe rcutane ously

85

4 .1

Radial styloid—fracture tre ate d with a radial colum n plate 241

4 .2

Distal radius—dorsally displaced e xtraarticular fracture

with a he adle ss com pre ssion scre w 2 .2

Scaphoid—displace d fracture tre ate d with a he adle ss

95

com pre ssion scre w 2 .3

Scaphoid—m ultifragm e ntary fracture tre ate d with a

2 .4

Scaphoid, proxim al pole —fracture tre ate d with a

103

111

he adle ss com pre ssion scre w 2 .5

Scaphoid, proxim al pole —nonunion tre ate d with a

Scaphoid, waist—nonunion with de form ity tre ate d with a

123

Scaphoid, proxim al pole —nonunion tre ate d with a

131

buttress plate 4 .4

Distal radius—shearing fracture treated with a buttress plate

273

4 .5

Distal radius—dorsally displaced intraarticular fracture

287

4.6

141

Pe rilunate dislocation tre ate d with K-wire s

157

2 .9

Transscaphoid pe rilunate fracture dislocation tre ate d

173

4 .7

4 .8

4 .9

30 9

Distal radius—m ultifragm e ntary intraarticular fracture

319

Distal radius—m ultifragm e ntary intraarticular fracture

329

plating and scre w 193

4.10

dislocation tre ate d with scre ws Multiple carpal pe rilunate fracture dislocation and

Distal radius—m ultifragm e ntary intraarticular fracture

with associate d scaphoid fracture tre ate d with triple

with K-wire s and a he adle ss scre w

2 .11

29 9

tre ate d with triple plating

2 .8

Transtrique tral transscaphoid pe rilunate fracture

Distal radius—multifragmentary intraarticular fracture

with de fe ct tre ate d with a palm ar plate

vascularize d bone graft

2 .10

265

treate d with a palmar plate

he adle ss com pre ssion scre w and bone graft 2 .7

Distal radius—lunate facet fracture treated with a

treated with double plating

he adle ss com pre ssion scre w and bone graft 2 .6

257

treated with a palmar plate 4 .3

he adle ss com pre ssion scre w and lag scre w

239

Distal radius—displace d intraarticular fracture treate d with

339

a bridge plate 203

scaphocapitate syndrom e tre ate d with scre ws

4.11

Distal radius—radiocarpal fracture dislocation treate d with

355

double plating

2 .12

Trape zium —displace d fracture tre ate d with lag scre ws

213

3

Ulna

219

3 .1

Ulnar styloid—fracture tre ate d with te nsion band wiring

221

3 .2

Ulna, he ad and ne ck—m ultifragm e ntary fracture tre ate d

231

with a hook plate

XIII

Table of conte nts

Appendix 5

Reconstructions and treatment of complications

369

5 .1

Distal radius—dorsal e xtraarticular malunion treate d with

371

oste otomy and double plating 5 .2

Distal radius—palmar e xtraarticular malunion treated with

Furthe r re ading

4 93

AO/ OTA Fracture and Dislocation Classification

4 99

387

oste otomy and plate 5 .3

Distal radius—intraarticular malunion treate d with

39 9

oste otomy and palmar plate 5 .4

Distal radius—e xtraarticular and intraarticular m alunion

417

tre ate d with oste otom y and dorsal double plating 5 .5

Rheumatoid arthritis treate d with radiolunate arthrodesis

429

5 .6

Kienbock’s disease treate d with total wrist arthrode sis

439

5 .7

Malunite d fracture with associate d ulnar abutm e nt

44 9

syndrom e tre ate d with an ulnar shorte ning oste otom y 5 .8

Long-standing nonunion tre ate d with re se ction of

467

the distal ulna and double plating of the radius 5 .9

Chronic inte rcarpal arthritis tre ate d with scaphoid

475

re se ction and 4 -corne r fusion

XIV

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Pa rt I

Surgical approach

Pa rt II Case s

2

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

1

Approaches

Pa rt II Case s

4

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

1.1

1

Palmar approach to the scaphoid

Su rgica l a p p ro a ch

In ju ries in volvin g th e scaph oid can be treated u sin g a palm ar approach .

Fig 1.1 -1

2

In d ica t io n s

Fractu res o th e scaph oid are typically described by th e location o th e ractu re, as proxim al pole (in th e proxim al th ird), scaph oid w aist (in th e cen tral th ird), or distal pole (in th e distal th ird). Th e palm ar approach to th e scaph oid is in dicated or displaced ractu res in th e cen tral or distal th irds ( a ). It is also in dicated or th e treatm en t o scaph oid ractu re n on u n ion s ( b ).

Fig 1.1-2 a – b

a

b

5

Pa rt I Surgical approache s

2

In d ica t io n s (co n t )

Th e palm ar approach also gives access to th ose irredu cible displaced scaph oid w aist (cen tral th ird) ractu res th at can n ot be redu ced an d xed by percu tan eou s tech n iqu es.

Fig 1.1-3

Fra ct u re p a t t e rn

Most scaph oid w aist ractu res are tran sverse ( a ); h ow ever, som e can be obliqu e eith er in th e h orizon tal ( b ) or vertical plan e ( c ).

Fig 1.1-4 a – c

a

6

b

c

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.1  Palmar approach to the scaphoid

3

Su rgica l a n a t o m y

Ca rp a l b o n e s

Th e bon es o th e w rist com prise th e carpu s or carpal bon es at th e proxim al en d o th e h an d, an d th e radial an d u ln ar bon es at th e distal en d o th e arm . Th e carpu s is m ade u p o eigh t carpal bon es, w h ich in clu de th e h am ate, capitate, trapezoid, an d trapeziu m in th e distal carpal row , an d th e pisi orm , triqu etru m , lu n ate, an d scaph oid in th e proxim al carpal row .

Capitate

Trapezoid

Fig 1.1-5

Hamate Trapezium Pisiform

A com plex series o so t-tissu e stru ctu res stabilize th e carpal bon es an d th eir con n ection to each oth er an d to th e radiu s an d u ln a. Th e scaph oid, h ow ever, is by ar th e m ost com m on ly in ju red carpal bon e.

Scaphoid

Triquetrum

Lunate

So ft t is s u e s

On th e palm ar side o th e w rist, th e ollow in g stru ctu res can also be ou n d: 1. Motor bran ch o th e m edian n erve 2. Palm ar cu tan eou s bran ch o th e m edian n erve 3. Median n erve 4. Pron ator qu adratu s m u scle 5. Flexor digitoru m pro u n du s ten don s 6. Flexor digitoru m su per cialis ten don s 7. Flexor carpi radialis (FCR) ten don 8. Radial artery.

Fig 1.1-6 a – b

1 2

3 4

5 6

7 8 a 6

5

3 2 4 7

8

b

7

Pa rt I Surgical approache s

4

Sk in in cis io n

An gle d s k in in cis io n

Im portan t an atom ical lan dm arks or th e an gled palm ar skin in cision are: • Th e scaph oid tu bercle • Th e FCR ten don .

Fig 1.1-7

Scaphoid tubercle

Median nerve Palmar cutaneous branch

Flexor carpi radialis tendon

Th e in cision lin e can be m arked on th e skin in lin e w ith th e FCR ten don , startin g at th e scaph oid tu bercle an d ru n n in g proxim ally or abou t 2 cm . Distal to th e scaph oid tu bercle, th e in cision an gles tow ard th e base o th e th u m b over th e scaph otrapezial join t. Be aw are o th e proxim ity o th is in cision to th e palm ar cu tan eou s bran ch o th e m edian n erve (as sh ow n in Fig 1.1-7 ) an d be su re to avoid in ju rin g it.

Fig 1.1-8

8

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.1  Palmar approach to the scaphoid

4

Sk in in cis io n (co n t )

Zigza g in cis io n

Altern atively, a zigzag palm ar in cision can be con stru cted u sin g th e sam e lan dm arks.

Fig 1.1-9

Scaphoid tubercle

Median nerve Palmar cutaneous branch

Flexor carpi radialis tendon

Liga t e t h e s u p e r ficia l p a lm a r b ra n ch o f t h e ra d ia l a r t e r y

Th e su per cial palm ar bran ch o th e radial artery passes tow ard th e palm , ru n n in g close to th e scaph oid tu bercle. I n ecessary, it can be ligated an d divided.

Fig 1.1-1 0

Superficial palmar branch Scaphoid tubercle

Palmar cutaneous branch of the median nerve

Flexor carpi radialis tendon Radial artery

Op e n t h e fle xo r ca rp i ra d ia lis s h e a t h

Th e FCR sh eath is open ed as ar distally as possible an d th e ten don retracted tow ard th e u ln ar side.

Fig 1.1-1 1

Superficial palmar branch Flexor carpi radialis tendon

Radial artery Palmar cutaneous branch of the median nerve

9

Pa rt I Surgical approache s

4

Sk in in cis io n (co n t )

Exp o s e t h e w ris t ca p s u le

Th e capsu le is th en in cised obliqu ely rom th e tu bercle distally tow ard th e palm ar rim o th e radiu s proxim ally. Th is in cision also in volves th e radioscaph ocapitate an d lon g radiolu n ate ligam en ts. As determ in ed by th e ractu re con gu ration , preserve as m u ch o th e palm ar ligam en t com plex as possible as it h elps to con tain th e proxim al pole an d preven ts palm ar tilt o th e scaph oid.

Fig 1.1-1 2

Scaphoid tubercle Radioscaphocapitate ligament Long radiolunate ligament

Z-s h a p e d ca p s u la r in cis io n

Altern atively, to preserve th e palm ar ligam en ts, a Z-sh aped in cision can be m ade in th e join t capsu le.

Fig 1.1-1 3

Scaphoid tubercle

Radioscaphocapitate ligament Long radiolunate ligament

Exp o s e t h e s ca p h o id

Retract th e divided radioscaph ocapitate ligam en t to expose th e scaph oid.

Fig 1.1-1 4

Thenar muscles Radioscaphocapitate ligament

Long radiolunate ligament

10

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.1  Palmar approach to the scaphoid

4

Sk in in cis io n (co n t )

I it is n ecessary to expose th e proxim al part o th e scaph oid, divide th e lon g radiolu n ate ligam en t proxim ally as ar as th e palm ar rim o th e radiu s.

Fig 1.1-1 5

Exp o s e t h e s ca p h o t ra p e zia l jo in t

Th e scaph otrapezial join t m u st be exposed to allow optim al position in g o a screw . Th e in cision is deepen ed distally, dividin g th e origin o th e th en ar m u scles in lin e w ith th eir bers.

Fig 1.1-1 6

Thenar muscles Radioscaphocapitate ligament

Th e scaph otrapezial join t is iden ti ed, th e scaph otrapezial ligam en t divided in th e lin e o its bers, an d th e join t capsu le open ed.

Fig 1.1-1 7

Scaphotrapezial ligament

Radioscaphocapitate ligament

11

Pa rt I Surgical approache s

5

Wo u n d clo s u re

Th e divided palm ar ligam en ts (radioscaph ocapitate an d lon g radiolu n ate) m u st be repaired with n e in terru pted su tu res to preven t secon dary carpal in stability. Approxim ate th e so t tissu es over th e scaph otrapezial join t. Test th e in tegrity o th e so t-tissu e repair by passive wrist m otion . Fin ally, th e FCR ten don sh eath is repaired an d covered with su bcu tan eou s tissu e.

Fig 1.1-18

Vid e o

Th is video dem on strates th e palm ar approach to th e carpals.

Vid e o 1 .1 -1

12

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.2

1

Dorsal approach to the scaphoid

Su rgica l a p p ro a ch

In ju ries in volvin g th e scaph oid can be treated u sin g a dorsal approach .

Fig 1.2 -1

2

In d ica t io n s

Th e dorsal approach to th e scaph oid is in dicated or all acu te displaced an d n on displaced ractu res o th e proxim al pole (proxim al th ird) ( a ). It is also in dicated or th e bon e gra tin g o proxim al pole n on u n ion s ( b ).

Fig 1.2-2 a – b

a

b

13

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

Ext e n s o r co m p a r t m e n t s

Th ere are ve exten sor com partm en ts on th e dorsu m o th e radiocarpal region an d on e exten sor com partm en t at th e u ln ocarpal region . Th ese com partm en ts or tu n n els con tain th e exten sor ten don s.

Fig 1.2-3

Th e rst com partm en t con tain s th e abdu ctor pollicis lon gu s (APL) an d exten sor pollicis brevis (EPB) ten don s. Th e secon d com partm en t con tain s th e exten sors carpi radialis lon gu s (ECRL) an d brevis (ECRB). Th e th ird com partm en t con tain s th e exten sor pollicis lon gu s (EPL) ten don . Th e ou rth com partm en t con tain s th e exten sor in dicis propriu s (EIP) an d th e exten sor digitoru m com m u n is (EDC). Th e th com partm en t con tain s th e exten sor digiti m in im i (EDM). Fin ally, th e sixth com partm en t h osts th e exten sor carpi u ln aris (ECU).

I

II III

IV

V

VI

Th e su per cial radial n erve (1) an d th e dorsal bran ch o th e u ln ar n erve (2) lie in th e su bcu tan eou s tissu es su per cial to th e exten sor com partm en ts an d are vu ln erable to in ju ry du rin g su rgical approach .

Fig 1.2-4

2 VI I

V

II

IV

III 1

14

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.2 Dorsal approach to the scaphoid

4

Sk in in cis io n

Make a straigh t dorsal skin in cision startin g over Lister tu bercle (th e bon y prom in en ce located at th e distal en d o th e radiu s) an d exten d th e in cision or abou t 4 cm distally.

Fig 1.2-5 a – b

a

b

15

Pa rt I Surgical approache s

4

Sk in in cis io n (co n t )

Id e n t ify t h e ra d ia l n e r ve

En su re to preserve an y parts o th e su per cial bran ch o th e radial n erve, w h ich ru n s in th e radial skin f ap o th e w ou n d.

Fig 1.2-6

Superficial branch of the radial nerve

In cis e t h e re t in a cu lu m

In cise th e distal part o th e exten sor retin acu lu m over th e EPL ten don , leavin g th e proxim al part in tact.

Fig 1.2-7

Superficial branch of the radial nerve

Extensor retinaculum Extensor pollicis longus

16

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.2 Dorsal approach to the scaphoid

4

Sk in in cis io n (co n t )

Open th e distal part o th e th ird exten sor com partm en t.

Fig 1.2-8

Re t ra ct io n o f t h e t e n d o n s

Th e EPL ten don is th en retracted radially togeth er w ith th e ten don s o th e secon d exten sor com partm en t (th e ECRB an d th e ECRL).

Fig 1.2-9

Th e ten don s o th e ou rth exten sor com partm en t are retracted in an u ln ar direction .

Extensor carpi radialis brevis Dorsal intercarpal ligament

Extensor pollicis longus

17

Pa rt I Surgical approache s

4

Sk in in cis io n (co n t )

Op e n in g t h e ca p s u le

Make a lon gitu din al or in verted T-sh aped in cision , startin g at th e dorsal rim o th e distal radiu s, an d exten din g to th e dorsal radiocarpal ligam en t.

Fig 1.2-1 0

Extensor carpi radialis brevis Dorsal intercarpal ligament Dorsal radiocarpal ligament

Extensor pollicis longus

Take care to preserve th e vessels to th e dorsal ridge o th e scaph oid. Th e capsu le sh ou ld n ot be stripped rom th is area.

Fig 1.2-1 1

Capitate

Scapholunate ligament Lunate Scaphoid

Dorsal radiocarpal ligament

18

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.2 Dorsal approach to the scaphoid

4

Sk in in cis io n (co n t )

Exp o s e t h e s ca p h o id

To expose th e proxim al pole o th e scaph oid, it is n ecessary to f ex th e wrist. Th e scaph oid n ow com es in to view. An d th e scaph olu n ate ligam en t can be iden ti ed.

Fig 1.2-12

5

Wo u n d clo s u re

Fig 1.2-1 3

Close th e capsu le w ith in terru pted su tu res.

It is n ot n ecessary to repair th e th ird exten sor com partm en t becau se th e proxim al part rem ain s in tact.

19

Pa rt I Surgical approache s

5

Wo u n d clo s u re (co n t )

Vid e o

Th is video dem on strates th e dorsal approach to th e carpals.

Vid e o 1 .2 -1

20

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.3

1

Combined approach to the lunate and perilunate injuries

Su rgica l a p p ro a ch

In ju ries in volvin g th e lu n ate or its su rrou n din g stru ctu res can be treated u sin g a com bin ed dorsal an d palm ar approach .

Fig 1.3 -1

2

In d ica t io n s

Th e com bin ed approach (u sin g both dorsal an d palm ar in cision s) is o ten in dicated or lu n ate an d perilu n ate in ju ries.

Fig 1.3-2 a – c

A lu n ate dislocation exists w h en th e lu n ate ( a ) loses con tact w ith th e lu n ate ossa o th e distal radiu s ( b ). How ever, a perilu n ate in ju ry exists w h en an adjoin in g carpal bon e is dam aged or dislocated bu t th e lu n ate itsel rem ain s in con tact w ith th e lu n ate ossa o th e distal radiu s ( c ). In m ost cases in volvin g th e com bin ed approach , th e dorsal approach is m ade rst. How ever, start w ith a palm ar approach in cases o palm ar dislocation o th e lu n ate or in th e rarer palm ar lu xation o oth er carpal bon es.

Normal a

Lunate dislocation b

Perilunate dislocation c

Note th at a com bin ed approach or th ese in ju ries is n ot alw ays n ecessary. Th e dorsal aspect o th e scaph olu n ate ligam en t is th e stron ger, so th e dorsal approach is in dicated to repair it an d to redu ce an y scaph olu n ate dissociation (ligam en t in ju ries). It is also in dicated to redu ce an d stabilize oth er perilu n ate ractu re dislocation s.

21

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

Ext e n s o r co m p a r t m e n t s

Th ere are ve exten sor com partm en ts in th e dorsoradial region an d on e exten sor com partm en t at th e dorsou ln ar region .

Fig 1.3-3

Th e secon d com partm en t con tain s th e exten sor carpi radialis lon gu s an d brevis. Th e th ird com partm en t con tain s th e exten sor pollicis lon gu s (EPL) ten don . Th e ou rth com partm en t con tain s th e exten sor in dicis propriu s an d th e exten sor digitoru m com m u n is. Perilu n ate in ju ries can be approach ed th rou gh th e secon d, th ird, an d ou rth com partm en ts.

I

II III

IV

V VI

So ft t is s u e s

On th e palm ar side o th e w rist, th e ollow in g stru ctu res can also be ou n d: 1. Motor bran ch o th e m edian n erve 2. Palm ar cu tan eou s bran ch o th e m edian n erve 3. Median n erve 4. Pron ator qu adratu s m u scle 5. Flexor digitoru m pro u n du s ten don s 6. Flexor digitoru m su per cialis ten don s 7. Flexor carpi radialis (FCR) ten don 8. Radial artery.

Fig 1.3-4 a – b

1 2

3 4

5 6

7 8 a 6

5

3 2 4 7

8

b

22

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.3   Combine d approach to the lunate and pe rilunate injurie s

4

Do rs a l s k in in cis io n

St ra igh t s k in in cis io n

Make a straigh t skin in cision begin n in g proxim ally an d u ln ar to Lister tu bercle an d en din g distally at th e level o th e th ird carpom etacarpal join t. Th e in cision sh ou ld be abou t 8 cm lon g. Th e in cision can be exten ded proxim ally or distally i n ecessary.

Fig 1.3-5

Ele va t e t h e s k in fla p

Preserve th e large lon gitu din al vein s an d ligate an d divide th e crossin g bran ch es to ach ieve exposu re.

Fig 1.3-6

Extensor retinaculum

Superficial branch of radial nerve

23

Pa rt I Surgical approache s

4

Do rs a l s k in in cis io n (co n t )

Elevate th e skin f aps, com plete w ith su bcu tan eou s tissu e, rom th e exten sor retin acu lu m . Th e su per cial bran ch o th e radial n erve sh ou ld be iden ti ed an d elevated w ith th e skin f ap.

Superficial branch of the radial nerve

Fig 1.3-7

Op e n t h e t h ird co m p a r t m e n t

In cise th e exten sor retin acu lu m over th e EPL ten don , open in g th e th ird exten sor com partm en t.

Fig 1.3-8

Fourth compartment Second compartment

Extensor retinaculum

Extensor pollicis longus tendon

Superficial cutaneous branch of the ulnar nerve

Superficial branch of radial nerve

Th e EPL ten don is released an d retracted radially, togeth er w ith th e exten sor ten don s o th e secon d com partm en t.

Fig 1.3-9

24

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.3   Combine d approach to the lunate and pe rilunate injurie s

4

Do rs a l s k in in cis io n (co n t )

Op e n t h e fo u r t h co m p a r t m e n t

Retract th e exten sor ten don s o th e ou rth com partm en t in an u ln ar direction to expose th e w rist capsu le.

Fig 1.3-1 0

Fourth compartment

Second compartment

Extensor pollicis longus tendon

Superficial cutaneous branch of the ulnar nerve

Superficial branch of radial nerve

Ra d ia lly b a s e d ca p s u la r in cis io n

To gain a com plete view o th e carpu s, a radially based capsu lar ligam en tou s f ap is elevated. Th e capsu lotom y in cision starts radially deep to th e f oor o th e secon d exten sor com partm en t.

Fig 1.3-1 1

Leave a rin ge o 2–3 m m o th e capsu lar attach m en t at th e dorsal rim o th e radiu s or su bsequ en t su tu re repair. Th e in cision occu rs as ollow s: 1. Th e in cision con tin u es in an u ln ar direction alon g th e dorsal rim o th e radiu s 2. It th en tu rn s distally in lin e w ith th e bers o th e radiolu n otriqu etral (dorsal radiocarpal) ligam en t 3. At th e triqu etru m it tu rn s radially in lin e w ith th e bers o th e dorsal in tercarpal ligam en t.

3

Dorsal intercarpal ligament 1

2

Radiolunotriquetral ligament

25

Pa rt I Surgical approache s

4

Do rs a l s k in in cis io n (co n t )

Pro t e ct t h e d is t a l ra d io u ln a r jo in t

Be care u l n ot to cu t th e dorsal radiou ln ar ligam en t or th e trian gu lar brocartilage o th e distal radiou ln ar join t, w h ich m u st be protected.

Fig 1.3-1 2

Radiolunotriquetral ligament Triangular fibrocartilage Dorsal intercarpal ligament

Dorsal radioulnar ligament

Ele va t e t h e ca p s u la r fla p

Th e capsu lar f ap is elevated by sh arp dissection in an u ln ar to radial direction .

Fig 1.3-1 3

Dorsal intercarpal ligament

S

C

H L

T

Radiolunotriquetral ligament

Th e proxim al carpal row w ith its in trin sic ligam en ts an d th e m idcarpal join t are exposed.

Fig 1.3-1 4

26

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.3   Combine d approach to the lunate and pe rilunate injurie s

5

Pa lm a r s k in in cis io n

A ter th e dorsal approach , w ith tem porary xation on th e dorsal side, th e palm ar approach is per orm ed i n ecessary.

Fig 1.3-1 5

Ext e n d e d ca rp a l t u n n e l in cis io n

Th e in cision begin s in th e palm , at th e level o th e distal edge o th e f exor retin acu lu m , in lin e w ith th e th ird m etacarpal. It con tin u es proxim ally in th e in terem in en ce crease to th e level o th e tran sverse f exor crease o th e w rist.

Fig 1.3-1 6

At th is poin t, th e in cision an gles 90 degrees in an u ln ar direction or 2 cm in th e lin e o th e w rist f exor crease. It th en tu rn s proxim ally as a sligh tly cu rved lon gitu din al exten sion as ar as n ecessary.

27

Pa rt I Surgical approache s

5

Pa lm a r s k in in cis io n (co n t )

Ele va t e t h e s k in fla p s

Elevate th e skin f aps by sh arp dissection , rstly rom th e su r ace o th e palm ar apon eu rosis distally, th en rom th e an tebrach ial ascia proxim ally, on th e u ln ar side o th e palm aris lon gu s ten don . Th is protects th e palm ar cu tan eou s bran ch o th e m edian n erve, w h ich passes to th e radial side o th e palm aris lon gu s ten don .

Fig 1.3-1 7

Palmar aponeurosis

Ulnar artery and nerve

Antebrachial fascia

Palmaris longus tendon

Median nerve Palmar cutaneous branch of the median nerve

Op e n t h e ca rp a l t u n n e l

Iden ti y th e m edian n erve, w h ich lies radial an d deep to th e palm aris lon gu s ten don . In sert a blu n t in stru m en t in to th e carpal tu n n el betw een th e m edian n erve an d th e f exor retin acu lu m . Now divide th e f exor retin acu lu m lon gitu din ally over th e blu n t in stru m en t, w h ich protects th e m edian n erve. Th e retin acu lu m sh ou ld be divided to th e u ln ar side o th e m edian n erve to protect its m otor bran ch to th e th en ar m u scles.

Fig 1.3-1 8

Flexor retinaculum

Motor branch of the thenar muscles

Median nerve Palmaris longus tendon Ulnar artery and nerve

28

Palmar cutaneous branch of the medial nerve

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.3   Combine d approach to the lunate and pe rilunate injurie s

5

Pa lm a r s k in in cis io n (co n t )

Re t ra ct t h e fle xo r t e n d o n s

To expose th e palm ar carpal ligam en ts, retract all th e f exor ten don s radially.

Fig 1.3-1 9

Ulnotriquetral ligament

Flexor tendons

Pronator quadratus muscle

Fig 1.3-2 0

On ly th e u ln ar n erve an d artery rem ain on th e

u ln ar side.

29

Pa rt I Surgical approache s

5

Pa lm a r s k in in cis io n (co n t )

Op t io n : a p p ro a ch t o t h e ra d ia l p a lm a r ca p s u le

Som etim es th e m edian n erve m u st be care u lly retracted radially togeth er w ith th e ten don o th e f exor pollicis lon gu s. Th e f exor ten don s o th e n gers are retracted in an u ln ar direction , th ereby exposin g th e radial side o th e palm ar capsu le.

Fig 1.3-2 1

Finger flexor tendons Flexor pollicis longus tendon

Median nerve Pronator quadratus muscle

6

Wo u n d clo s u re

Clo s e t h e ca p s u la r in cis io n

On th e dorsal side, repair th e radially based f ap w ith in terru pted su tu res.

Fig 1.3-2 2

To avoid th e risk o isch em ic ru ptu re o th e EPL, it is recom m en ded th at it be le t above th e exten sor retin acu lu m in th e su bcu tan eou s tissu e. I an in cision is also m ade on th e palm ar side, th e skin is closed in th e stan dard ash ion .

30

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.4

1

Radiopalmar approach to the thumb base

Su rgica l a p p ro a ch

In ju ries in volvin g th e base o th e th u m b can be treated u sin g a radiopalm ar approach .

Fig 1.4-1

2

In d ica t io n s

Th is approach is in dicated or ractu res o th e trapeziu m as w ell as or in traarticu lar ractu res o th e rst carpom etacarpal join t, su ch as Ben n ett or Rolan do ractu res. It is also in dicated or basal m etacarpal ractu res.

Fig 1.4-2

Trapezoid Trapezium

Scaphoid

31

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

Th e join t su r aces o th e trapeziu m an d th u m b m etacarpal resem ble tw o reciprocally in terlockin g saddles. Th is articu lar geom etry, th e ligam en tou s su pport system , an d th e th u m b m u scles all w ork in syn ergy to en able opposition o th e th u m b to th e n gers.

Fig 1.4-3 a – b

a

Th e stron g palm ar obliqu e ligam en t is essen tial as a stabilizin g u n it o th e base o th e th u m b m etacarpal; it in serts in to th e articu lar m argin o th e palm ar beak on th e u ln ar aspect o th e rst m etacarpal base. On th e radial side o th e m etacarpal base is th e in sertion o th e abdu ctor pollicis lon gu s (APL) ten don . Th e addu ctor pollicis exerts a orce th at pu lls th e th u m b in a palm ar an d u ln ar direction .

b

Fig 1.4-4

Adductor pollicis

Palmar oblique ligament Abductor pollicis longus tendon

4

Sk in in cis io n Superficial branch of the radial nerve

Tw o di eren t skin in cision s can be u sed: • Th e straigh t radiopalm ar in cision • Th e cu rved in cision , described by Wagn er. Th e straigh t in cision is m ade in th e dorsoradial aspect o th e th en ar em in en ce at th e tran sition betw een th e dorsal an d palm ar skin . It starts abou t 1 cm distal to th e tip o th e radial styloid an d exten ds distally or 4–5 cm .

Fig 1.4-5

Th e su per cial bran ch o th e radial n erve divides in to several bran ch es in th is area. Iden ti y an d protect th ese bran ch es to avoid trou blesom e n eu rom a orm ation . Th e radial artery crosses th e proxim al lim it o th e in cision in an obliqu e direction an d m u st also be iden ti ed, protected, an d preserved.

32

Radial artery

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.4 Radiopalmar approach to the thumb base

4

Sk in in cis io n (co n t )

Th e Wagn er in cision ollow s th e th en ar em in en ce in a gen tle cu rve tow ard its palm ar aspect. Th e disadvan tage o th is in cision is th e risk o scar orm ation across th e w rist crease an d lesion s o n erve bran ch es.

Fig 1.4-6

Superficial branch of the radial nerve

Radial artery

Ele va t e t h e fla p

Elevate th e f aps o skin an d su bcu tan eou s tissu e by blu n t dissection , iden ti yin g an d protectin g th e division s o th e su per cial bran ch o th e radial n erve an d th e APL ten don . Gen tle retraction w ith elastic vessel loops aids th e exposu re.

Fig 1.4-7

Abductor pollicis longus tendon

Superficial branch of the radial nerve

Abductor pollicis longus tendon

How ever, th e excessive retraction o th e f aps can im pair vascu larity o th e tissu es.

Fig 1.4-8

Superficial branch of the radial nerve

33

Pa rt I Surgical approache s

4

Sk in in cis io n (co n t )

De t a ch t h e t h e n a r m u s cle s

A ter retractin g th ese stru ctu res, th e th en ar m u scles com e in to view . Th ey are th en detach ed rom th eir origin s at th e base o th e rst m etacarpal an d ref ected in a palm ar direction .

Fig 1.4-9

Abductor pollicis longus tendon

Thenar muscles

Abductor pollicis longus tendon

Preservin g a sm all part o th e in sertion w ill later h elp w ith reattach m en t o th e th en ar m u scles.

Fig 1.4-1 0

Thenar muscles

Ca p s u lo t o m y

Per orm a tran sverse or lon gitu din al capsu lotom y to expose th e join t.

Fig 1.4-1 1

Abductor pollicis longus tendon

Thenar muscles

34

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.4 Radiopalmar approach to the thumb base

4

Sk in in cis io n (co n t )

In s p e ct t h e jo in t

In spect th e join t by rotatin g th e th u m b in to pron ation an d su pin ation , w h ile exertin g lon gitu din al traction . Th is m an eu ver also h elps to assess th e ractu re geom etry an d to redu ce Ben n ett ractu res.

Fig 1.4-1 2

5

Wo u n d clo s u re

Close th e capsu le w ith in terru pted su tu res. Reattach th e th en ar m u scles to th e base o th e rst m etacarpal u sin g in terru pted su tu res.

Fig 1.4-1 3

35

Pa rt I Surgical approache s

5

Wo u n d clo s u re (co n t )

Vid e o

Th is video dem on strates th e radiopalm ar approach to th e th u m b base.

Vid e o 1 .4 -1

36

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.5

1

Dorsoradial approach to the distal radius

Su rgica l a p p ro a ch

In ju ries in volvin g th e radial styloid can be treated u sin g a dorsoradial approach .

Fig 1.5 -1

2

In d ica t io n s

Depen din g on th e speci c ractu re pattern , a dorsal approach betw een th e variou s exten sor com partm en ts I-VI is ch osen .

Fig 1.5-2

In in ju ries in volvin g th e radial styloid, an approach betw een th e rst an d secon d exten sor com partm en ts (A) is in dicated.

III

IV V

II

VI

A

I

Radius

Ulna

37

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

An a t o m ica l s n u ffb o x

Th e exten sor pollicis lon gu s an d th e exten sor pollicis brevis are th e lan dm arks or th e an atom ical sn u box, with th e tip o th e radial styloid orm in g th e f oor.

Fig 1.5-3

Anatomical snuffbox Extensor pollicis longus

Radial styloid Extensor pollicis brevis

Im portan t stru ctu res arou n d th e an atom ical sn u box in clu de th e su per cial bran ch es o th e radial n erve, wh ich sh ou ld be care u lly protected du rin g an y xation procedu re. Th e radial artery crosses th e f oor o th e an atom ical sn u box an d sh ou ld also be protected.

Fig 1.5-4

Radial artery

38

Superficial branch of radial nerve

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.5 Dorsoradial approach to the distal radius

4

Sk in in cis io n

A straigh t in cision is m ade over th e an atom ical sn u box an d exten ded distally an d proxim ally, to th e n ecessary exten t, as illu strated. Th e tw o resu ltan t skin / su bcu tan eou s f aps are raised by blu n t dissection rom th e u n derlyin g exten sor retin acu lu m .

Fig 1.5-5

Exp o s u re

Th e su per cial cu tan eou s bran ch es o th e radial n erve are iden ti ed an d protected. Th e radial styloid is approach ed betw een th e rst an d secon d com partm en ts an d th en exposed by sh arp dissection .

Fig 1.5-6

Superficial branch of radial nerve

39

Pa rt I Surgical approache s

4

Sk in in cis io n (co n t )

Th e rst an d secon d com partm en ts can be elevated as n ecessary.

Fig 1.5-7

Superficial branch of radial nerve

5

Wo u n d clo s u re

Th e skin is closed in a stan dard ash ion .

40

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.6

1

Modi ed Henry palmar approach to the distal radius

Su rgica l a p p ro a ch

In ju ries in volvin g th e distal radiu s can be treated u sin g a m odi ed Hen ry palm ar approach .

Fig 1.6 -1

2

In d ica t io n s

Th e m odi ed Hen ry approach is su itable or m ost ractu res o th e distal radiu s.

Fig 1.6-2

41

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

So ft t is s u e s

On th e palm ar side o th e w rist, th e ollow in g stru ctu res can be ou n d: 1. Motor bran ch o th e m edian n erve 2. Palm ar cu tan eou s bran ch o th e m edian n erve 3. Median n erve 4. Pron ator qu adratu s m u scle 5. Flexor digitoru m pro u n du s ten don s 6. Flexor digitoru m su per cialis ten don s 7. Flexor carpi radialis (FCR) ten don 8. Radial artery.

Fig 1.6-3 a – b

1 2

3 4

5 6

7 8 a 6

5

3 2 4 7

8

b

42

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.6 Modif e d Henry palmar approach to the distal radius

3

Su rgica l a n a t o m y (co n t )

Bo n y a n a t o m y

In addition to th e su rrou n din g so t tissu es, th e distal radiu s con tain s a n u m ber o bon y protru sion s: 1. Uln ar styloid 2. Uln ar h ead 3. Sigm oid n otch 4. Lu n ate acet 5. Lister tu bercle 6. Scaph oid acet 7. Radial styloid 8. Watersh ed lin e.

Fig 1.6-4 a – b

3

1 a

2

4

6

7

1

2

3

8

7

5 b

Wa t e rs h e d lin e

Th e w atersh ed lin e represen ts th e m argin betw een th e stru ctu res th at m ay be elevated proxim ally an d th e capsu le o th e w rist join t, w h ich sh ou ld be respected.

Fig 1.6-5

43

Pa rt I Surgical approache s

4

Pla n n in g t h e in cis io n

Th e m odi ed Hen ry approach u ses th e plan e betw een th e FCR ten don an d th e radial artery. Th e classic Hen ry approach goes betw een th e brach ioradialis an d th e radial artery, th at is, radial to th e radial artery; h ow ever, th e m odi ed Hen ry approach is u ln ar to th e radial artery. Th e FCR ten don is palpated be ore m akin g th e skin in cision to th e radial side.

Fig 1.6-6

Palmar cutaneous branch of median nerve

Flexor pollicis longus

Median nerve

Flexor carpi radialis Modified Henry approach

Pronator quadratus

Classic Henry approach

Radial artery

A distal exten sion o th e in cision in a zigzag ash ion across th e w rist f exion crease w ill allow m obilization o th e FCR ten don or a m ore exten sile approach .

Fig 1.6-7

Pit fa ll

Th e radial artery an d th e palm ar cu tan eou s bran ch o th e m edian n erve are at risk du rin g th is approach .

44

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.6 Modif e d Henry palmar approach to the distal radius

5

Sk in in cis io n

Make th e skin in cision alon g th e radial border o th e FCR ten don . Th e sh eath is open ed an d th e ten don retracted tow ard th e u ln ar side. Deepen th e in cision betw een th e f exor pollicis lon gu s (FPL) ten don an d th e radial artery.

Fig 1.6-8

Care m u st be taken to avoid dam agin g th e radial artery on th e radial side an d th e palm ar cu tan eou s bran ch o th e m edian n erve on th e u ln ar side.

Palmar cutaneous branch of median nerve Flexor carpi radialis tendon

Radial artery

Flexor pollicis longus tendon

Th e FPL m u scle belly is sw ept aw ay tow ard th e u ln a. Th is in creases th e space an d exposes th e pron ator qu adratu s m u scle.

Fig 1.6-9

Pronator quadratus

Flexor pollicis longus tendon

45

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

Pe a rl

Th e pron ator qu adratu s m u scle sh ou ld be elevated u sin g an L-sh aped in cision . Th e h orizon tal lim b is placed at th e w atersh ed lin e. Th is lies a ew m illim eters proxim al to th e join t lin e; th e position o th e join t lin e can be determ in ed by a h ypoderm ic n eedle placed in th e join t.

Fig 1.6-1 0

Pronator quadratus

Exp o s in g t h e d is t a l ra d iu s

Th e pron ator qu adratu s m u scle is in cised on its radial border, exposin g th e distal radiu s. It is stripped o th e distal radiu s togeth er w ith th e periosteu m .

Fig 1.6-1 1

46

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.6 Modif e d Henry palmar approach to the distal radius

6

Wo u n d clo s u re

Th e pron ator qu adratu s sh ou ld be placed over th e plate. Every attem pt sh ou ld be m ade to reattach th e h orizon tal lim b o th e pron ator qu adratu s elevation to th e capsu le. I possible, it sh ou ld be reattach ed to its radial in sertion .

Fig 1.6-1 2

Th e ten don sh eath m ay be closed, bu t care m u st be taken to avoid catch in g th e cu tan eou s bran ch o th e m edian n erve. Th e skin is th en closed.

Vid e o

Th is video dem on strates th e palm ar approach to th e distal radiu s.

Vid e o 1 .6 -1

47

Pa rt I Surgical approache s

48

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.7

1

Ulnar palmar approach to the distal radius

Su rgica l a p p ro a ch

In ju ries in volvin g th e distal radiu s can be treated u sin g an u ln ar palm ar approach .

Fig 1.7 -1

2

In d ica t io n s

An u ln ar palm ar approach is pre erred to expose th e palm ar lu n ate acet. Th e u ln ar palm ar approach also acilitates exposu re o th e sigm oid n otch , th e palm ar w rist capsu le, th e distal radiou ln ar join t, an d th e distal u ln a ( a ). It is less su itable or th e radial part o th e distal radiu s.

Fig 1.7-2 a – b

For m ore com plex ractu res, an u ln ar palm ar exten sile approach m ay be u sed. I it is desired to decom press th e carpal tu n n el, th is can be per orm ed eith er th rou gh an u ln ar palm ar exten sile approach or tw o separate approach es ( b ).

a

b

49

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

Details on th e an atom y in volved in th is approach can be ou n d in th e su rgical an atom y topic in ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s.

4

Pla n n in g t h e in cis io n

Th e u ln ar palm ar approach u ses th e plan e betw een th e u ln ar artery an d n erve on on e side an d th e f exor ten don s on th e oth er side.

Fig 1.7-3

Ulnar nerve

Ulnar artery Flexor digitorum superficialis tendon Flexor carpi ulnaris tendon

50

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.7 Ulnar palmar approach to the distal radius

5

Sk in in cis io n

Th e in cision starts at th e w rist crease an d ru n s proxim ally parallel to th e u ln a ( a ). It can be exten ded alon g th e w rist crease an d distally in to th e palm . Th e in terval is developed betw een th e u ln ar artery an d th e f exor ten don s ( b ).

Fig 1.7-4 a – b

a

Ulnar artery

Flexor digitorum superficialis tendon

b

Dis s e ct io n

Th e f exor ten don s an d m edian n erve are retracted tow ard th e radial side to provide excellen t exposu re o th e pron ator qu adratu s.

Fig 1.7-5

Ulnar artery

Pronator quadratus

Flexor tendons

51

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

Th e pron ator qu adratu s is in cised as m u ch as n ecessary.

Fig 1.7-6

Ulnar artery

Pronator quadratus

Flexor tendons

Expose th e u ln ar side o th e distal radiu s by elevatin g th e in cised portion o th e pron ator qu adratu s.

Fig 1.7-7

Ulna

52

Radius

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.7 Ulnar palmar approach to the distal radius

5

Sk in in cis io n (co n t )

Ext e n s io n o f u ln a r p a lm a r a p p ro a ch

Th e u ln ar palm ar approach can be exten ded distally. Th is allow s decom pression o th e carpal tu n n el an d gives good access to th e radiocarpal stru ctu res in h igh en ergy in ju ries.

Fig 1.7-8

6

Wo u n d clo s u re

Th e skin is closed in th e stan dard ash ion .

53

Pa rt I Surgical approache s

54

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.8

1

Dorsal approach to the distal radius

Su rgica l a p p ro a ch

In ju ries in volvin g m u lti ragm en tary articu lar ractu res, or both th e radial an d in term ediate colu m n s o th e distal orearm , can be approach ed th rou gh a sin gle dorsal skin in cision w ith m u ltiple approach es th rou gh th e exten sor com partm en ts.

Fig 1.8 -1

2

In d ica t io n s

Prin cip le o f co lu m n s

Th e distal orearm can be th ou gh t o in term s o th ree colu m n s. Th e u ln a orm s on e colu m n (th e u ln ar colu m n ) w h ile th e radiu s can be separated in to tw o (th e in term ediate colu m n an d th e radial colu m n ).

m u e

m t

m a

u l

i

u d l

o o c e c l

m r

a r i

a e d n t l

a R

n

U I

Distally at th e w rist join t, th e radial colu m n articu lates w ith th e scaph oid w h ile th e in term ediate colu m n articu lates w ith th e lu n ate. Th e u ln ar colu m n term in ates distally at th e TFCC.

n

n

c

o

l

Th e radial colu m n in clu des th e radial styloid an d scaph oid ossa w h ile th e in term ediate colu m n in clu des th e lu n ate ossa an d th e sigm oid n otch , w h ich is part o th e distal radiou ln ar join t (DRUJ). Th e u ln ar colu m n com prises th e distal u ln a w ith th e trian gu lar brocartilage com plex (TFCC).

n

Fig 1.8-2

55

Pa rt I Surgical approache s

2

In d ica t io n s (co n t )

Th is 3-colu m n con cept h elps in describin g th e location o w rist in ju ries an d is a h elp u l biom ech an ical m odel or u n derstan din g th e path om ech an ics o w rist ractu res.

Depen din g on th e speci c ractu re pattern , a dorsal approach betw een th e variou s exten sor com partm en ts I-VI is ch osen .

Fig 1.8-3

III

B

C

IV

V

II

In in ju ries requ irin g a dorsal approach to th e distal radiu s, approach es (m arked as A, B, or C) betw een th e variou s exten sor com partm en ts are in dicated: A: Approach to th e radial colu m n B: Approach to th e in term ediate colu m n C: Approach to th e in term ediate colu m n or th e dorsal lu n ate acet an d distal radiou ln ar join t.

VI

A

I

Radius

3

Ulna

Su rgica l a n a t o m y

Ext e n s o r co m p a r t m e n t s

Th ere are ve exten sor com partm en ts in th e dorsoradial region (I-V) an d on e exten sor com partm en t in th e dorsou ln ar region (VI).

Fig 1.8-4

In a dorsal approach to th e distal radiu s, n u m erou s com partm en ts m ay be in volved.

I

56

II

III

IV

V

VI

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.8 Dorsal approach to the distal radius

4

Sk in in cis io n

Th e radial an d in term ediate colu m n s can be approach ed separately u sin g a sin gle dorsal skin in cision .

Fig 1.8-5

5

Ap p ro a ch t o t h e ra d ia l co lu m n

Tw o in cis io n o p t io n s

Depen din g on th e ractu re con gu ration , variou s retin acu lar in cision s are possible to deal w ith radial colu m n ractu res. Eith er o th e ollow in g option s can be ch osen : 1. Approach to th e radial colu m n betw een th e rst an d secon d exten sor com partm en ts 2. Approach to th e radial colu m n u n der th e secon d exten sor com partm en t.

Fig 1.8-6

2

III

IV V

II

VI

1

I

Radius

Ulna

57

Pa rt I Surgical approache s

5

Ap p ro a ch t o t h e ra d ia l co lu m n (co n t )

Op t io n 1 : b e t w e e n firs t a n d s e co n d co m p a r t m e n t s

Th e approach in option 1 allow s plate position in g on th e radial side o th e radial colu m n w h en it is n ot n ecessary to expose th e articu lar su r ace. Th e radial colu m n is approach ed w ith a su bcu tan eou s dissection tow ard th e radial side.

Fig 1.8-7

Extensor pollicis longus

A ter exposin g th e exten sor pollicis lon gu s (EPL), a secon d approach is m ade th rou gh th e retin acu lu m betw een th e rst an d secon d exten sor com partm en ts. Iden ti y th e sen sory bran ch o th e radial n erve, w h ich lies in th e su bcu tan eou s f ap above th e rst com partm en t an d m u st be protected.

Sensory branch of radial nerve

I it is di cu lt to obtain satis actory redu ction o a radial styloid ractu re, it can be h elp u l to release th e brach ioradialis ten don .

In cis io n t h ro u gh firs t co m p a r t m e n t

Th e rst exten sor com partm en t is in cised at th e level o th e m u scu loten din ou s tran sition an d is released u p to th e tip o th e radial styloid. Th e ten don s o th e rst com partm en t are released an d m obilized.

Fig 1.8-8

Extensor carpi radialis brevis

58

Extensor pollicis longus

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.8 Dorsal approach to the distal radius

5

Ap p ro a ch t o t h e ra d ia l co lu m n (co n t )

Su b p e rio s t e a l e le va t io n o f s e co n d co m p a r t m e n t

Th e secon d com partm en t is elevated su bperiosteally, leavin g th e com partm en t itsel in tact. Th e radial colu m n is n ow exposed.

Fig 1.8-9

Extensor pollicis longus

Op t io n 2 : e le va t io n u n d e r t h e s e co n d e xt e n s o r co m p a r t m e n t

In th is approach , Lister tu bercle is iden ti ed on th e radial side an d th e secon d com partm en t is partially elevated. Th e EPL ten don can be retracted to th e u ln ar side.

Fig 1.8-1 0

Extensor pollicis longus

59

Pa rt I Surgical approache s

5

Ap p ro a ch t o t h e ra d ia l co lu m n (co n t )

Ele va t io n o f s e co n d co m p a r t m e n t

Th e secon d com partm en t an d its con ten ts are elevated rom th e distal radiu s by sh arp dissection .

Fig 1.8-1 1

Extensor pollicis longus

Th e ECRB ten don is retracted rom th e f oor o th e com partm en t. Th is allow s access to th e radiocarpal articu lar su r ace on th e radial colu m n .

Fig 1.8-1 2

Extensor carpi radialis brevis

60

Extensor pollicis longus

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.8 Dorsal approach to the distal radius

6

Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n

In cis io n o f t h e re t in a cu lu m

In th e approach to th e in term ediate colu m n (B), th e th ird com partm en t is open ed in lin e w ith th e EPL ten don . Wh en open in g th e exten sor com partm en t, be care u l n ot to cu t th e ten don .

Fig 1.8-1 3

III

B

IV V

II

VI

I

Radius

Th e in cision is exten ded proxim ally in lin e w ith th e EPL. Distally, open th e exten sor retin acu lu m as ar as n eeded. It is recom m en ded to preserve th e distal part so th at th e ten don still glides tow ard th e th u m b. Altern atively, th e com partm en t can be open ed distally an d th e ten don elevated an d retracted radially.

Ulna

Fig 1.8-1 4

Extensor pollicis longus

61

Pa rt I Surgical approache s

6

Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n (co n t )

Mo b iliza t io n o f e xt e n s o r p o llicis lo n gu s t e n d o n

Th e EPL ten don is reed an d a vessel loop is passed arou n d it.

Fig 1.8-1 5

Extensor pollicis longus

Su b p e rio s t e a l e le va t io n o f t h e fo u r t h co m p a r t m e n t

Th e ou rth com partm en t is elevated su bperiosteally, leavin g th e com partm en t itsel in tact. Th e in term ediate colu m n is n ow exposed.

Fig 1.8-1 6

62

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.8 Dorsal approach to the distal radius

6

Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n (co n t )

Op t io n : a r t h ro t o m y

On ce th e com partm en ts h ave been elevated an d th e distal radiu s exposed, th e capsu le can be open ed to expose th e articu lar su r ace. A plate can be applied to th e radial colu m n th rou gh th is approach . Th e EPL an d ECRB ten don s can be retracted in eith er direction , as dictated by th e ractu re con gu ration .

Fig 1.8-1 7

Th e capsu lar in cision sh ou ld be big en ou gh to see th e lu n ate acet an d a part o th e scaph oid acet in cases o distal radial articu lar com pression or carpal bon e in ju ry.

7

Extensor pollicis longus Extensor carpi radialis brevis

Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n fo r t h e d o rs a l lu n a t e fa ce t a n d d is t a l ra d io u ln a r jo in t

An approach betw een th e ou rth an d exten sor com partm en ts (C) is also possible.

Fig 1.8-1 8

th

III

IV

C V

II

VI

I

Radius

Ulna

63

Pa rt I Surgical approache s

7

Ap p ro a ch t o t h e in t e rm e d ia t e co lu m n fo r t h e d o rs a l lu n a t e fa ce t a n d d is t a l ra d io u ln a r jo in t (co n t )

Th is w ill allow clear access to th e u ln ar side o th e in term ediate colu m n to treat lu n ate acet an d DRUJ in ju ries.

Fig 1.8-1 9

8

Wo u n d clo s u re

A ran ge o w ou n d closu res exist or th e variou s dorsal approach es to th e distal radiu s. Th ese are described in u rth er detail in Part II Cases.

Vid e o

Th is video dem on strates th e dorsal approach to th e distal radiu s.

Vid e o 1 .8 -1

64

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.9

1

Extended dorsal approach to the distal radius

Su rgica l a p p ro a ch

In ju ries in volvin g th e distal radiu s can be treated u sin g an exten ded dorsal approach .

Fig 1.9 -1

2

In d ica t io n s

Th e exten ded dorsal approach can be u sed or w rist u sion s or or join t bridgin g (span n in g) plate xation o m u lti ragm en tary in traarticu lar distal radial ractu res.

Fig 1.9-2

65

Pa rt I Surgical approache s

3

Su rgica l a n a t o m y

Ext e n s o r co m p a r t m e n t s

Th ere are ve exten sor com partm en ts in th e dorsoradial region (I-V) an d on e exten sor com partm en t in th e dorsou ln ar region (VI).

Fig 1.9-3

In an exten ded dorsal approach to th e distal radiu s, n u m erou s com partm en ts m ay be in volved.

I

4

II

III

IV

V

VI

Pla n n in g t h e in cis io n

Wh en m obilizin g th e skin f aps, m ake su re n ot to in ju re th e su per cial radial n erve.

Fig 1.9-4

66

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.9 Extende d dorsal approach to the distal radius

5

Sk in in cis io n

In cis io n o p t io n s

Distal incision

Distal extension

Dorsal approach

Proximal extension a

b

Proximal incision c

Depen din g on th e ractu re con gu ration or disorder, variou s in cision s are possible. Th e ollow in g option s can be ch osen : 1. Lon gitu din al skin in cision ( a ) 2. Stan dard dorsal in cision w ith an addition al exten ded proxim al or exten ded distal in cision or both ( b ) 3. Proxim al an d distal in cision s on ly ( c ).

Fig 1.9-5 a – c

Op t io n 1 : lo n git u d in a l s k in in cis io n

A lon gitu din al skin in cision is m ade alon g a lin e over Lister tu bercle to th e in terspace betw een th e secon d an d th ird m etacarpal.

Fig 1.9-6

67

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

In cis io n o f re t in a cu lu m

Th e th ird com partm en t is open ed in lin e with th e exten sor pollicis lon gu s (EPL). Wh en open in g th e exten sor com partm en t, be care u l n ot to cu t th e ten don . Th e in cision is exten ded proxim ally in lin e with th e EPL ten don . Distally, th e exten sor retin acu lu m is u lly open ed.

Fig 1.9-7

Extensor pollicis longus

Mo b ilize t h e e xt e n s o r p o llicis lo n gu s

Th e EPL ten don is reed an d a vessel loop is passed arou n d it. Th e ten don is retracted tow ard th e radial side.

Fig 1.9-8

Extensor pollicis longus

68

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.9 Extende d dorsal approach to the distal radius

5

Sk in in cis io n (co n t )

Su b p e rio s t e a l e le va t io n o f t h e fo u r t h co m p a r t m e n t

Th e ou rth com partm en t is elevated su bperiosteally, leavin g th e com partm en t itsel in tact. Th e in term ediate colu m n is n ow exposed. Th e ten don s o th e ou rth exten sor com partm en t are retracted to th e u ln ar side. I n ecessary, th e ten don s o th e secon d exten sor com partm en t are m obilized to th e radial side.

Fig 1.9-9

Th e periosteu m is in cised on th e dorsal side o th e th ird m etacarpal an d th e in terosseou s m u scles elevated su bperiostally, i n ecessary.

Fig 1.9-1 0

69

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

Op t io n 2 : d o rs a l in cis io n w it h a d d it io n a l p ro xim a l o r d is t a l in cis io n s

Distal extension

Distal extension

Dorsal approach

Dorsal approach

Proximal extension

Proximal extension

a

b

In option 2, a stan dard dorsal in cision can be m ade w ith eith er an addition al exten ded proxim al or exten ded distal in cision or both . How ever, it is rst n ecessary to determ in e w h ich m etacarpal align s best w h en th e ractu re is redu ced. Note th at a m in im u m o th ree screw s sh ou ld be placed in th e m etacarpal. Th e m eth od or determ in in g w h ich m etacarpal to u se is as ollow s: 1. Provision ally redu ce th e ractu re 2. Place th e plate on to th e dorsal su r ace o th e w rist 3. Use th e im age in ten si er, to m ake sm all adju stm en ts in radiou ln ar deviation allow in g th e optim al plate location to be determ in ed over eith er th e secon d or th ird m etacarpal 4. Make th e in cision s.

Fig 1.9-1 1a –b

70

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.9 Extende d dorsal approach to the distal radius

5

Sk in in cis io n (co n t )

Ma rk in cis io n lin e s t h ro u gh t h e p la t e h o le s

Usin g th is approach , it is h elp u l to m ark all in cision s at th e begin n in g th rou gh th e plate h oles. Draw a 3 cm straigh t rst skin in cision lin e over th e ch osen m etacarpal. A secon d in cision lin e o 2 cm is draw n over Lister tu bercle. Th e th ird an d n al straigh t in cision lin e o 3 cm is draw n over th e radial sh a t h oles.

Fig 1.9-1 2

Ma ke t h e d is t a l in cis io n

A 3 cm in cision is m ade at th e base o th e selected m etacarpal an d con tin u ed over th e sh a t. Th e m etacarpal is exposed w h ile th e exten sor ten don s are retracted an d protected.

Fig 1.9-1 3

Extensor pollicis longus Extensor carpi radialis longus Extensor carpi radialis brevis

71

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

Ma ke t h e d o rs a l in cis io n a n d m o b ilize t h e e xt e n s o r p o llicis lo n gu s

Th e m iddle in cision is recom m en ded to avoid an y dam age to th e EPL ( a ). Palpate Lister tu bercle an d m ake a 2 cm lon gitu din al in cision directly over th e bon y lan dm ark. Fu lly release th e EPL an d retract it tow ard eith er th e radial or u ln ar side depen din g on th e ractu re con gu ration ( b ). Mobilizin g th e EPL acilitates plate in sertion , ractu re redu ction , an d stabilization o th e articu lar su r ace, as w ell as th e application o bon e gra t or llin g voids (i n ecessary). Th is in cision also allow s slidin g o th e plate u n der th e secon d com partm en t ten don s to avoid im pin gin g th em u n der th e plate.

Fig 1.9-1 4a –b

Extensor pollicis longus Extensor carpi radialis longus Extensor carpi radialis brevis

Extensor pollicis brevis Abductor pollicis longus Extensor carpi radialis longus Extensor carpi radialis brevis a

b

72

Extensor pollicis longus

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.9 Extende d dorsal approach to the distal radius

5

Sk in in cis io n (co n t )

Ma ke t h e p ro xim a l in cis io n

Extensor pollicis brevis Abductor pollicis longus

Extensor pollicis brevis Abductor pollicis longus

Extensor carpi radialis longus Extensor carpi radialis brevis

Extensor carpi radialis longus Extensor carpi radialis brevis

a

b

Usin g th e im age in ten si er or gu idan ce, an in cision m easu rin g approxim ately 3 cm is m ade over th e dorsal aspect o th e radiu s ju st proxim al to th e m u scle bellies o th e abdu ctor pollicis lon gu s (APL) an d th e exten sor pollicis brevis (EPB) ten don s, in lin e w ith th e exten sor carpi radialis lon gu s (ECRL) an d brevis (ECRB) ten don s.

Fig 1.9-1 5a –b

Th e exact location o th e in cision m ay depen d on w h eth er th e plate w ill attach distally at th e secon d or th ird m etacarpal. For a secon d-m etacarpal xation by blu n t dissection , th e in terval betw een th e ECRL an d ECRB is developed an d th e diaph ysis o th e radiu s is exposed ( a ). For a th ird-m etacarpal xation by blu n t dissection , th e in terval betw een th e rst com partm en t (con tain in g th e APL an d EPB ten don s) an d secon d com partm en t (ECRL an d ECRB ten don s) is developed an d th e diaph ysis o th e radiu s is exposed ( b ). Retract th e rst com partm en t m u scles u ln arly an d th e secon d com partm en t radially.

73

Pa rt I Surgical approache s

5

Sk in in cis io n (co n t )

Op t io n 3 : p ro xim a l a n d d is t a l in cis io n s

As an altern ative, th e approach can be m ade u sin g ju st proxim al an d distal in cision s.

Fig 1.9-1 6

Distal incision

Proximal incision

Th is is don e by m arkin g th e skin at th e level o th e proxim al an d distal screw h oles o th e plate an d m akin g 3–4 cm in cision s.

Fig 1.9-1 7

74

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.9 Extende d dorsal approach to the distal radius

6

Wo u n d clo s u re

Th e skin is closed in a stan dard ash ion .

75

Pa rt I Surgical approache s

76

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1.10

1

Ulnar approach to the distal ulna

Su rgica l a p p ro a ch

In ju ries in volvin g th e distal u ln a can be treated u sin g an u ln ar approach .

Fig 1.1 0-1

2

In d ica t io n s

Th e u ln ar approach is in dicated or all ractu res o th e distal u ln a.

Fig 1.10 -2

Radius

Ulna

77

Pa rt I Surgical approache s

3

Sk in in cis io n

Th e u ln ar sh a t an d th e ractu re gap betw een th e u ln ar styloid an d th e distal m etaph ysis are u su ally easily palpated.

Fig 1.10 -3

A straigh t lon gitu din al in cision is m ade over th e distal u ln a between th e ten don s o th e exten sor an d f exor carpi u ln aris. Extensor carpi ulnaris

Flexor carpi ulnaris

Dis s e ct io n

Th e dorsal bran ch o th e u ln ar n erve sh ou ld be able to be seen . Care sh ou ld be taken to avoid in ju ry to th is n erve. Th e ractu re site is th en exposed, i n ecessary, releasin g th e u ln ar attach m en t o th e exten sor retin acu lu m .

Fig 1.10 -4

Dorsal branch of ulnar nerve

78

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

1 Approache s 1.10  Ulnar approach to the distal ulna

3

Sk in in cis io n (co n t )

Su pin ation o th e orearm resu lts in th e u ln ar styloid lyin g dorsally. Th is exposes th e distal u ln a w ith ou t in ter eren ce rom th e exten sor carpi u ln aris ( a ). Pron ation o th e orearm exposes th e u ln ar styloid in th e cen ter o th e approach ( b ).

Fig 1.10 -5a –b

Flexor carpi ulnaris

a

Extensor carpi ulnaris

Extensor carpi ulnaris

b

4

Flexor carpi ulnaris

Wo u n d clo s u re

Th e exten sor retin acu lu m is repaired as n ecessary, an d th e w ou n d is closed in layers.

Vid e o

Th is video dem on strates th e u ln ar approach to th e distal u ln a.

Vid e o 1 .1 0-1

79

Pa rt I Surgical approache s

80

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Pa rt II

Cases

Proximal interphalangeal (PIP) joint

Pa rt II Case s

82

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

2

Carpals

Pa rt II Case s

84

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

2.1

1

Scaphoid—nondisplace d fracture treate d percutane ously with a headle ss compre ssion screw

Ca s e d e s crip t io n

A 26-year-old m an ell on to h is ou tstretch ed righ t h an d du rin g a clu b soccer gam e n otin g im m ediate acu te pain . An exam in ation revealed pain in th e an atom ical sn u box o h is w rist. Th e AP an d lateral x-rays revealed a ractu re lin e across th e w aist o th e scaph oid, h ow ever, carpal align m en t appeared n orm al.

Fig 2.1-1 a –b

a

b

a

b

c

Th e 2-D an d 3-D CT scan s iden ti ed th e ractu re as h avin g m in im al displacem en t bu t goin g th rou gh both cortices o th e scaph oid in th e ron tal an d sagittal plan es (arrow s).

Fig 2.1-2a – c

2

In d ica t io n s

No n d is p la ce d s ca p h o id fra ct u re s

Percu tan eou s (m in im ally in vasive) xation is largely in dicated or n on displaced or m in im ally displaced ractu res o th e w aist o th e scaph oid.

Fig 2 .1-3

85

Pa rt II Case s

2

In d ica t io n s (co n t )

In t e rn a l fixa t io n vs n o n o p e ra t ive t re a t m e n t

Im a gin g

In gen eral, in tern al xation o ractu res is th ou gh t to provide e ective bon e h ealin g in at least th e sam e i n ot less tim e th an n on operative treatm en t, bu t th at th e period o im m obilization is sh orten ed. Percu tan eou s treatm en t brin gs th e advan tages o avoidin g a w ide su rgical approach , preservin g th e palm ar ligam en t com plex an d local vascu larity, an d avoidin g th e exten ded im m obilization requ ired or h ealin g a ter a w ider open exposu re.

With n on displaced an d m in im ally displaced scaph oid ractu res, con ven tion al x-rays o ten do n ot adequ ately dem on strate th e com plete ractu re con gu ration . As sh ow n in th e case description o th is patien t, CT scan s w ere th ere ore per orm ed an d are stron gly recom m en ded i a percu tan eou s procedu re is plan n ed.

Readers o th is pu blication are im m ediately rem in ded th at in som e in stan ces o w rist in ju ry, n on operative treatm en t is a viable altern ative. How ever, th e detailed cases provided th rou gh ou t th is book ou tlin e situ ation s w h ere, or th ose patien ts, su rgical tech n iqu es w ere deem ed th e m ore appropriate treatm en t option .

An a t o m ica l co n s id e ra t io n s

Va s cu la rit y

Dorsal

a

b

c

d

l

l Palmar

e

With all scaph oid ractu res, th e an atom y an d vascu larity o th e scaph oid n eed to be con sidered. Close to 80% o th e su r ace o th e scaph oid is covered w ith articu lar cartilage, w h ich greatly lim its th e poin ts o en try or xation devices. An addition al con strain t is th e cu rved m orph ology o th e scaph oid. Th is m ean s th at it can be di cu lt to pass a w ire or xation device alon g th e tru e lon g axis o th e bon e, yet th is is th e im plan t location th at provides th e greatest stability an d com pression . Occasion ally, access to th e correct distal en try poin t or a device can on ly be gain ed by a lim ited excision o th e overh an gin g edge o th e trapeziu m .

Fig 2.1-4 a – e

a

b

Th e blood su pply o th e scaph oid is derived rom tw o sou rces. Th e m ain sou rce is a grou p o blood vessels en terin g th e dorsal su r ace o th e distal pole ( a ). Th is is th e largest con tribu tion to th e vascu larity o th e scaph oid as th e dorsal grou p su pplies th e proxim al tw o th irds o th e bon e. How ever, th e proxim al pole relies on a retrograde blood f ow , a act th at m akes th is part o th e scaph oid m ore pron e to su er avascu lar bon e n ecrosis an d a con sequ en t n on u n ion .

Fig 2.1-5 a – b

A secon d grou p o vessels en ters th e palm ar aspect o th e distal pole ( b ). Th ese vessels con tribu te largely to th e vascu larity o th e distal th ird.

86

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.1 Scaphoid—nondisplace d fracture tre ate d percutane ously with a he adle ss compre ssion scre w

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.1 m m K-w ires, 150 m m len gth Hypoderm ic n eedle Osteotom e Im age in ten si er

Be ore startin g th e procedu re, re-exam in e th e ractu re pattern u n der an im age in ten si er. Be su re th at th e ractu re is su itable or a percu tan eou s tech n iqu e an d th at n o secon dary displacem en t h as occu rred. Position th e patien t su pin e an d place th e orearm on th e h an d table. By abdu ctin g th e patien t’s sh ou lder it is possible or th e su rgeon an d th e assistan t to sit on eith er side o th e h an d table. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.1-6

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Tw o approach es exist or percu tan eou s screw xation , en terin g eith er palm arly ( a ) or dorsally ( b ) to reach th e scaph oid rom eith er th e distal or proxim al pole. For th e patien t in th is ch apter, th e palm ar approach w as u sed, en terin g th rou gh th e distal pole o th e scaph oid.

Fig 2.1-7 a – b

87

Pa rt II Case s

4

Su rgica l a p p ro a ch (co n t )

Hyp e re xt e n d t h e w ris t

Ma rk t h e s k in

To assist in th e approach , place a rolled tow el or bolster u n der th e w rist an d h yperexten d it. Th e u se o th e su pport h elps access th e correct en try poin t or a gu ide w ire.

Fig 2.1-9

It can be h elp u l to m ark on th e skin th e position o th e scaph oid, th e palm ar rim o th e distal radiu s, an d th e level o th e scaph otrapezial join t.

Fig 2.1-8

Sk in in cis io n

A stab in cision o 5–10 m m is m ade distally to th e scaph otrapezial join t. Deepen th e in cision th rou gh th e su bcu tan eou s tissu es by blu n t dissection th en in cise th e capsu le o th e scaph otrapezial join t. Th e distal pole o th e scaph oid is n ow accessible or in sertion o a K-w ire, w h ich w ill be u sed as a gu ide w ire. 5

Re d u ct io n

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire Palmar ridge of trapezium

a

b

a

Th e correct en try poin t or th e gu ide wire is th e cen ter o th e distal pole o th e scaph oid. However, to get proper access, it m ay be n ecessary to rem ove th e palm ar ridge o th e trapeziu m with an osteotom e or a bon e n ibbler/ ron geu r. Th is reveals th e distal pole o th e scaph oid an d allows th e path o th e gu ide wire to be m ade m ore cen trally with in th e bon e.

Fig 2.1-10a –b

88

b

Use a h ypoderm ic n eedle to determ in e th e in sertion poin t radiologically be ore in sertin g th e gu ide w ire.

Fig 2.1-1 1a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.1 Scaphoid—nondisplace d fracture tre ate d percutane ously with a he adle ss compre ssion scre w

5

Re d u ct io n (co n t )

In s e r t t h e gu id e w ire

Th e gu ide w ire sh ou ld be in serted th rou gh a drill gu ide ( a ). I n o drill gu ide is available, u se a protective sleeve. Th e position o th e w ire sh ou ld be as perpen dicu lar as possible to th e ractu re lin e ( b – c ). In obliqu e ractu res, th is prin ciple m ay h ave to be com prom ised. Do n ot pen etrate beyon d th e proxim al cortex o th e scaph oid.

Fig 2 .1 -12 a – c

a

a Fig 2.1-1 3a –c

b

c

b

c

Th e gu ide w ire w as in serted at th e con rm ed en try poin t.

89

Pa rt II Case s

6

Fixa t io n

Me a s u re s cre w le n g t h

Drillin g

x

x a

b

x minus 2-3mm

Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedicated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle or a reliable m easu rem en t ( a ). Altern atively, i th e dedicated m easu rin g device is n ot available, take an oth er gu ide w ire o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( b ). Th e di eren ce betw een th e protru din g en ds o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .

Use on ly th e dedicated drill bit. A pow er drill w ill exert less orce on th e ragm en ts th an m an u al drillin g an d w ill redu ce th e risk o displacin g th e ragm en ts. A sm all pow er drill w ith slow rotation is th e pre erred ch oice. Use salin e solu tion to cool th e drill bit in order to m in im ize th erm al in ju ry. Ch eck th e position o th e tip o th e drill bit u n der im age in ten si cation .

Fig 2.1-1 4a –b

Fig 2.1-1 5

Se le ct t h e s cre w

b

a

c

d

Select th e appropriately sized can n u lated (ie, h ollow ) h eadless com pression screw ( a –c ). Th e selected screw is in serted in to th e in tern al th read o th e com pression sleeve ( d ).

Fig 2.1-1 6a –d

90

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.1 Scaphoid—nondisplace d fracture tre ate d percutane ously with a he adle ss compre ssion scre w

6

Fixa t io n (co n t )

In s e r t t h e s cre w

Th e screw an d com pression sleeve are in serted over th e gu ide w ire.

Fig 2.1-1 7

a

a

b

c

Th e screw is tigh ten ed u n til su com pression is ach ieved.

Fig 2.1-1 8a –c

cien t

b

Th e can n u lated screw driver is in serted. Th e com pression sleeve is h eld still, u sin g th e th u m b an d in dex n ger to rm ly h old th e com pression sleeve, as th e screw driver tu rn s th e screw an d advan ces it ou t o th e com pression sleeve an d in to th e bon e. Com pression is m ain tain ed by th e com pression sleeve du rin g th is action .

Fig 2.1-1 9a –b

91

Pa rt II Case s

6

Fixa t io n (co n t )

Ad va n ce a n d co u n t e rs in k t h e s cre w

a

b

En s u re co rre ct s cre w a n d t h re a d le n g t h

c

Th e screwdriver h as th ree colored m arkin gs th at are visible at th e edge o th e com pression sleeve. Th e green m ark in dicates th e screw is still u lly retain ed with in th e com pression sleeve ( a ). Th e yellow m ark in dicates th e screw h as been advan ced level with th e su r ace o th e bon e ( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k 2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g th e com pression sleeve station ary.

Fig 2.1-20a –c

a

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.1-2 1a –b

Co m p le t e t h e fixa t io n

a

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.1-2 2

92

b

In traoperative im ages o th e patien t sh ow th e placem en t o th e h eadless screw in lin e w ith th e lon gitu din al axis o th e scaph oid w ith th e screw crossin g th e ractu re lin e.

Fig 2.1-2 3a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.1 Scaphoid—nondisplace d fracture tre ate d percutane ously with a he adle ss compre ssion scre w

7

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 2.1-2 4

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

Followin g su rgery, begin active con trolled ran ge o m otion exercises. Active m otion exercises an d later resistan ce exercises sh ou ld be in itiated based u pon th e su rgeon ’s decision as to tim e a ter su rgery an d patien t com plian ce. Load-bearin g activities are u su ally delayed u n til radiological eviden ce o bon e h ealin g. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist.

Fig 2.1-26

Rest th e w rist w ith a w ell-padded below -elbow splin t or 48–72 h ou rs. For am bu latin g patien ts, dispen se w ith th e splin t an d apply an elastic ban dage. I n ecessary, pu t th e arm in a slin g an d elevate to above th e h eart.

Fig 2.1-2 5

93

Pa rt II Case s

8

Ou t co m e

At th e 1-year ollow -u p, th e AP an d lateral x-rays in dicated excellen t h ealin g.

Fig 2 .1-2 7a –b

a

a Fig 2.1-2 8a –d

b

b

d

c

Th ere w as u ll clin ical m otion an d retu rn o n orm al stren gth .

Vid e o

Th is video dem on strates a scaph oid ractu re procedu re treated w ith percu tan eou s xation w ith a 3.0 m m h eadless com pression screw .

Vid e o 2 .1 -1

94

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.2

1

Scaphoid—displaced fracture treated with a headless compression screw

Ca s e d e s crip t io n

A 38-year-old con stru ction w orker in ju red h is dom in an t le t w rist w h en h e ell rom a 3 m plat orm at w ork. Th e in itial x-rays con rm ed an u n stable displaced ractu re o th e w aist o th e scaph oid.

Fig 2.2-1a – b

a

2

b

In d ica t io n s

Dis p la ce d s ca p h o id fra ct u re s

Ch o ice o f im p la n t

a

b

Acu te scaph oid ractu res are con sidered to be displaced wh en th ere is a 1 m m gap between th e ragm en ts on an y sin gle view . Displacem en t in an acu te ractu re in creases th e risks o n on u n ion i th e in ju ry is m an aged n on operatively in a cast. Con sequ en tly, con sideration m u st be given to redu ction an d stabilization by in tern al xation .

A 2.4 m m or 3.0 m m im plan t u sin g retrograde in sertion (distal en try poin t) is in dicated or scaph oid waist ractu res or w h en th e proxim al ragm en t is larger th an 10 m m ( a ). For sm aller proxim al ragm en ts, th e u se o an an tegrade in sertion (proxim al en try poin t) w ith sin gle or m u ltiple m in i h eadless bon e screw s (1.5 m m ) is advisable ( b ). As th is patien t h ad a scaph oid w aist ractu re, a palm ar retrograde in sertion w as requ ired.

An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s

Im a gin g

Th e scaph oid’s u n iqu e an atom y an d vascu larity m u st also be con sidered. Re er to th e in dication s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly w ith a percu tan eou s screw or m ore in orm ation .

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g.

Fig 2.2-3a –b Fig 2.2-2

95

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.1 m m K-w ires Osteotom e Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Su pin ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.2-4

4

Su rgica l a p p ro a ch

Ap p ro a ch

Hyp e re xt e n d t h e w ris t

In cases w h ere redu ction can n ot be ach ieved closed, a direct open approach is n ecessary. Th e su rgical approach u sed or th is patien t w as a palm ar approach in volvin g a radial lon gitu din al an gled skin in cision (see ch apter 1.1 Palm ar approach to th e scaph oid).

Fig 2.2-6

Fig 2.2-5

96

To assist in th e approach , place a rolled tow el or bolster u n der th e w rist an d h yperexten d it. Th e u se o th e su pport h elps access th e correct en try poin t or a gu ide w ire. Th is position also h elps to redu ce th e scaph oid ragm en ts.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.2 Scaphoid—displace d fracture tre ate d with a he adle ss compre ssion scre w

5

Re d u ct io n

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

In s e r t t h e gu id e w ire

Palmar ridge of trapezium

a

Th e correct en try poin t or th e gu ide w ire is th e cen ter o th e distal pole o th e scaph oid. How ever, to get proper access, it m ay be n ecessary to rem ove th e palm ar ridge o th e trapeziu m w ith an osteotom e or a bon e n ibbler/ ron geu r. Th is reveals th e distal pole o th e scaph oid an d allow s th e path o th e gu ide w ire to be m ade m ore cen trally w ith in th e bon e.

Fig 2.2-7

b

Th e gu ide wire sh ou ld be in serted th rou gh a drill gu ide ( a ). I n o drill gu ide is available, u se a protective sleeve. Th e position o th e wire sh ou ld be as perpen dicu lar as possible to th e ractu re lin e ( b ). In obliqu e ractu res, th is prin ciple m ay h ave to be com prom ised. Do n ot pen etrate beyon d th e proxim al cortex o th e scaph oid.

Fig 2.2-8a –b

A secon d K-w ire is u se u l to preven t rotation o th e ragm en ts as com pression is ach ieved. Th e secon d K-w ire sh ou ld be rem oved be ore n al tigh ten in g o th e screw . Im age in ten si cation in at least tw o plan es is u sed to con rm accu rate advan cem en t o th e gu ide w ire in th e scaph oid axis an d perpen dicu lar to th e ractu re plan e. Redu ction can o ten be ach ieved by com pression alon e as th e can n u lated screw is care u lly in serted.

Fig 2.2-9 a –b

a

b

97

Pa rt II Case s

6

Fixa t io n

Me a s u re s cre w le n g t h

x

x

a

b

x minus 2–3 mm

c

Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedicated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle or a reliable m easu rem en t ( a ) (as sh ow n on th e patien t) ( b ). Altern atively, i th e dedicated m easu rin g device is n ot available, take an oth er gu ide w ire o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( c ). Th e di eren ce betw een th e protru din g en ds o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .

Fig 2.2-10a –c

Drillin g

Se le ct t h e s cre w

a

Use on ly th e dedicated drill bit. A pow er drill w ill exert less orce on th e ragm en ts th an m an u al drillin g an d w ill redu ce th e risk o displacin g th e ragm en ts. A sm all pow er drill w ith slow rotation is th e pre erred ch oice. Use salin e solu tion to cool th e drill bit in order to m in im ize th erm al in ju ry. Ch eck th e position o th e tip o th e drill bit u n der im age in ten si cation .

Fig 2.2-1 1

98

b

Select th e appropriately sized can n u lated h eadless com pression screw ( a ). Th e selected screw is in serted in to th e in tern al th read o th e com pression sleeve ( b ).

Fig 2.2-1 2a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.2 Scaphoid—displace d fracture tre ate d with a he adle ss compre ssion scre w

6

Fixa t io n (co n t )

In s e r t t h e s cre w

a

b

a

Th e screw an d com pression sleeve are in serted over th e gu ide w ire.

Fig 2.2-1 3a –b

a

b

b

c

Th e screw is tigh ten ed u n til su com pression is ach ieved.

Fig 2.2-1 4a –c

cien t

c

Th e can n u lated screw driver is in serted. Th e com pression sleeve is h eld still, u sin g th e th u m b an d in dex n ger to rm ly h old th e com pression sleeve, as th e screw driver tu rn s th e screw an d advan ces it ou t o th e com pression sleeve an d in to th e bon e. Com pression is m ain tain ed by th e com pression sleeve du rin g th is action .

Fig 2.2-1 5a –c

99

Pa rt II Case s

6

Fixa t io n (co n t )

Ad va n ce a n d co u n t e rs in k t h e s cre w

a

b

En s u re co rre ct s cre w a n d t h re a d le n g t h

c

Th e screwdriver h as th ree colored m arkin gs th at are visible at th e edge o th e com pression sleeve. Th e green m ark in dicates th e screw is still u lly retain ed with in th e com pression sleeve ( a ). Th e yellow m ark in dicates th e screw h as been advan ced level with th e su r ace o th e bon e ( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k 2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g th e com pression sleeve station ary.

Fig 2.2-16a –c

a

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.2-1 7a –b

Co m p le t e t h e fixa t io n

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.2-1 8

100

Th e in traoperative x-ray con rm ed correct position in g o th e im plan t togeth er w ith redu ction o th e u n stable ractu re.

Fig 2.2-1 9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.2 Scaphoid—displace d fracture tre ate d with a he adle ss compre ssion scre w

7

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 2.2-2 0

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

Follow in g su rgery, begin active con trolled ran ge o m otion exercises. Active m otion exercises an d later resistan ce exercises sh ou ld be in itiated based u pon th e su rgeon ’s decision as to tim e a ter su rgery an d patien t com plian ce. Load-bearin g activities are u su ally delayed u n til radiological eviden ce o bon e h ealin g. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist.

Fig 2.2-2 2

Th e type an d du ration o postoperative im m obilization depen ds on a n u m ber o actors in clu din g th e qu ality o th e in tern al xation as w ell as patien t activity an d reliability. It m ay be n ecessary to rest th e w rist or several w eeks in a plaster or rem ovable splin t. Du rin g th at tim e, th e patien t is en cou raged to rem ove th e splin t or sh ort periods to allow gen tle w rist m otion .

Fig 2.2-2 1

101

Pa rt II Case s

8

Ou t co m e

a

b

At th e 14-m on th ollow -u p, th e x-rays con rm ed h ealin g.

Fig 2.2-2 3a –b

a

b

c

d

Fig 2.2-2 4a –d

102

Th e patien t h ad ach ieved a u ll ran ge o m otion .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.3

1

Scaphoid—multifragmentary fracture treated with a headless compression screw and lag screw

Ca s e d e s crip t io n

A 29-year-old teach er w as in volved in a h igh -speed collision on h is m otorcycle. He in ju red h is righ t dom in an t w rist. Th e x-rays con rm ed a displaced m u lti ragm en tary ractu re o th e scaph oid.

Fig 2.3-1a – b

a

2

b

In d ica t io n s

Mu lt ifra gm e n t a r y s ca p h o id fra ct u re s

Ch o ice o f im p la n t

Acu te displaced an d m u lti ragm en tary scaph oid ractu res are o ten th e resu lt o h igh -en ergy im pact. Th ey are u n stable ractu res an d th ere is a stron g possibility o later displacem en t even i th ey do n ot appear displaced on prim ary presen tation . Th ese in ju ries are at a h igh risk o n on u n ion i th e in ju ry is m an aged n on operatively in a cast. Con sequ en tly, con sideration m u st be given to open redu ction an d stabilization by in tern al xation .

Fig 2.3-3

Fig 2.3-2

In m u lti ragm en tary ractu res, a 2.4 m m or 3.0 m m im plan t is in dicated or stabilization o th e large ragm en ts. For th e sm aller addition al ragm en ts, th e u se o m in i h eadless bon e screws or sm all cortical lag screws is advisable. K-wires are always an option i th e in trodu ction o an im plan t proves di cu lt. For th is patien t, a com bin ation o a h eadless com pression screw an d a lag screw was requ ired.

A system atic approach to th e stabilization o each o th e large ragm en ts m ay be requ ired. Wh en th e ragm en ts are too sm all or in dividu al stabilization , con sideration sh ou ld be given to excision o th ese ragm en ts an d replacem en t by prim ary bon e gra t. 103

Pa rt II Case s

2

In d ica t io n s (co n t )

An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s

Im a gin g

Th e scaph oid’s u n iqu e an atom y an d vascu larity m u st also be con sidered. Re er to th e in dication s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly w ith a h eadless com pression screw or m ore in orm ation .

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g.

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 Modu lar screw set 1.5 or 2.0 1.1 m m K-w ires Poin ted redu ction orceps Osteotom e Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. In m u lti ragm en tary ractu res, a dorsal an tegrade or palm ar retrograde approach can be u sed, depen din g on ractu re con gu ration . Pron ate th e orearm on th e h an d table or a dorsal approach . In u n u su al circu m stan ces, a com bin ed dorsal an d palm ar approach m ay be requ ired. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.3-4

104

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.3 Scaphoid—multifragmentary fracture tre ate d with a he adle ss com pre ssion scre w and lag scre w

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a dorsal approach du e to th e particu lar ractu re con gu ration (see ch apter 1.2 Dorsal approach to th e scaph oid).

Fig 2.3-5

a

b

For th is patien t, a lon gitu din al dorsoradial skin in cision was m ade, startin g over th e distal radiu s, an d exten din g toward th e base o th e th u m b passin g arou n d th e dorsal aspect o th e scaph oid.

Fig 2.3-6a –b

105

Pa rt II Case s

5

Re d u ct io n

Dire ct re d u ct io n

In s e r t K-w ire s

Fig 2.3-7

With m u lti ragm en tary scaph oid ractu res, it is o ten di cu lt to ach ieve closed redu ction . I open redu ction is requ ired, redu ce th e ractu re w ith sm all poin ted redu ction orceps.

Fig 2.3-8

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

In s e r t t h e gu id e w ire

Th e correct en try poin t or th e gu ide w ire is in th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion .

Fig 2.3-1 0

Fig 2.3-9

I th e ractu re can n ot be redu ced w ith th e orceps, in sert a K-w ire in to each ragm en t an d u se th e w ires as joysticks to m an ipu late th e ragm en ts.

Th e gu ide w ire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g th e in trodu ction o th e gu ide w ire, th e w rist sh ou ld be in f exion oth erw ise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph otrapezial join t w ith th e gu ide w ire. In m u lti ragm en tary ractu res, th e gu ide w ire also h elps to m ain tain th e redu ction . Im age in ten si cation in at least tw o plan es is requ ired to con rm accu rate advan cem en t o th e gu ide w ire in th e scaph oid axis an d to m ake su re th at th ere is n o rotation al de orm ity.

106

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.3 Scaphoid—multifragmentary fracture tre ate d with a he adle ss com pre ssion scre w and lag scre w

6

Fixa t io n

In s e r t la g s cre w

Us e o f la g s cre w s

a

Mu lti ragm en tary ractu res in volvin g th e proxim al h al o th e scaph oid can n ot be xed w ith a h eadless screw alon e. Addition al K-w ires, or as in th is case an addition al lag screw , sh ou ld be con sidered.

Fig 2.3-1 1

A 1.5 m m lag screw is rst placed in to th e scaph oid to m ake th e 3-part ractu re in to 2 parts. Th e com m in u ted ragm en t is directly secu red to th e body o th e scaph oid.

b

Be su re to in sert th e screw as a lag screw , w ith a glidin g h ole in th e n ear cortex, an d a th readed h ole in th e ar cortex ( a ). In sertin g a screw across a ractu re plan e th at is th readed in both cortices (position screw ) w ill h old th e ragm en ts apart an d apply n o in ter ragm en tary com pression ( b ).

Fig 2.3-1 2a –b

Co u n t e rs in k in g

a

b

Also en su re to cou n tersin k th e screw to redu ce th e risk o so t-tissu e irritation , so th at th e screw h ead h as m axim al con tact area with th e bon e.

Fig 2.3-13a –b

107

Pa rt II Case s

6

Fixa t io n (co n t )

Me a s u re s cre w le n g t h

a

b

x minus 2–3 mm

Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedicated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle or a reliable m easu rem en t ( a ). Altern atively, i th e dedicated m easu rin g device is n ot available, take an oth er gu ide w ire o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( b ). Th e di eren ce betw een th e protru din g en ds o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .

Fig 2 .3 -1 4a –b

Drillin g

Use on ly th e dedicated drill bit. A pow er drill w ill exert less orce on th e ragm en ts th an m an u al drillin g an d w ill redu ce th e risk o displacin g th e ragm en ts. A sm all pow er drill w ith slow rotation is th e pre erred ch oice. Use salin e solu tion to cool th e drill bit in order to m in im ize th erm al in ju ry. Ch eck th e position o th e tip o th e drill bit u n der im age in ten si cation .

Fig 2.3-1 5

108

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.3 Scaphoid—multifragmentary fracture tre ate d with a he adle ss com pre ssion scre w and lag scre w

6

Fixa t io n (co n t )

Se le ct a n d in s e r t t h e s cre w

a

b

En s u re co rre ct s cre w a n d t h re a d le n g t h

a

b

Fig 2.3-1 6a –b

Select th e appropriately sized can n u lated h eadless compression screw. In sert th e screw over th e gu ide wire. However, as th is is a m u lti ragm en tary ractu re, stron g com pression / overcom pression with th e screw is n ot recom m en ded becau se o th e possibility o collapse o th e ractu re. In stead o a com pression screw, a position screw is recom m en ded in th is situ ation , alth ou gh by virtu e o th e di eren tial pitch o th e th reads on th e screw, th ere will be som e com pression regardless. On e o th e advan tages o th ese h eadless screws is th at th ey can be in serted with ou t th e com pression sleeve, h elpin g to avoid th e possible com plication o u n stable ractu re collapse.

Fig 2.3-1 7a –b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Ad va n ce t h e s cre w

Co m p le t e t h e fixa t io n

Th e proxim al en d o th e screw sh ou ld be advan ced u n til it is bu ried ben eath th e su bch on dral bon e.

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

109

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .

Fig 2.3-18

8

Ou t co m e

a Fig 2.3-19a –c

a Fig 2.3-2 0a –b

110

b

c

At th e 2-year ollow-u p, PA, obliqu e, an d lateral x-rays con rm ed u ll h ealin g.

b

Th e patien t h ad n early u ll ran ge o w rist exten sion an d f exion .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.4

1

Scaphoid, proximal pole —fracture treated with a headless compression screw

Ca s e d e s crip t io n

a

b

c

A 20-year-old u n iversity stu den t w as seen in th e em ergen cy departm en t ollow in g a all on to h is ou tstretch ed righ t h an d. Th e m an su ered w rist pain , w h ich w as elicited by th e f exion o th e w rist, du rin g palpation over th e sn u box, an d w h en axial com pression w as applied to th e th u m b. Th e in itial PA x-ray sh ow ed a tin y ractu re o th e proxim al pole o th e scaph oid. Addition al CT scan s w ere per orm ed in th e tru e lon gitu din al axis o th e scaph oid in th e coron al an d sagittal plan e, w h ich also in dicated th e proxim al pole ractu re. Th e sagittal view sh ow ed th at th e ragm en t w as n ot as sm all as w as su spected w ith th e x-ray.

Fig 2.4-1a – c

2

In d ica t io n s

Pro xim a l p o le fra ct u re s

Scaph oid ractu res are th e m ost com m on carpal ractu res an d approxim ately 10–20% o th ese in volve th e proxim al pole. Th e proxim al pole relies largely on a retrograde blood f ow , so th e bon e relies on distal to proxim al in traosseou s blood su pply or h ealin g. Th is m akes proxim al pole ractu res h igh ly pron e to avascu lar bon e n ecrosis, delayed u n ion , an d n on u n ion . Non operative treatm en t requ ires a prolon ged period o im m obilization o 3–6 m on th s. Th ere ore, operative treatm en t via a dorsal approach sh ou ld be con sidered.

Fig 2.4-2

111

Pa rt II Case s

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s

Th e scaph oid’s u n iqu e an atom y an d vascu larity are critically im portan t in cases in volvin g th e proxim al pole. Re er to th e in dication s topic in ch apter 2.1 Scaph oid— n on displaced ractu re treated percu tan eou sly w ith a h eadless com pression screw or m ore in orm ation .

Im a gin g a

b

c

For proxim al pole ractu res, i th e proxim al ragm en t is large en ou gh , a 2.4 m m or 3.0 m m im plan t u sin g an tegrade in sertion is advisable ( a ). For sm aller proxim al ragm en ts, sin gle or m u ltiple m in i h eadless bon e screws (1.5 m m ) can be u sed ( b ). For very sm all ragm en ts (f akes), K-wires m ay be a better option ( c). For th is patien t, a h eadless com pression screw u sin g an an tegrade in sertion was requ ired.

Fig 2.4-3a –c

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g. Addition al CT scan s in th e tru e lon gitu din al axis o th e scaph oid are h elp u l to iden ti y de orm ity.

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.1 m m K-w ires Poin ted redu ction orceps Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.4-4

112

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.2 Dorsal approach to th e scaph oid).

Fig 2.4-5

5

Re d u ct io n

Dire ct re d u ct io n

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

Use sm all poin ted redu ction orceps to redu ce th e ractu re.

Fig 2.4-7

Fig 2.4-6

Th e correct en try poin t or th e gu ide w ire is in th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion .

113

Pa rt II Case s

5

Re d u ct io n (co n t )

In s e r t t h e gu id e w ire

a

b

Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction ( a ). Du rin g th e in trodu ction o th e gu ide wire, th e wrist sh ou ld be in f exion oth erwise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph otrapezial join t with th e gu ide wire. Th e gu ide wire was care u lly in serted across th e patien t’s ractu re ( b ).

Fig 2.4-8a –b

a

b

Im age in ten si cation in at least two plan es was u sed to con rm accu rate advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e ractu re plan e.

Fig 2.4-9a –b

114

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w

6

Fixa t io n

Me a s u re s cre w le n g t h

a

b

x minus 2–3 mm

Tw o m eth ods can be em ployed or m easu rin g th e desired len gth o th e h eadless screw . In sert th e dedicated m easu rin g device over th e gu ide w ire, th rou gh th e drill gu ide, w h ich m u st be rm ly position ed on th e tu bercle or a reliable m easu rem en t (as sh ow n on th e patien t) ( a ). Altern atively, i th e dedicated m easu rin g device is n ot available, take an oth er gu ide w ire o th e sam e len gth an d place its tip on to th e bon e at th e in sertion poin t ( b ). Th e di eren ce betw een th e protru din g en ds o th e tw o w ires in dicates th e len gth o th e drill h ole or th e screw . Su btract 2–3 m m to determ in e th e screw len gth .

Fig 2.4-1 0a –b

Drillin g

a

b

Use on ly th e dedicated drill bit. A pow er drill w ill exert less orce on th e ragm en ts th an m an u al drillin g an d w ill redu ce th e risk o displacin g th e ragm en ts. A sm all pow er drill w ith slow rotation is th e pre erred ch oice ( a ). Use salin e solu tion to cool th e drill bit in order to m in im ize th erm al in ju ry. Ch eck th e position o th e tip o th e drill bit u n der im age in ten si cation . In traoperative im age o drillin g in to th e a ected scaph oid ( b ).

Fig 2.4-1 1a –b

115

Pa rt II Case s

6

Fixa t io n (co n t )

Se le ct t h e s cre w

a

b

Select th e appropriately sized can n u lated h eadless com pression screw . Th e selected screw is in serted in to th e in tern al th read o th e com pression sleeve.

Fig 2.4-1 2a –b

In s e r t t h e s cre w

a

b

Th e screw an d com pression sleeve are in serted over th e gu ide w ire ( a ), as sh ow n in th e in traoperative im age ( b ).

Fig 2.4-1 3a –b

116

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w

6

Fixa t io n (co n t )

a

b

c

Th e screw is tigh ten ed u n til su com pression is ach ieved.

Fig 2.4-1 4a –c

a

cien t

b

Th e can n u lated screw driver is in serted. Th e com pression sleeve is h eld still, u sin g th e th u m b an d in dex n ger to rm ly h old th e com pression sleeve, as th e screw driver tu rn s th e screw an d advan ces it ou t o th e com pression sleeve an d in to th e bon e. Com pression is m ain tain ed by th e com pression sleeve du rin g th is action .

Fig 2.4-1 5a –b

117

Pa rt II Case s

6

Fixa t io n (co n t )

Ad va n ce a n d co u n t e rs in k t h e s cre w

a

b

En s u re co rre ct s cre w a n d t h re a d le n g t h

c

a

Th e screwdriver h as th ree colored m arkin gs th at are visible at th e edge o th e com pression sleeve. Th e green m ark in dicates th e screw is still u lly retain ed with in th e com pression sleeve ( a ). Th e yellow m ark in dicates th e screw h as been advan ced level with th e su r ace o th e bon e ( b ). Th e red m ark in dicates th e screw h as been cou n tersu n k 2 mm u n der th e bon e su r ace ( c). Cou n tersin k th e screw by tu rn in g th e screwdriver sh a t wh ile sim u ltan eou sly h oldin g th e com pression sleeve station ary.

Fig 2.4-16a –c

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.4-1 7a –b

Co m p le t e t h e fixa t io n

a

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.4-1 8

118

b

In traoperative im ages sh ow ed th ere w as correct position in g o th e screw .

Fig 2.4-1 9a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .

Fig 2.4-20

8

Ou t co m e

a

a

b

At th e 6-m on th ollow -u p ollow in g th e in itial trau m a, th e PA an d lateral x-rays sh ow ed com plete h ealin g o th e ractu re.

Fig 2.4-2 1a –b

b

Th ere w as restored ran ge o m otion an d an excellen t u n ction al ou tcom e.

Fig 2.4-2 2a –b

119

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

Us in g a n a d d it io n a l gu id e w ire

a

b

Th e torqu e orces o th e screw on den se bon e in you n g patien ts are h igh th at an addition al gu ide w ire m ay be requ ired. Th is w as so or a 17-year-old em ale sch ool stu den t su stain in g a ractu re to th e proxim al pole o h er scaph oid a ter a all over h er ou tstretch ed h an d du rin g sportin g activities.

Fig 2.4-2 3a –b

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n In s e r t t h e gu id e w ire s

a

b

In order to avoid u n desirable rotation o th e distal ragm en t o th e scaph oid du rin g screw tigh ten in g, in stead o on e gu ide w ire, tw o parallel gu ides w ere u sed. Im age in ten si cation in at least tw o plan es is recom m en ded to con rm th e accu rate location o both gu ide w ires in th e scaph oid.

Fig 2.4-2 4a –b

120

a

b

On ce th e location o th e gu ides h as been ch ecked, drillin g is per orm ed, ollow ed by th e in sertion o th e screw . In cases o m u lti ragm en tation rom th e proxim al th ird to th e scaph oid w aist, th e addition al gu ide can be le t in place to rein orce th e xation .

Fig 2.4-2 5a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.4 Scaphoid, proximal pole —fracture tre ate d with a he adle ss compre ssion scre w

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Ou t co m e

a

b

a

Con rm th e position o th e screw u sin g im age in ten si cation . Note th at a u lly th readed screw w as actu ally u sed in th is case, h ow ever, th e prin ciples an d tech n iqu es rem ain th e sam e.

Fig 2.4-2 6a –b

a

b

c

d

Fig 2.4-2 8a –e

b

Th e x-rays sh ow ed com plete ractu re h ealin g 1 year a ter th e in itial trau m a.

Fig 2.4-2 7a –b

e

Im portan tly or th is you n g aspirin g ath lete, th ere w as an excellen t u n ction al ou tcom e.

121

Pa rt II Case s

122

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.5

1

Scaphoid, proximal pole—nonunion treated with a headless compression screw and bone graft

Ca s e d e s crip t io n

A 21-year-old m ale stu den t presen ted w ith w rist pain , sw ellin g, an d lim itation o m otion h avin g h ad a all on to an ou tstretch ed righ t h an d som e tim e earlier. Th e redu ced ran ge o m otion in volved f exion o 15 degrees, exten sion o 40 degrees, w ith pron ation an d su pin ation n orm al. Pain w as elicited by f exion o th e w rist, du rin g palpation over th e sn u box, an d w h en axial com pression w as applied to th e th u m b. Th e PA an d lateral x-rays dem on strated a well-de n ed n on u n ion .

Fig 2.5-1a –b

a

b

Th e im ages also dem on strated sclerosis (h arden in g) o th e proxim al pole o th e scaph oid, su ggestin g avascu larity, bu t th ere w ere n o m ajor ch an ges to th e sh ape o th e bon e an d n o su bstan tial bon e resorption w as eviden t.

Fig 2.5-2

Th e CT scan sh ow ed a n on u n ion w ith a den se proxim al pole. Th e CT scan s w ere per orm ed in th e tru e lon gitu din al axis o th e scaph oid an d in dicated n on u n ion with m u ltiple cysts located proxim al to th e dorsal apex ridge, w ith m in or dorsal displacem en t o th e distal portion o th e scaph oid. No collapse w as eviden t an d th e in trascaph oid an gle w as 35 degrees.

Fig 2.5-3

123

Pa rt II Case s

2

In d ica t io n s

Pro xim a l p o le n o n u n io n

Th ere are variou s reason s w h y a ractu re can ail to h eal, su ch as late diagn osis, in adequ ate im m obilization , or severity o trau m a. Scaph oid ractu res su er a h igh rate o n on u n ion an d th e poor vascu larity o th e scaph oid is o ten to blam e (re er to th e in dication s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly w ith a h eadless com pression screw ). Th ere are oth er actors th at can also in f u en ce th e rate o scaph oid u n ion , su ch as th e trem en dou s orces o f exion an d exten sion th at act over th is bon e, an d th e act th at approxim ately 80% o th e scaph oid su r ace is covered w ith cartilage an d bath ed in syn ovial f u id, resu ltin g in bon e h ealin g by direct h ealin g w ith ou t callu s orm ation .

Fig 2.5-4

Proxim al pole ractu res rely largely on a distal to proxim al in traosseou s blood f ow an d are th ere ore especially pron e to delayed u n ion an d n on u n ion . A n on u n ion will resu lt in osteoarth ritis o th e wrist (also kn own as arth ritis). Non operative treatm en t o acu te proxim al pole ractu res requ ires a prolon ged period o im m obilization (3–6 m on th s), th ere ore operative treatm en t is recom m en ded at an early stage.

Go a ls o f s u rgica l t re a t m e n t o f a s ca p h o id n o n u n io n

Ch o ice o f im p la n t

Th e ollow in g are th e m ain goals or th e su rgical treatm en t o scaph oid n on u n ion s: • To restore an atom y (m orph ology an d scaph oid len gth ) • To obtain h ealin g • To stop progression o carpal in stability • To redu ce progression o osteoarth ritis. a

b

c

For proxim al pole n on u n ion s, i th e proxim al ragm en t is large en ou gh , a 2.4 m m or 3.0 m m im plan t u sin g an tegrade in sertion is advisable ( a ). For sm aller proxim al ragm en ts, sin gle or m u ltiple m in i h eadless bon e screw s (1.5 m m ) can be u sed ( b ). For very sm all ragm en ts (f akes), K-w ires m ay be a better option ( c ). For th is patien t, a h eadless com pression screw com bin ed w ith bon e gra tin g w as requ ired.

Fig 2.5-5 a – c

Im a gin g

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g. Also, CT scan s in th e tru e lon gitu din al axis o th e scaph oid are h elp u l in order to iden ti y de orm ity.

124

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.5 Scaphoid, proximal pole —nonunion tre ate d with a he adle ss com pre ssion scre w and bone graft

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.1 m m K-w ires Poin ted redu ction orceps Au togen ou s bon e gra t equ ipm en t Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.5-6

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.2 Dorsal approach to th e scaph oid).

Fig 2.5-7

Th rou gh a sm all dorsal approach an d dorsal capsu lotom y, th e n on u n ion was iden ti ed. Min im al bon e resorption an d m in im al ractu re sclerosis were n oted. Th e brou s tissu e in terposed in th e n on u n ion area was rem oved u sin g a sm all cu rette u n til h ealth y bon e was ou n d on both sides. Care was taken to en su re th e extern al sh ape o th e scaph oid was n ot ch an ged sign i can tly to m ain tain n orm al carpal kin em atics.

Fig 2.5-8

125

Pa rt II Case s

5

Re d u ct io n

Dire ct re d u ct io n

Bo n e gra ft

Lister tubercle

Use sm all poin ted redu ction orceps to redu ce th e n on u n ion .

Harvest th e gra t m aterial rom th e distal radiu s. A good an d sa e place is proxim al an d sligh tly radial to Lister tu bercle.

Fig 2.5-9

Fig 2.5-1 0

Ha r ve s t in g

2 cm

Make a 2 cm lon gitu din al in cision proxim al to Lister tu bercle. Retract th e ten don s o th e secon d com partm en t radially, an d th e exten sor pollicis lon gu s in an u ln ar direction .

Fig 2.5-1 1

126

Use a ch isel to cu t th ree sides o a sm all squ are. Li t th e dorsal radial cortex as a f ap. A ter h arvestin g can cellou s bon e, replace th e “lid”, an d su tu re th e periosteu m an d th e skin in cision . Use a pu sh er in stru m en t to im pact th e bon e gra t.

Fig 2 .5 -1 2

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.5 Scaphoid, proximal pole —nonunion tre ate d with a he adle ss com pre ssion scre w and bone graft

5

Re d u ct io n (co n t ) De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

Can cellou s bon e gra t taken rom th e distal radiu s w as in terposed in th e n on u n ion area.

Fig 2.5-1 3

Th e correct en try poin t or th e gu ide w ire is in th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion .

Fig 2.5-1 4

In s e r t t h e gu id e w ire

Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g th e in trodu ction o th e gu ide wire, th e wrist sh ou ld be in f exion oth erwise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph otrapezial join t with th e gu ide wire.

Fig 2.5-15

Vascu larity w as evalu ated an d ou n d to be adequ ate th rou gh direct observation o th e bleedin g spots on th e proxim al pole. Wh ile m on itorin g w ith th e im age in ten si er, th e gu ide w ire w as advan ced th rou gh th e drill gu ide rom proxim al to distal in to th e bon e u n til th e tip w as an ch ored in th e ar cortex.

Fig 2.5-1 6

Im age in ten si cation in at least tw o plan es sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide w ire in th e scaph oid axis an d perpen dicu lar to th e n on u n ion .

127

Pa rt II Case s

6

Fixa t io n

Sca p h o id fixa t io n

a

b

c

A ter m easu rin g an d drillin g, th e h eadless com pression screw w as settled on th e com pression sleeve, placed th rou gh th e drill gu ide, an d care u lly tigh ten ed u n til com pression o th e n on u n ion w as ach ieved. Force u l tigh ten in g w as avoided as th is cou ld cau se strippin g o th e sh a t th read. Predrillin g m ade it su bstan tially easier to in sert th e screw in to den se bon e.

Fig 2.5-1 7a –c

Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated w ith a h eadless com pression screw .

En s u re co rre ct s cre w a n d t h re a d le n g t h

a

Co m p le t e t h e fixa t io n

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.5-1 8a –b

128

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.5-1 9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.5 Scaphoid, proximal pole —nonunion tre ate d with a he adle ss com pre ssion scre w and bone graft

6

Fixa t io n (co n t )

Th rou gh direct vision , it w as con rm ed th at per ect redu ction w as ach ieved an d th at th e screw h ad been su n k ben eath th e articu lar cartilage.

Fig 2.5-2 0

a

b

With th e h elp o th e im age in ten si er th e correct location o th e screw w as con rm ed.

Fig 2.5-2 1a –b

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .

Fig 2.5-22

129

Pa rt II Case s

8

Ou t co m e

a

a

b

b

At th e 6-m on th ollow -u p th e postoperative x-rays sh ow ed th ere h ad been com plete h ealin g.

Fig 2 .5 -23 a – b

a

b

c

d

Fig 2.5-2 5a –d

130

Th ere w as also excellen t u ln ar an d radial deviation .

Fig 2.5-2 4a –b

At th is stage, excellen t ran ge o m otion w as also sh ow n .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.6

1

Scaphoid, waist—nonunion with deformity treated with a headless compression screw and bone graft

Ca s e d e s crip t io n

A 47-year-old store m an ager presen ted with a sym ptom atic n on u n ion o th e scaph oid o h is righ t h an d ollowin g an earlier in ju ry. He presen ted with pain , lim ited ran ge o m otion , and a weak grip. Th e PA, PA in u ln ar deviation , an d lateral x-rays revealed a well-de n ed n on u n ion with de orm ity o th e scaph oid.

Fig 2.6-1a –c

a

b

c

Th e 2-D CT scan s clearly de n ed th e n on u n ion bu t with ou t radiograph ic eviden ce o osteoarth ritis.

Fig 2.6-2a –b

a

a

b

b

c

d

Wh ile th e MRIs sh ow ed preserved cartilage w ith in th e radioscaph oid join t, th e 3-D CT scan sh ow ed a “h u m pback” de orm ity pattern o th e scaph oid.

Fig 2.6-3a – d

131

Pa rt II Case s

2

In d ica t io n s

Sca p h o id w a is t n o n u n io n

No n u n io n a n d t h e h u m p b a ck d e fo rm it y

40° a

b

Fig 2.6-4

For a variety o reason s, scaph oid ractu res su er a h igh rate o n on u n ion , an d a n on u n ion o a scaph oid w aist ractu re presen ts a w ell-recogn ized risk o developin g in tercarpal arth ritis. With scaph oid w aist n on u n ion s, th e goal is o ten n ot on ly to gain u n ion bu t also to restore th e n orm al u n ction al an atom y o th e scaph oid, w h ich m ay h ave becom e de orm ed. Addition ally, it is im portan t to correctly restore th e scaph oid’s relation sh ip to th e adjacen t lu n ate carpal bon e.

Fig 2.6-5a –b

In ractu res o th e waist o th e scaph oid, th e distal h al ten ds to rotate in to f exion in relation to th e proxim al h al , th e lu n ate, an d th e triqu etru m , wh ich all lie in exten sion . Th is can resu lt in a rotation al an d an gu lar de orm ity an d a n on u n ion kn own as h u m pback de orm ity. Fu rth erm ore, du e to th e orces exerted over th e scaph oid in its palm ar aspect, it su ers bon e loss with con sequ en t sh orten in g. Th ese ch an ges to th e bon e o ten in du ce carpal collapse.

Sca p h o id n o n u n io n a d va n ce d co lla p s e

Ca rp a l co lla p s e co rre ct io n

Du e to th e ch an ges o load over th e radiocarpal join t, de orm ities o th e scaph oid can also be respon sible or cau sin g osteoarth ritis, w h ich can produ ce w h at is kn ow n as scaph oid n on u n ion advan ced collapse (SNAC). I osteoarth ritis develops, on ly salvage recon stru ction procedu res can be o ered.

Wh ere th ere are in dication s o carpal collapse as a resu lt o scaph oid de orm ity, an osteotom y or corticocan cellou s bon e gra t m ay be requ ired to ll th e de ect. Th is w ill h elp to in du ce h ealin g an d to preven t th e developm en t o osteoarth ritis bu t also h elps to restore scaph oid len gth . Fixation w ith a screw to com plete th e procedu re th en im proves overall stability.

Go a ls o f s u rgica l tre a tm e n t o f a s ca p h o id n o n u n io n

Th e ollowin g are th e m ain goals or th e su rgical treatm en t o scaph oid n on u n ion s: • To restore an atom y (m orph ology an d scaph oid len gth ) • To obtain h ealin g • To stop progression o carpal in stability • To redu ce progression o osteoarth ritis.

132

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.6 Scaphoid, waist—nonunion with de formity tre ate d with a he adle ss compre ssion scre w and bone graft

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

Im a gin g

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g. Also, CT scan s in th e tru e lon gitu din al axis o th e scaph oid are h elp u l in order to iden ti y de orm ity.

For scaph oid w aist n on u n ion s, a 2.4 m m or 3.0 m m im plan t u sin g retrograde in sertion is advisable. For th is patien t, a h eadless com pression screw com bin ed w ith bon e gra tin g w as requ ired.

Fig 2.6-6

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.1 m m K-w ires Poin ted redu ction orceps Au togen ou s bon e gra t equ ipm en t Osteotom e Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Su pin ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.6-7

133

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Hyp e re xt e n d t h e w ris t

To assist in th e approach , place a rolled towel or bolster u n der th e wrist an d h yperexten d it. Th e u se o th e su pport h elps access th e correct en try poin t or a gu ide wire. Th is position also h elps to redu ce th e scaph oid ragm en ts.

Fig 2.6-9

Th e su rgical approach u sed was a palm ar approach (see ch apter 1.1 Palm ar approach to th e scaph oid).

Fig 2.6-8

a

b

In itially, an in cision lin e w as m arked crossin g th e w rist crease at an an gle ( a ). A ter th e in cision , th e su per cial palm ar bran ch o th e radial artery w as protected w ith a vessel lou pe ( b ).

Fig 2.6-1 0a –b

a

b

Th e palm ar capsu le w as th en open ed in a Z-plasty m eth od (u sin g a Z-sh aped in cision to relieve ten sion in scar tissu e) ( a ). Th is w as don e to preserve th e orien tation o th e radioscaph oid ligam en t. Th e n on u n ion w ith sclerotic m argin s w as th en exposed ( b ).

Fig 2.6-1 1a –b

134

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.6 Scaphoid, waist—nonunion with de formity tre ate d with a he adle ss compre ssion scre w and bone graft

5

Re d u ct io n

Bo n e gra ft

Ha r ve s t in g

2–4 cm

Iliac crest

Harvest th e corticocan cellou s gra t m aterial rom th e iliac crest. For m ost de ects, can cellou s or corticocan cellou s bon e gra t can be obtain ed rom th e distal radiu s. How ever, or th ose n on u n ion s th at requ ire su bstan tial debridem en t o sclerotic bon e en ds or h ave xed rotatory de orm ities, a larger gra t rom th e iliac crest sh ou ld be con sidered.

Fig 2.6-1 2

Make a 2 cm lon gitu din al in cision over th e lateral aspect o th e palpable iliac crest avoidin g th e very an terior aspect an d th e ilio em oral n erve.

Fig 2.6-1 3

In s e r t t h e b o n e gra ft

a

Expose th e crest over a 2–3 cm segm en t an d m ark ou t th e preplan n ed gra t size to be h arvested. Con sider th e sh ape an d size o th e de ect in th e scaph oid an d h ow th e gra t su r aces w ill con tact th e tw o scaph oid pieces. Harvest th e selected gra t u sin g a sh arp osteotom e. Con trol bleedin g w ith a w ou n d pack an d u se a sm all su ction drain i n ecessary. Close th e skin an d apply a pressu re dressin g.

Fig 2.6-1 4

b

Disim pact th e tw o ragm en ts u sin g a K-w ire or den tal pick to m ake room or th e gra t. Per orm th e osteotom y an d decortication o th e n on u n ion site an d en su re th e scaph oid is len gth en ed to its approxim ate origin al size ( a ). Use a pu sh er in stru m en t to im pact th e bon e gra t an d ll th e w h ole n on u n ion cavity ( b ). Con rm redu ction u sin g im age in ten si cation .

Fig 2.6-1 5a –b

135

Pa rt II Case s

5

Re d u ct io n (co n t )

a

b

A large n on u n ion de ect w as eviden t. Follow in g decortication o th e n on u n ion site, corticocan cellou s bon e gra t w as placed in to th e de ect.

Fig 2.6-1 6a –b

Dire ct re d u ct io n

Te m p o ra r y K-w ire

Use sm all poin ted redu ction orceps to redu ce th e n on u n ion .

Fig 2.6-1 8

Fig 2.6-1 7

Altern atively, in sert a provision al K-w ire to stabilize th e ragm en ts an d to m ain tain rotation al align m en t du rin g drillin g. Wh en in sertin g th e K-w ire, be care u l n ot to con f ict w ith th e plan n ed track o th e gu ide w ire or th e can n u lated screw .

Th e n on u n ion w as redu ced an d th e scaph oid w as given a m ore n orm al align m en t as seen in th e in traoperative im ages.

Fig 2.6-1 9a –b

a

136

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.6 Scaphoid, waist—nonunion with de formity tre ate d with a he adle ss compre ssion scre w and bone graft

5

Re d u ct io n (co n t )

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

In s e r t t h e gu id e w ire

Palmar ridge of trapezium

Th e correct en try poin t or th e gu ide w ire is th e cen ter o th e distal pole o th e scaph oid. How ever, to get proper access, it m ay be n ecessary to rem ove th e palm ar ridge o th e trapeziu m w ith an osteotom e or a bon e n ibbler/ ron geu r. Th is reveals th e distal pole o th e scaph oid an d allow s th e path o th e gu ide w ire to be m ade m ore cen trally w ith in th e bon e.

Fig 2.6-2 0

a

Th e gu ide w ire sh ou ld be in serted th rou gh a drill gu ide. I n o drill gu ide is available, u se a protective sleeve. Th e position o th e w ire sh ou ld be as perpen dicu lar as possible to th e n on u n ion plan e. Do n ot pen etrate beyon d th e proxim al cortex o th e scaph oid.

Fig 2.6-2 1

b

A ter exposu re o th e patien t’s scaph otrapezial join t, a gu ide wire was placed th rou gh a drill gu ide. Th e placem en t o th e wire was con rm ed with in traoperative im agin g.

Fig 2.6-22a –b

137

Pa rt II Case s

6

Fixa t io n

Sca p h o id fixa t io n

a

b

c

With th e gu ide w ire in place an d w ith care n ot to dam age th e gra t, th e h eadless screw w as in serted across th e scaph oid n on u n ion th rou gh th e distal pole.

Fig 2.6-2 3a –c

Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .

En s u re co rre ct s cre w a n d t h re a d le n g t h

a

Co m p le t e t h e fixa t io n

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.6-2 4a –b

138

Be ore n al tigh ten in g, rem ove th e gu ide w ire. Make su re th at th e th reads at th e n ear en d o th e screw are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.6-2 5

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.6 Scaphoid, waist—nonunion with de formity tre ate d with a he adle ss compre ssion scre w and bone graft

6

Fixa t io n (co n t )

a

b

Correct placem en t o th e h eadless screw was con rm ed th rou gh in traoperative im agin g. Note th e large corticocan cellou s gra t.

Fig 2.6-26a –b

7

Du rin g w ou n d closu re, th e capsu lar in cision w as care u lly closed to approxim ate th e edges o th e capsu lar ligam en ts.

Fig 2.6-2 7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow-u p, rem oval o stitch es, an d im m obilization as requ ired. Followin g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated with a h eadless com pression screw.

Fig 2.6-28

8

Ou t co m e

a

b

c

d

At th e 1-m on th ollow-u p, th e AP an d lateral x-rays sh owed th e h eadless screw an d bon e gra t were in th e righ t position ( a –b ), an d at 3-m on th s, th e x-rays in dicated th at partial in corporation o th e bon e gra t h ad occu rred ( c–d ).

Fig 2.6-29a –d

139

Pa rt II Case s

8

Ou t co m e (co n t )

At th e 3-year ollow -u p, th e AP an d lateral x-rays revealed total in corporation o th e bon e gra t an d com plete h ealin g o th e n on u n ion . Fig 2 .6 -3 0a – b

a

b

a

b

By th is stage, th e patien t h ad obtain ed an excellen t u n ction al ou tcom e.

Fig 2.6-3 1a –d

c

d

Good grip stren gth in th e in ju red le t h an d w as also sh ow n .

Fig 2.6-32a –b

a

140

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.7

1

Scaphoid, proximal pole—nonunion treated with a vascularized bone graft

Ca s e d e s crip t io n

A 30-year-old m ale sh opkeeper presen ted w ith w rist pain , u n ction al lim itation , an d lim ited ran ge o m otion o th e righ t w rist. He recalled an in ju ry to h is righ t h an d su ered in a m otor veh icle acciden t 8 m on th s prior. Th e PA an d lateral x-rays revealed a scaph oid proxim al pole n on u n ion w ith ragm en tation at th e n on u n ion site.

Fig 2 .7 -1 a –b

a

b

Fu rth er in vestigation with T1 an d T2 MRI im ages dem on strated com plete absen ce o vascu larity to th e proxim al pole ragm en t, wh ile a 2-D CT im age sh owed th e n on u n ion with a sm all sclerotic proxim al pole ragm en t.

Fig 2.7-2a –c

a

2

b

c

In d ica t io n s

Pro xim a l p o le n o n u n io n w it h a b s e n ce o f va s cu la rit y

As h as been previou sly discu ssed, scaph oid ractu res su er a h igh rate o n on u n ion w ith th e poor vascu larity o th e scaph oid o ten at au lt (re er to th e in dication s topic in ch apter 2.1 Scaph oid—n on displaced ractu re treated percu tan eou sly w ith a h eadless com pression screw ). Proxim al pole ractu res rely largely on a distal to proxim al in traosseou s blood f ow an d are th ere ore especially pron e to delayed u n ion an d n on u n ion . Avascu lar n ecrosis can also be th e cau se o scaph oid ractu re n on u n ion , occu rrin g m ost requ en tly in th e proxim al pole. Scaph oid n on u n ion s h ave a h igh risk o progressin g to osteoarth ritis w ith in a ew years ollow in g th e in ju ry, yet e ective h ealin g o th e n on u n ion dram atically redu ces th is risk.

Fig 2.7-3

141

Pa rt II Case s

2

In d ica t io n s (co n t )

Va s cu la rize d b o n e gra ft in g

a

b

c

d

Vascu larized bon e gra tin g in volves th e elevation o an appropriate size o gra t tissu e w ith a cen trally located vessel ( a – c ). It is th en care u lly placed in to th e prepared ractu re or n on u n ion site ( d ).

Fig 2.7-4 a – d

Stu dies h ave sh ow n th at vascu larized bon e gra tin g can be u sed e ectively to provide im proved blood su pply an d in crease th e poten tial or h ealin g. Wh ile eviden ce con tin u es to be gath ered regardin g w h eth er vascu larized bon e gra tin g is con clu sively m ore e ective th an stan dard n on vascu larized tech n iqu es, it h as been con sidered logical to em ploy a vascu larized gra t in situ ation s w h ere vascu larity h as been com prom ised. Addition ally, vascu larized bon e gra t h arvested rom th e distal radiu s con ers sign i can t th eoretical advan tages an d also redu ces th e im pact o don or site m orbidity rom a distan t site.

Go a ls o f s u rgica l t re a t m e n t o f a s ca p h o id n o n u n io n

Th e ollow in g are th e m ain goals or th e su rgical treatm en t o scaph oid n on u n ion s: • • • •

142

Restore an atom y (m orph ology an d scaph oid len gth ) Obtain h ealin g Stop progression o carpal in stability Redu ce progression o osteoarth ritis.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

Im a gin g

Obtain in g a u ll series o scaph oid x-rays o th e a ected an d n orm al con tralateral side is n ecessary or su rgical plan n in g. A CT scan in th e tru e lon gitu din al axis o th e scaph oid is also h elp u l in order to iden ti y de orm ity. Gadolin iu m en h an ced T1 MRI scan s are in dicated w h en assessin g th e vascu larity o th e proxim al ragm en t.

a

b

For scaph oid n on u n ion s with loss o vascu larity, i th e proxim al ragm en t is large en ou gh , a 2.4 m m or 3.0 m m im plan t u sin g an tegrade in sertion is advised. For sm aller proxim al ragm en ts, sin gle or m u ltiple m in i h eadless bon e screws (1.5 m m ) can be u sed. For th is patien t, two m in i h eadless bon e screws com bin ed with dorsal vascu larized bon e gra tin g was requ ired.

Fig 2.7-5a –b

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Min i h eadless screw set 1.5 1.1 m m K-w ires Au togen ou s bon e gra t equ ipm en t Im age in ten si er Kn ow ledge o th e tech n iqu e or dorsal 1,2 in tercom partm en tal su praretin acu lar artery (1,2 ICSRA) vascu larized bon e gra tin g

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.7-6

143

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.2 Dorsal approach to th e scaph oid). However, on th is occasion , th e in cision in volved a dorsoradial lon gitu din al cu rved skin in cision , startin g over th e base o th e th u m b an d exten din g proxim ally or abou t 6–8 cm . Th is approach allows or a dorsal pedicled 1,2 ICSRA gra t.

Fig 2.7-7

144

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

5

Re d u ct io n

Do rs a l va s cu la rize d b o n e gra ft in g

Radial artery

1,2 ICSRA

a

b

Radial sensory nerve

Distal

Proximal

APL

Pedicled vascu larized bon e gra ts u sed in scaph oid n on u n ion su rgery are based on tw o di eren t arteries. On e vascu lar pedicle is ou n d on th e dorsal su r ace o th e distal radiu s, th e oth er on th e palm ar su r ace. Th e dorsal pedicle is based on th e 1,2 in tercom partm en tal su praretin acu lar artery (1,2 ICSRA) ( a –b ). A dorsal vascu larized gra t u sin g th ese vessels allows excellen t m obility to treat n on u n ion s in all region s o th e scaph oid, in clu din g th e proxim al pole ( c ).

Fig 2.7-8a –c

ECRL

1,2 ICSRA

c

Excis in g t h e n o n u n io n

Prepare th e n on u n ion by excisin g brou s tissu e to h ealth y can cellou s su r aces. Disim pact th e ragm en ts u sin g a K-w ire or den tal pick to m ake room or th e gra t. En su re scaph oid len gth en in g to its approxim ate origin al size.

Fig 2 .7 -9

145

Pa rt II Case s

5

Re d u ct io n (co n t )

Ele va t e t h e b o n e gra ft

a

b

c

d

e

Th e vascu larized bon e gra t is care u lly h arvested an d h an dled to avoid tw istin g o th e vascu lar pedicle ( a –b ). It w ill later be in serted in to th e previou sly prepared de ect in th e scaph oid ( c–d ). Ten sion on th e vascu lar pedicle m u st be avoided. A tem porary K-w ire is a u se u l m eth od o stabilizin g th e redu ction an d avoids risk o dam age to th e vascu lar pedicle ( e ).

Fig 2.7-1 0a –e

a

b

For th e patien t, th e vascu larized distal radiu s bon e gra t (1,2 ICSRA) w as elevated on its pedicle.

Fig 2.7-1 1a –b

146

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

5

Re d u ct io n (co n t )

Pre p a re a t ro u gh if n e e d e d

De t e rm in e in s e r t io n p o in t a n d in s e r t t h e gu id e w ire

A trou gh th at crossed th e n on u n ion site or later in sertion o th e bon e gra t was plan n ed.

Fig 2.7-13

I can n u lated h eadless bon e screws are u sed, determ in e th e gu ide wire en try poin t (in th e cen ter o th e proxim al pole) an d in sert th e gu ide wire. Do n ot pen etrate th e scaph otrapezial join t with th e gu ide wire. Im age in ten si cation in at least two plan es sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e n on u n ion .

Fig 2.7-12

6

Fixa t io n

Sca p h o id fixa t io n

Followin g creation o th e trou gh across th e n on u n ion site, two 1.5 m m h eadless screws were placed across th e n on u n ion th rou gh th e proxim al pole in to th e body o th e scaph oid. However, becau se th e proxim al ragm en t was sm all it was decided to u se an in itial screw to gu aran tee scaph oid sh ape an d stability be ore creation o th e trou gh .

Fig 2.7-14

Th e xation procedu re ollows th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw, in sertin g th e screw, an d advan cin g an d cou n tersin kin g th e screw. For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated with a h eadless com pression screw. However, in th is particu lar case, th e 1.5 m m m in i h eadless bon e screws are n on can n u lated an d th ere ore requ ire n o gu ide wires.

147

Pa rt II Case s

6

Fixa t io n (co n t )

En s u re co rre ct s cre w a n d t h re a d le n g t h

a

Co m p le t e t h e fixa t io n

b

It is vital th at th e th readed section o th e tip o th e screw passes com pletely beyon d th e ractu re plan e i in ter ragm en tary com pression is to be ach ieved. Also en su re th at th e screw is n ot too lon g n or overtigh ten ed as it cou ld protru de beyon d th e cortical su r ace an d lose com pression , or en dan ger th e so t tissu es, especially ten don s an d n eu rovascu lar stru ctu res.

Fig 2.7-1 5a –b

Be ore n al tigh ten in g, rem ove an y gu ide w ires (i can n u lated screw s w ere u sed). Make su re th at th e th reads at th e n ear en d o th e screw s are u lly bu ried in th e bon e at th e in sertion site. Ch eck th e n al position o th e screw s an d scaph oid stability u sin g im age in ten si cation or x-rays.

Fig 2.7-1 6

In s e r t a n d co m p le t e t h e va s cu la rize d gra ft

a

b

With th e n on u n ion site n ow stabilized w ith on e screw previou sly placed, th e vascu larized gra t w as in serted in to th e trou gh across th e n on u n ion . Th is w as ollow ed w ith a secon d screw u sed to x th e gra t to th e scaph oid. Th e w ou n d w as th en closed takin g care n ot to dam age or com press th e vascu lar pedicle.

Fig 2.7-1 7a –b

Note th at in cases w h ere th ere is bon e loss an d cyst orm ation at th e n on u n ion site, th e bon e gra t sh ou ld be in serted in to th e de ect be ore stabilization w ith bon e screw s. How ever, w h en in trodu cin g th e gra t rst an d th en in sertin g screw s, be care u l th at screw in sertion does n ot orce ou t or dam age th e gra t. 148

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

6

Fixa t io n (co n t )

a

b

Th e in traoperative im ages con rm ed th e correct placem en t o th e screw s.

Fig 2.7-1 8a –b

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.2 Scaph oid—displaced ractu re treated w ith a h eadless com pression screw .

Fig 2.7-19

149

Pa rt II Case s

8

Ou t co m e

At th e 3-year ollow-u p, th e PA an d lateral x-rays an d th e h yperpron ation an d sem ipron ation obliqu e x-rays sh owed com plete h ealin g o th e n on u n ion with stable screw xation an d n o eviden ce o avascu lar n ecrosis o th e proxim al pole.

Fig 2.7-20a –d

a

b

c

a

b

c

d

d

At th is stage, th e patien t h ad a n early u ll ran ge o m otion .

Fig 2 .7-21 a –f

e

f

Excellen t grip stren gth h ad also been restored.

Fig 2 .7 -2 2a – b

a

150

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

No n u n io n t re a t e d w it h a p a lm a r va s cu la rize d b o n e gra ft

a

b

c

Ju st as it is possible to treat a scaph oid n on u n ion w ith a dorsal vascu larized bon e gra t, it is also possible to treat su ch in ju ries w ith a palm ar vascu larized bon e gra t. A 16-year-old stu den t an d recreation al skier lan ded aw kw ardly w h ile skiin g. He h ad pain an d restricted m ovem en t in h is le t w rist bu t th ou gh t it likely to be a so t-tissu e in ju ry. A ter 3 m on th s, h e atten ded h is local h ospital as h e w as still experien cin g pain w ith m ovem en t, w eakn ess o grip, an d a n oticeable loss o exten sion (40 degrees com pared w ith 65 degrees in th e opposite w rist). Exam in ation con rm ed a “ u lln ess” in th e an atom ical sn u box an d ten dern ess to rm pressu re. Plain PA an d lateral x-rays revealed an establish ed n on u n ion at th e proxim al w aist o th e scaph oid w ith a h u m p-back de orm ity ( a –b ). A T1-w eigh ted MRI scan w ith gadolin iu m en h an cem en t dem on strated dim in ish ed blood f ow in th e proxim al ragm en t ( c ). On u rth er qu estion in g, h e recalled an in ciden t 18 m on th s earlier w h en h e h ad in ju red th e sam e w rist allin g rom h is skateboard.

Fig 2.7-2 3a –c

Pa lm a r va s cu la rize d b o n e gra ft in g

a

b

For palm ar vascu larized bon e gra t treatm en t o scaph oid w aist n on u n ion s, th e palm ar pedicle is u sed, w h ich is based on th e palm ar radial carpal artery, an an astom otic (m u ltibran ch ed) vessel betw een th e radial artery an d th e an terior in terosseou s artery. Th e gra t provides a stron g stru ctu ral com pon en t to th e procedu re by virtu e o th e th ick cortical bon e o th e palm ar cortex o th e distal radiu s.

Fig 2.7-2 4a –b

151

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

a

b

c

Th is palm ar gra t is particu larly u se u l in scaph oid w aist n on u n ion s w ith a h u m p back de orm ity, w h ere correction o th e de orm ity is as im portan t as ach ievin g u n ion .

Fig 2 .7 -2 5 a – c

Su rgica l a p p ro a ch

a

b

Th e su rgical approach u sed w as a palm ar approach (see ch apter 1.1 Palm ar approach to th e scaph oid). Retrograde xation sh ou ld be per orm ed w ith eith er 1.5 m m m in i h eadless screw s or 2.4 m m / 3.0 m m can n u lated h eadless com pression screw s.

Fig 2.7-2 6a –b

152

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n Excis in g t h e n o n u n io n

a

b

Prepare th e n on u n ion by excisin g brou s tissu e to h ealth y can cellou s su r aces. For th is patien t, cyst orm ation w as n oted an d w as rem oved. Disim pact th e ragm en ts u sin g a K-w ire or den tal pick to m ake room or th e gra t ( a ). En su re scaph oid len gth en in g to its approxim ate origin al size ( b ).

Fig 2.7-2 7a –b

Ele va t e t h e b o n e gra ft

Vascular pedicle

a

b

c

Th e palm ar radial carpal artery pedicle is ou n d distal to th e pron ator qu adratu s an d is care u lly separated rom th e overlyin g ascia ( a –b ). Th e pron ator qu adratu s is retracted ( b ) to reveal th e periosteal vessels. Th e pedicle is cau terized at its u ln ar lim it an d a prem easu red rectan gu lar bon e gra t is h arvested rom th e distal radiu s, still attach ed to th e pedicle ( c ). A h ypoderm ic n eedle placed in th e radiocarpal join t preven ts in adverten t dam age to th e articu lar su r ace du rin g h arvest o bon e gra t.

Fig 2.7-2 8a –c

153

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) In s e r t t h e va s cu la rize d gra ft

In sert th e bon e gra t in to th e prepared de ect, correctin g th e h u m p back de orm ity. Th e vascu larized bon e gra t is care u lly h an dled to avoid tw istin g o th e vascu lar pedicle attach ed to th e gra t, an d ten sion on th e vascu lar pedicle m u st also be avoided. Con rm redu ction u sin g im age in ten si cation .

Fig 2.7-2 9

Th e patien t’s vascu larized gra t can be seen in place.

Fig 2.7-3 0

De t e rm in e in s e r t io n p o in t a n d in s e r t t h e gu id e w ire

I can n u lated h eadless bon e screw s are u sed, determ in e th e gu ide w ire en try poin t an d in sert th e gu ide w ire. Im age in ten si cation in at least tw o plan es sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide w ire in th e scaph oid axis an d perpen dicu lar to th e n on u n ion .

Fig 2.7-3 1

154

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.7 Scaphoid, proximal pole —nonunion tre ate d with a vascularize d bone graft

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t )

a

b

Th e gu ide w ire sh ou ld be in serted th rou gh a drill gu ide. I n o drill gu ide is available, u se a protective sleeve. In traoperative im ages sh ow th e gu ide w ire in sertion .

Fig 2.7-3 2a –b

Ad d it io n a l t e m p o ra r y K-w ire

An addition al tem porary K-w ire can be in serted to stabilize th e ragm en ts an d to m ain tain rotation al align m en t du rin g drillin g. Wh en in sertin g th e addition al K-w ire, be care u l n ot to con f ict w ith th e plan n ed track o th e gu ide w ire or th e can n u lated screw .

Fig 2.7-3 3

155

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Sca p h o id fixa t io n

a

b

A sin gle h eadless screw was placed in to th e body o th e scaph oid an d th rou gh th e gra t.

Fig 2.7-34a –b

Th e xation procedu re ollows th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw, in sertin g th e screw, an d advan cin g an d cou n tersin kin g th e screw. Wh en an addition al tem porary K-wire h as been u sed, it m u st be rem oved be ore n al tigh ten in g o th e screw. For u rth er in orm ation on th ese steps see ch apter 2.2 Scaph oid—displaced ractu re treated with a h eadless com pression screw. A n al ch eck o position an d len gth o th e im plan t was per orm ed rom several an gles to en su re n o overpen etration .

Ou t co m e

a

b

Th e procedu re resu lted in h ealin g o th e n on u n ion an d retu rn to n orm al m ovem en t an d activity levels.

Fig 2.7-3 5a –b

156

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.8

1

Perilunate dislocation treated with K-wires

Ca s e d e s crip t io n

a

b

c

A 28-year-old salesm an an d am ateu r su r er was swept o h is su r board wh ile ridin g a large wave. He presen ted to th e em ergen cy departm en t experien cin g pain , de orm ity, an d edem a o h is righ t wrist, accom pan ied by n u m bn ess o th e n gers. On th e PA x-rays, a trian gu lar pro le o th e lu n ate was sh own rath er th an a n orm al qu adrilateral sh ape ( a –b ). Th is was du e to an an terior dislocation an d widen in g between th e scaph oid an d lu n ate. Th e lateral x-ray also sh owed th e palm ar dislocation o th e lu n ate. Th e capitate was displaced proxim ally toward th e distal radial articu lar su r ace. Th e “spilled teacu p” con gu ration o th e lu n ate was a classic sign o a lu n ate dislocation ( c).

Fig 2.8-1a –c

a

b

c

Th e sagittal 2-D CT scan s sh owed th e palm ar dislocation o th e lu n ate ( a ) an d th e em pty lu n ate acet o th e radiu s with som e sm all ch ip ractu res o th e lu n ate ( b ). However, th ere was a n orm al an atom ical relation sh ip between th e h am ate an d th e triqu etru m ( c).

Fig 2.8-2a –c

Th e dorsal view 3-D CT scan con rm ed th e palm ar dislocation o th e lu n ate, alth ou gh th e scaph oid kept its n orm al an atom ical relation sh ip with th e radiu s an d th e distal carpal row. A sm all ch ip ractu re o th e dorsal aspect o th e lu n ate (arrow) presen ted th e possibility (later con rm ed) th at th ere was an avu lsion o th e dorsal scaph olu n ate ligam en t.

Fig 2.8-3

157

Pa rt II Case s

2

In d ica t io n s

Pe rilu n a t e d is lo ca t io n s

Perilu n ate dislocation s are ligam en tou s in ju ries th at resu lt rom h igh -en ergy trau m a an d in volve dam age to th e capsu loligam en tou s con n ection s o th e lu n ate to its adjacen t carpal bon es an d th e radiu s. Th ey can lead to severe disru ption o carpal an atom y, resu ltin g in pro ou n d ch an ges in w rist biom ech an ics. O all w rist dislocation s, perilu n ate dislocation s are th e m ost com m on .

Ca rp a l liga m e n t a n a t o m y a n d ru p t u re

a

Palmar intrinsic ligaments

b

Dorsal intrinsic ligaments

c

Palmar extrinsic ligaments

d

Dorsal extrinsic ligaments

Bon es o th e wrist are given su pportin g stability by a wide ran ge o ligam en ts. Th e carpal rows are su pported by stou t in trin sic ligam en ts ( a –b ), wh ich begin an d en d with in th e sam e carpal row. Th ese ligam en ts are rein orced by a com plex system o palm ar an d dorsal extrin sic ligam en ts ( c–d ), wh ich begin an d en d in di eren t rows. Ru ptu re o th e in trin sic ligam en ts is called “dissociation ”. Ru ptu re o th e extrin sic ligam en ts alon e cau ses a “n on dissociative” in ju ry.

Fig 2.8-4a –d

158

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

2

In d ica t io n s (co n t )

Th e Pe rilu n a t e In s t a b ilit y Cla s s ifica t io n

Th e progression o ligam en tou s dam age an d th e sequ en ce o in ju ries th at can occu r in a perilu n ate dislocation w ere in vestigated by May eld an d colleagu es in an atom ical specim en experim en tation . Th eir n din gs con rm ed th at m ost carpal dislocation s arou n d th e lu n ate are th e con sequ en ce o a sim ilar path om ech an ical even t, th e so-called progressive perilu n ate in stability. Th e ou r types (or stages) o carpal destabilization w ere iden ti ed as ollow s: • • • •

Stage Stage Stage Stage

I: Scaph olu n ate dissociation II: Lu n ocapitate dislocation III: Midcarpal dislocation IV: Lu n ate dislocation .

Stage I: Scaph olu n ate dissociation

Stage I: Scaph olu n ate dissociation in volves tearin g o th e scaph olu n ate ligam en t. An y in creased separation between th e scaph oid an d lu n ate is kn own as th e Terry Th om as or David Letterm an sign , n am ed a ter am ou s en tertain ers with pron ou n ced gaps in th eir ron t teeth .

Fig 2.8-5a –b

a

b

Stage II: Lu n ocapitate dislocation

Stage II: Lu n ocapitate dislocation is wh ere th e lu n ate rem ain s align ed n orm ally with th e distal radiu s bu t th e su rrou n din g carpal bon es are dislocated. Th e lu n ocapitate join t becom es disru pted.

Fig 2.8-6a –b

a

b

159

Pa rt II Case s

2

In d ica t io n s (co n t )

Stage III: Midcarpal dislocation

Stage III: Midcarpal dislocation is wh ere both th e lu n ate an d capitate h ave lost align m en t with th e distal radiu s. Th e lu n otriqu etral ligam en t an d or triqu etral bon e are a ected.

Fig 2.8-7a –b

a

b

Stage IV: Lu n ate dislocation

Radiolunate ligament a

b

Stage IV: A lu n ate dislocation is w h ere th ere is dislocation o th e lu n ate an d in ju ry to th e dorsal radiolu n ate ligam en t. Th e u n iqu e teacu p appearan ce o th e lu n ate an d th e extrem e an gle th at can resu lt in th is in ju ry creates w h at is kn ow n as th e spilled teacu p sign .

Fig 2.8-8 a – b

160

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

2

In d ica t io n s (co n t )

Co m p le t e d is lo ca t io n s o f t h e lu n a t e

Dis ru p t io n o f t h e d o rs a l ra d io lu n o t riq u e t ra l liga m e n t co m p le x

Radiolunotriquetral ligament

a

b

In stage IV com plete dislocation s o th e lu n ate, th e lu xation is u su ally in a palm ar direction . Th e greater orce requ ired to produ ce th is in ju ry is respon sible or m assive disru ption o both th e dorsal an d palm ar ligam en ts.

Fig 2.8-9 a – b

a

Normal

b

Spilled tea cup

Th ere can also be a disru ption o th e dorsal radiolu n otriqu etral ligam en t com plex.

Fig 2.8-1 0a –b

Im a gin g

Diagn osis o sim ple ligam en t dissociation can be di cu lt as th ere m igh t be n o im m ediate carpal bon e m ovem en t or dislocation , an d x-rays m ay appear n orm al. Takin g stress x-rays w ith th e h an d h oldin g a pen cil, or exam ple, m ay cau se gaps betw een th e carpals to open an d be m ore clearly iden ti ed. Perilu n ate dislocation s sh ou ld be su spected wh en a patien t presen ts with a pain u l an d swollen wrist a ter a h igh -en ergy h yperexten sion in ju ry an d sign s o m edian n erve com pression . Th e n al diagn osis n eeds to be based on a care u l radiograph ic exam in ation . Alth ou gh in th e coron al view abn orm al overlappin g o th e carpal bon es an d alteration o “Gilu la´s arcs” can be observed, a tru e lateral view is th e best way to m ake th e diagn osis ( or u rth er in orm ation on u sin g arcs to determ in e carpal in ju ry see th e in dication s topic in ch apter 2.10 Tran striqu etral tran sscaph oid perilu n ate ractu re dislocation treated with screws). Lateral x-rays can also sh ow th e spilled teacu p con gu ration o a dislocated lu n ate. Addition ally, as th e capitate displaces proxim ally toward th e distal radial articu lar su r ace, on x-rays th e displaced lu n ate h as a trian gu lar pro le ( Fig 2.8-1a –b ), rath er th an its n orm al qu adrilateral sh ape. Th ese can be di cu lt in ju ries to m an age, with m an y goin g on to h ave ligam en t repair ailu re an d developin g som e osteoarth ritis o th e wrist. A CT scan is also o great h elp o erin g m ore precise detail o th e in ju ry in order to plan th e su rgery in a m ore logical an d accu rate w ay.

161

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

1.4 m m to 1.6 m m K-w ires Poin ted redu ction orceps Bon e an ch ors Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.8-11

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision .

Fig 2.8-1 2a –b

162

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

5

Re d u ct io n

Pre lim in a r y re d u ct io n o f t h e lu n a t e

a

b

c

Closed redu ction is a prelim in ary to operative treatm en t an d h as th ree ben e ts: • It restores carpal align m en t • It im proves th e patien t’s com ort • It redu ces pressu re on th e m edian n erve.

Fig 2.8-1 3a –c

Redu ction o th e dislocated lu n ate is ach ieved by distractin g th e w rist ( a ) an d applyin g direct th u m b pressu re over th e lu n ate rom palm ar to dorsal ( b ). Th e h an d is th en gen tly f exed, an d on ce redu ction h as occu rred, th e distraction is gen tly relaxed ( c ).

Op e n re d u ct io n o f t h e lu n a t e

I closed redu ction is n ot su ccess u l, open redu ction is n ecessary as soon as possible du e to th e risk o m edian n erve com prom ise, o pain , an d to preserve blood su pply to th e lu n ate.

For th is patien t, a radially based capsu lotom y w as per orm ed an d th e f ap w as elevated an d h eld w ith tw o su tu res exposin g th e dorsal aspect o th e carpu s. Th e lu n ate w as redu ced by lon gitu din al traction an d by th e u se o a periosteal elevator w ith care taken n ot to dam age th e articu lar cartilage.

Fig 2.8-14

163

Pa rt II Case s

5

Re d u ct io n (co n t )

As s e s s m e n t o f d o rs a l a n d p ro xim a l liga m e n t re m n a n t s

Th e scaph olu n ate ligam en t can be avu lsed rom eith er th e scaph oid or rom th e lu n ate. In th is case, th e ligam en t was avu lsed rom th e lu n ate, rem ain in g attach ed to th e scaph oid as is sh own by th e arrow. Th e avu lsion site was appropriately debrided to im prove con tact an d h ealin g.

Fig 2.8-15

Op e n re d u ct io n o f t h e s ca p h o lu n a t e jo in t

a

b

c

d

Use two joystick K-wires, in sertin g th em deep in to th e bon e, to exten d th e scaph oid an d f ex th e lu n ate, an d th en close th e gap. A poin ted redu ction orceps h elps to secu re th e redu ction tem porarily. Con rm redu ction u sin g im age in ten si cation in two plan es.

Fig 2.8-16a –d

164

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

5

Re d u ct io n (co n t )

< 60°

On th e lateral view , w ith th e w rist n eu tral, ch eck th at th e radiu s, lu n ate, an d capitate are in lin e, th at th e scaph olu n ate an gle is < 60 degrees, an d th at th ere is n o dorsal tilt o th e lu n ate.

Fig 2.8-1 7

6

Th e clin ical im age sh ows th e joystick K-wires bein g in serted in to each o th e scaph oid an d th e lu n ate. Th ey were u sed to com plete th e closu re o th e scaph olu n ate diastasis.

Fig 2.8-18

Fixa t io n

Sca p h o lu n a t e liga m e n t re p a ir

Th e scaph oid an d lu n ate bon es sh ou ld be secu red by tran s xation w ith tw o K-w ires in serted percu tan eou sly, rom scaph oid to lu n ate. Con rm th e position o th e w ires u sin g im age in ten si cation .

Fig 2.8-1 9

A ter th e gap betw een th e scaph oid an d th e lu n ate w as redu ced u sin g th e tw o joysticks an d m ain tain ed by th e poin ted redu ction orceps, percu tan eou s K-w ires were in trodu ced betw een th e scaph oid an d lu n ate, betw een th e triqu etru m an d lu n ate, an d betw een th e scaph oid an d th e capitate.

Fig 2.8-2 0

165

Pa rt II Case s

6

Fixa t io n (co n t )

Pe a rl: a lt e rn a t ive K-w ire in s e r t io n

a

b

Th e tran s xation K-w ires can be in serted in to th e scaph oid rom in side ou tw ard prior to th e redu ction an d th en advan ced in to th e lu n ate across th e scaph olu n ate articu lation on ce redu ction h as been ach ieved.

Fig 2 .8 -21 a –c

c

a

c

Tear at scaphoid

Repair at scaphoid

b

Tear at lunate

d

Repair at lunate

Th e an ch or is in serted dorsally in to th e debrided area o th e scaph oid ( a ) or in to th e lu n ate i th e ligam en t is avu lsed rom th at bon e ( b ). Th e en try poin t or th e an ch or m u st be placed in su ch a position th at th e lin e o pu ll o th e su tu re is sligh tly obliqu e, to resist rotation al orces between both bon es. O ten on e an ch or will be su cien t bu t occasion ally two an ch ors are n eeded. Th e an ch or su tu re is in serted in to th e torn en d o th e ligam en t ( c–d ).

Fig 2.8-22a –d

166

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

6

Fixa t io n (co n t )

Op t io n : t ra n s o s s e o u s liga m e n t re fixa t io n

I bon e an ch ors are n ot available, th e avu lsed ligam en t is attach ed u sin g su tu res th at are passed th rou gh sm all tu n n els drilled in to th e proxim al pole o th e scaph oid.

Fig 2.8-2 3

a Fig 2.8-2 4a –b

Scaphoid

b

Lunate

Th e an ch or su tu res in th e ligam en t are th en tied.

For th is patien t, tw o an ch ors w ere in serted in to th e debrided area o th e dorsal aspect o th e lu n ate, an d th e an ch or su tu res w ere passed th rou gh th e ligam en t an d tied.

Fig 2.8-25

167

Pa rt II Case s

6

Fixa t io n (co n t )

Lu n o t riq u e t ra l liga m e n t re p a ir

a

b

c

d

In perilu n ate in ju ries, th e lu n otriqu etral ligam en t can also be torn . Th is can occu r rom th e lu n ate (m ost com m on ) ( a ), in its m idsu bstan ce ( b ), or rom th e triqu etru m ( c ), an d th ere can be a bon y avu lsion rom eith er bon e ( d ).

Fig 2.8-26a –d

Th ere m u st be su cien t ligam en t rem n an t or repair with bon e an ch ors, oth erwise it is repaired by direct su tu re or tran s xation o both bon es with eith er K-wires or a sm all screw depen din g on th e n atu re o th e in ju ry. Regardless o th e repair tech n iqu e u sed, it is recom m en ded to su pport th e so t-tissu e repair u sin g tran s xation with two K-wires ( or approxim ately 6–10 weeks). Redu ction an d xation o th e lu n otriqu etral align m en t is u su ally possible u sin g a dorsal approach .

168

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

6

Fixa t io n (co n t )

Re p a ir w it h b o n e a n ch o rs

a

b

Wh en th ere is su cien t ligam en t rem n an t, th e lu n otriqu etral join t is redu ced an d two K-wires are in serted percu tan eou sly rom th e u ln ar side o th e triqu etru m across th e lu n otriqu etral join t in to th e lu n ate ( a ). Con rm th e position o th e wires u sin g im age in ten si cation . I th e detach m en t occu rs rom th e lu n ate, th e an ch or is placed on th e lu n ate ( b ) so th e ligam en t can be reattach ed u sin g th e su tu res o th e an ch or ( c ). I th e detach m en t occu rs rom th e triqu etru m , th e an ch or is placed on th at bon e in stead.

Fig 2.8-27a –c

c

169

Pa rt II Case s

6

Fixa t io n (co n t )

Re p a ir w it h a s cre w

Re p a ir w it h d ire ct s u t u re

Wh en th ere is bon y avu lsion o th e lu n otriqu etral ligam en t rom eith er bon e, th e ragm en t can be xed w ith n e K-w ires or a sm all screw .

Fig 2.8-2 9

Fig 2.8-2 8

Direct su tu re o th e ligam en t m ay also be

possible.

Co m p le t e t h e fixa t io n

a

Th e capsu lotom y f ap w as th en xed u sin g m u ltiple su tu res.

Fig 2.8-3 0

170

b

In traoperative im ages sh ow ed n orm al relation sh ips in th e lu n otriqu etral an d scaph olu n ate join ts, an d in th e lateral view , th ere w as a n orm al colin ear relation sh ip betw een th e capitate th e lu n ate an d th e radiu s.

Fig 2.8-3 1a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.8 Pe rilunate dislocation tre ate d with K-wire s

7

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 2.8-3 2

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

Wh en both cast an d K-w ires h ave been rem oved, active con trolled ran ge o m otion exercises can begin at th e w rist. Load-bearin g activities are u su ally delayed u n til radiological eviden ce o bon e h ealin g. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist.

Fig 2.8-3 4

In perilu n ate in ju ries in volvin g K-w ire xation , th e K-w ires can be rem oved at 6–8 w eeks. It m ay also be n ecessary to rest th e w rist or 8–12 w eeks in a sh ort arm splin t or cast. Un til rem oval o th e cast, atten tion m u st be paid to en su re active m obilization o th e associated join ts o th e n gers, elbow , an d sh ou lder.

Fig 2.8-3 3

171

Pa rt II Case s

8

Ou t co m e

a

b

At th e 8-week ollow-u p, th e x-rays sh owed n orm al an atom ical relation sh ips with in th e carpu s. As a resu lt, th e K-wires were rem oved an d th e patien t was sen t or ph ysical th erapy.

Fig 2.8-35a –b

a

b

c

d

Fig 2.8-3 6a –d

172

Th e patien t later regain ed n ear n orm al ran ge o m otion .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.9

1

Transscaphoid perilunate fracture dislocation treated with K-wires and a headless screw

Ca s e d e s crip t io n

a

b

c

d

A 19-year-old m an su stain ed an in ju ry to h is righ t h an d du rin g an am ateu r m otocross race acciden t, presen tin g w ith n oticeable sw ellin g at th e w rist. Th e AP an d lateral x-rays dem on strated an terior dislocation o th e lu n ate w ith th e classic spilled teacu p position in g. Th e im ages also sh ow ed a m arkedly displaced ractu re o th e w aist o th e scaph oid.

Fig 2 .9 -1a –d

a

b

Follow in g closed redu ction o th e lu n ate dislocation , th e 2-D CT scan s in th e ron tal plan e sh ow ed th e displaced scaph oid ractu re.

Fig 2.9-2a – b

173

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

c

Sagittal view 2-D scan s also sh ow ed displacem en t in th e ron tal plan e.

Fig 2.9-3 a – c

a Fig 2.9-4 a – c

174

b

c

Th e scaph oid ractu re w as also clearly dem on strated in th e 3-D CT scan s in th e sagittal plan e.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

2

In d ica t io n s

Pe rilu n a t e fra ct u re d is lo ca t io n s

O all wrist dislocation s, perilu n ate dislocation s are th e m ost com m on . Th ey are ch aracterized by a progressive disru ption o capsu loligam en tou s con n ection s o th e lu n ate to th e adjacen t carpal bon es an d radiu s. Th ere are m an y clin ical orm s o perilu n ate dislocation an d th ey can be con ven ien tly classi ed in to two m ajor grou ps: th e pu re perilu n ate dislocation an d th e perilu n ate ractu re dislocation , wh ere th e ligam en t disru ption is associated with a variety o carpal ractu res arou n d th e lu n ate.

Fig 2.9-5

Perilu n ate ractu re dislocation s presen t an exten sive array o in ju ries. Fractu res o carpal bon es adjacen t to th e lu n ate can occu r in stead o on ly ligam en tou s ru ptu res wh en th e disru ptin g orce propagates arou n d th e m idcarpal join t. However, it is recogn ized th at m ore th an 90% o all perilu n ate ractu res in volve th e scaph oid. Recogn ition an d repair o all bon y an d so t-tissu e com pon en ts are essen tial in order to restore carpal stability an d to preven t posttrau m atic degen erative join t disease. Con cu rren t bon y an d so t-tissu e lesion s o th e carpu s are n ot m u tu ally exclu sive (eg, con com itan t scaph oid ractu re an d scaph olu n ate ru ptu re). Bu t u n like th e pu re ligam en tou s in ju ry o th e perilu n ate dislocation , perilu n ate ractu re dislocation in ju ries can be well treated by care u l atten tion to th e bon y elem en ts.

175

Pa rt II Case s

2

In d ica t io n s (co n t )

Lu n a t e d is lo ca t io n s w it h t ra n s s ca p h o id fra ct u re

a

b

In stage IV com plete dislocation s o th e lu n ate, th e lu xation is u su ally in a palm ar direction ( a ). Wh en th ere is an addition al tran sscaph oid ractu re, th e proxim al scaph oid ragm en t can ollow th e dislocated lu n ate ( b ).

Fig 2.9-6a –b

Dis ru p t io n o f t h e d o rs a l ra d io lu n o t riq u e t ra l liga m e n t co m p le x

Ch o ice o f im p la n t

For perilu n ate in ju ries w ith a scaph oid ractu re, i th e proxim al ragm en t is large en ou gh , 2.4 m m or 3.0 m m im plan ts u sin g an tegrade in sertion can be con sidered. Scaphoid fracture

Im a gin g

Radiolunotriquetral ligament

a

Normal

b

Spilled tea cup

Th ere can also be a disru ption o th e dorsal radiolu n otriqu etral ligam en t com plex.

Fig 2.9-7 a – b

176

Diagn osis o perilu n ate ractu re dislocation s is based on th e h istory o trau m a, clin ical exam in ation , an d radiograph ic exam in ation . In th e coron al view , abn orm al overlappin g o carpal bon es an d alteration o “Gilu la´s arcs” can be observed, bu t a tru e lateral view is also recom m en ded ( or u rth er in orm ation on u sin g arcs to determ in e carpal in ju ry see th e in dication s topic in ch apter 2.10 Tran striqu etral tran sscaph oid perilu n ate ractu re dislocation treated w ith screw s). Lateral x-rays can sh ow th e spilled teacu p con gu ration o a dislocated lu n ate (as sh ow n in Fig 2.9-1 d ). Also look or th e trian gu lar pro le o a displaced lu n ate w h en th e capitate displaces proxim ally tow ard th e distal radial articu lar su r ace. Obtain in g CT scan s can o er m ore precise detail o th e in ju ry, in th is case dem on stratin g th is patien t’s scaph oid ractu re in th e ron tal plan e ( Fig 2.9-2 a –b ) an d in th e sagittal view ( Fig 2.9-3 a – c ).

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 1.4 m m to 1.6 m m K-w ires Poin ted redu ction orceps Bon e an ch ors Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.9-8

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision . Th e dorsal approach can also be u tilized to repair oth er carpal in ju ries.

Fig 2.9-9 a – b

177

Pa rt II Case s

4

Su rgica l a p p ro a ch (co n t )

Th e scaph oid ractu re w as exposed th rou gh th e dorsal approach .

Fig 2.9-10

5

Re d u ct io n

Pre lim in a r y re d u ct io n o f t h e lu n a t e

a

b

c

Closed redu ction is prelim in ary to operative treatm en t an d h as th ree ben e ts: • It restores carpal align m en t • It im proves th e patien t’s com ort • It redu ces pressu re on th e m edian n erve.

Fig 2.9-11a –c

Redu ction o th e dislocated lu n ate is ach ieved by distractin g th e wrist an d applyin g direct th u m b pressu re over th e lu n ate rom palm ar to dorsal. Th e h an d is th en gen tly f exed, an d on ce redu ction h as occu rred, th e distraction is gen tly relaxed.

Op e n re d u ctio n o f th e lu n a te

I closed redu ction is n ot su ccess u l, open redu ction is n ecessary as soon as possible du e to th e risk o m edian n erve com prom ise, o pain , an d to preserve blood su pply to th e lu n ate.

178

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

5

Re d u ct io n (co n t )

Dire ct re d u ct io n o f t h e s ca p h o id

De t e rm in e in s e r t io n p o in t fo r t h e gu id e w ire

Use sm all poin ted redu ction orceps to redu ce th e scaph oid ractu re.

Fig 2.9-1 3

Fig 2.9-1 2

Th e correct en try poin t or th e gu ide w ire is at th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion .

In s e r t t h e gu id e w ire

Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g th e in trodu ction o th e gu ide wire, th e wrist sh ou ld be in f exion oth erwise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph otrapezial join t with th e gu ide wire.

Fig 2.9-1 4

Th e ractu re w as redu ced an d h eld w ith a poin ted redu ction orceps an d th e K-w ire w as in serted u n der im age gu idan ce.

Fig 2.9-1 5

Im age in ten si cation in at least two plan es sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e ractu re. 179

Pa rt II Case s

6

Fixa t io n

Sca p h o id fixa t io n

a

b

Usin g a dorsal approach or th is scaph oid w aist ractu re, stable xation w as ach ieved w ith in sertion o a 3.0 m m h eadless screw .

Fig 2.9-1 6a –b

Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.3 Scaph oid— m u lti ragm en tary ractu re treated w ith a h eadless com pression screw an d lag screw .

Lu n o t riq u e t ra l liga m e n t re p a ir

In tran sscaph oid perilu n ate ractu re dislocation s, th e lu n otriqu etral ligam en t can also be torn . Th is can occu r rom th e lu n ate (m ost com m on ), in its m idsu bstan ce, or rom th e triqu etru m , an d th ere can be a bon y avu lsion rom eith er bon e.

Fig 2.9-17

There must be su cient ligament remnant or repair with bone anchors otherwise it is repaired by direct suture or trans xation o both bones with either K-wires or a small screw depending on the natu re o the injury. Regardless o the repair technique used, it is recommended to support the so t-tissue repair using tran s xation with two K-wires ( or approximately 6–10 weeks). Redu ction an d xation o th e lu n otriqu etral align m en t is u su ally possible u sin g a dorsal approach .

180

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

6

Fixa t io n (co n t )

Re p a ir w it h b o n e a n ch o rs

a

b

Wh en th ere is su cien t ligam en t rem n an t, th e lu n otriqu etral join t is redu ced an d tw o K-w ires are in serted percu tan eou sly rom th e u ln ar side o th e triqu etru m across th e lu n otriqu etral join t in to th e lu n ate ( a ). Con rm th e position o th e w ires u sin g im age in ten si cation . I th e detach m en t occu rs rom th e lu n ate, th e an ch or is placed on th e lu n ate ( b ) so th e ligam en t can be reattach ed u sin g th e su tu res o th e an ch or ( c ). I th e detach m en t occu rs rom th e triqu etru m , th e an ch or is placed on th at bon e in stead.

Fig 2.9-1 8a –c

c

181

Pa rt II Case s

6

Fixa t io n (co n t )

Re p a ir w it h a s cre w

Re p a ir w it h d ire ct s u t u re

Wh en th ere is bon y avu lsion o th e lu n otriqu etral ligam en t rom eith er bon e, th e ragm en t can be xed w ith n e K-w ires or a sm all screw .

Fig 2.9-2 0

Fig 2.9-1 9

Direct su tu re o th e ligam en t m ay also be

possible.

Co m p le t e t h e fixa t io n

Th e capsu lotom y f ap is th en closed.

a

b

c

In traoperative im ages sh ow th e direct repair o th e dorsal lu n otriqu etral ligam en t an d placem en t o tw o K-w ires across th e join t.

Fig 2.9-2 1a –c

182

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

6

Fixa t io n (co n t )

a

b

Im m ediate postoperative x-rays dem on strate th e an atom ical redu ction an d K-wire xation .

Fig 2.9-22a –b

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.8 Perilu n ate dislocation treated w ith K-w ires.

Fig 2.9-23

183

Pa rt II Case s

8

Ou t co m e

a

b

At th e 12-m on th ollow -u p, th e x-rays sh ow ed a h ealed scaph oid ractu re an d n orm al lu n ate align m en t.

Fig 2.9-2 4a –b

a

b

c

d

Fig 2.9-2 5a –d

184

Th e patien t h ad ach ieved n ear u ll u n ction al recovery.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

Tra n s s ca p h o id p e rilu n a t e fra ct u re d is lo ca t io n t re a t e d u s in g m u lt ip le s cre w s a n d via b o t h d o rs a l a n d p a lm a r s u rgica l a p p ro a ch e s

a

b

c

A 21-year-old m an su stain ed a tran sscaph oid perilu n ate ractu re dislocation as a resu lt o a m otorcycle in ju ry. Th e clin ical appearan ce o th e h an d an d w rist sh ow ed severe dorsal de orm ity an d sw ellin g. Th e AP an d lateral x-rays dem on strated th at th e capitate w as dorsally dislocated over th e lu n ate, an d th ere w as a displaced proxim al pole ractu re o th e scaph oid.

Fig 2.9-2 6a –c

In d ica t io n s

In th is perilu n ate in ju ry, th e capitate h as becom e dislocated rom its n orm al position in g, an d th e lu n ate h as lost its n orm al align m en t w ith th e distal radiu s. Th e lu n otriqu etral ligam en t w as also a ected. Th is m akes it a stage III m idcarpal ractu re dislocation .

Fig 2.9-27

Stage III

In cases o exten sive displacem en t, m u lti ragm en tation , or scaph oid bon e de ect, xation w ith a sin gle screw alon e is u n likely to give en ou gh stability. In th ese cases, a com bin ation o tw o screw s or a screw an d a K-w ire m ay be n ecessary to ach ieve th e requ ired stability. In addition , both dorsal an d palm ar su rgical approach es m ay be n ecessary. Be ore th e n al xation , redu ce all displaced ragm en ts. In cases o m u lti ragm en tation , bon e gra tin g m ay be in dicated.

185

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

Co m b in e d d o rs a l a n d p a lm a r s u rgica l a p p ro a ch e s

a

b

Alon g with th e u su al dorsal approach , an addition al palm ar approach will reveal th e ch aracteristic disru ption s o th e extrin sic palm ar ligam en ts. A palm ar approach sh ou ld be con sidered wh en th ere is m edian n erve dis u n ction or wh en it is n ot possible to do e ective redu ction by a dorsal on ly approach . By doin g th is, it also allows better access to th e palm ar ban d o th e lu n otriqu etral ligam en t (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries).

Fig 2.9-28a –b

a Fig 2.9-2 9a –b

186

b

Th e dorsal ( a ) an d palm ar ( b ) approach es to th e w rist w ere ou tlin ed on th e skin .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

Pa lm a r s id e

a

b

Becau se o th e speci c n atu re o th is in ju ry, th e in itial su rgical approach w as on th e palm ar side w ith release o th e tran sverse carpal ligam en t an d m edian n erve ( a ). Th e con ten ts o th e carpal tu n n el are care u lly retracted in order to see th e tear in th e palm ar capsu lar ligam en ts an d th e position in g o th e lu n ate an d capitate bon es ( b ).

Fig 2.9-3 0a –b

Do rs a l s id e

A stan dard dorsal approach is th en also per orm ed (as described earlier in th is ch apter).

187

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n Re d u ct io n o f ca rp a ls

Re d u ct io n o f t h e s ca p h o id

On ce th e dorsal approach was per orm ed, th e carpal bon es were redu ced in relation to th e lu n ate (as seen th rou gh th e dorsal exposu re).

Fig 2.9-3 2

Fig 2.9-31

Th e scaph oid ractu re w as th en redu ced an d h eld w ith a poin ted redu ction orceps. A gu ide w ire w as placed th rou gh a drill gu ide an d con rm ed w ith in traoperative im agin g.

Fixa t io n o f t h e s ca p h o id

a Fig 2 .9 -3 3 a – b

b

Stable xation o th e scaph oid ractu re w as ach ieved w ith in sertion o tw o 2.4 m m h eadless com pression

screw s. Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated w ith a h eadless com pression screw .

188

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Fixa t io n o f t h e p a lm a r liga m e n t s

Th e palm ar approach reveals th e disru ption s o th e extrin sic palm ar ligam en ts, wh ich occu r th rou gh th e space o Poirier (an an atom ical weak spot in th e f oor o th e carpal tu n n el th at can allow m ovem en t o th e distal carpal row away rom th e lu n ate). A ren t or tear in th e palm ar capsu le, between proxim al an d distal ligam en t arch es, exposes th e m idcarpal join t an d th e lu n otriqu etral ligam en t.

Fig 2.9-34

a

b

Th e m idcarpal join t is irrigated, loose bodies or su bch on dral f akes are rem oved, an d th e ren t is repaired an atom ically u sin g in terru pted resorbable su tu res.

Fig 2.9-3 5a –b

189

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Lu n o t riq u e t ra l liga m e n t re p a ir

a

b

c

Th e lu n otriqu etral join t w as stabilized w ith tw o sm ooth K-w ires an d th e lu n otriqu etral ligam en t w as th en repaired u sin g a bon e an ch or in th e lu n ate.

Fig 2.9-3 6a –c

Th e xation procedu re ollow s th e u su al steps o assessin g ligam en t rem n an t, percu tan eou s in sertion o K-w ires, placin g o bon e an ch or, an d reattach in g th e ligam en t u sin g th e an ch or su tu res. Th is procedu re is explain ed m ore u lly earlier in th is ch apter.

Ou t co m e

a

b

At th e in itial ollow -u p at arou n d 6 w eeks, th ere w ere sign s o e ective h ealin g. Th e K-w ires w ere th en rem oved.

Fig 2.9-3 7a –b

190

a

b

Th ere w as an excellen t radiological resu lt by th e 1-year ollow -u p.

Fig 2.9-3 8a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.9 Transscaphoid pe rilunate fracture dislocation tre ate d with K-wire s and a he adle ss scre w

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t )

a

b

c

d

e

f

Fig 2.9-3 9a –f

a

At th is stage, n ear u ll w rist m otion w as ach ieved w ith n o residu al discom ort.

b

Fig 2 .9 -4 0a – b

Good grip stren gth h ad also retu rn ed.

191

Pa rt II Case s

192

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.10

1

Transtriquetral transscaphoid perilunate fracture dislocation treated with screws

Ca s e d e s crip t io n

a

b

a

A 23-year-old m ale u n iversity stu den t su ered a all on h is ou tstretch ed righ t h an d w h ile ridin g a bicycle. He presen ted to th e em ergen cy departm en t w ith n u m bn ess in th e n gers, severe pain , an d de orm ity o th e w rist. Th e x-rays revealed overlappin g o th e carpal bon es, loss o con tin u ity o Gilu la’s arcs, an d a displaced ractu re o th e scaph oid. In th e lateral view , th e capitate w as dislocated dorsally w h ile th e lu n ate m ain tain ed its n orm al an atom ical relation sh ip w ith th e radiu s.

Fig 2.10 -1a –b

a

b

c

b

Redu ction w as ach ieved u n der sedation in th e em ergen cy departm en t providin g im m ediate im provem en t to patien t pain an d n u m bn ess o th e n gers. Th e su bsequ en t x-rays revealed per ect redu ction to th e carpal bon es an d th e scaph oid ractu re.

Fig 2.10 -2a –b

d

In addition , CT scan s revealed a per ect an atom ical relation sh ip between th e carpal bon es. However, wh ile th ere was per ect redu ction o th e scaph oid proxim al pole ractu re, th e CT scan revealed a previou sly u n detected ractu re o th e triqu etru m . Th e triqu etral ractu re appeared displaced, raisin g th e su spicion (an d later proved) th at th ere was also an avu lsion o th e lu n otriqu etral ligam en t. Th e axial view CT scan sh owed th e ractu re o th e triqu etru m was on th e palm ar aspect, wh ich is wh ere th e stron ger part o th e lu n otriqu etral ligam en t is attach ed.

Fig 2.10-3a –d

193

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

Th e dorsal an d palm ar view 3-D CT scan s o ered a m ore precise perspective o both th e scaph oid an d triqu etral ractu res.

Fig 2.10-4a –b

a

2

b

In d ica t io n s

Pe rilu n a te fra ctu re d islo ca tio n s in vo lvin g th e triq u e tru m

Perilu n ate ractu re dislocation s presen t an exten sive array o in ju ries. Fractu res o th e carpal bon es adjacen t to th e lu n ate can occu r in stead o isolated ligam en t ru ptu res, w h en th e disru ptin g orce propagates arou n d th e m idcarpal join t. Wh ile m ost perilu n ate ractu res in volve th e scaph oid, oth er carpal bon es in clu din g th e triqu etru m can be in volved. Recogn ition an d repair o all bon y an d so t-tissu e com pon en ts are essen tial in order to restore carpal stability an d to preven t posttrau m atic degen erative join t disease.

Fig 2.10 -5

Arcs

Arcs are lin es th at can be draw n or im agin ed on x-ray/ CT im ages o th e h an d an d w rist to h elp assess th e align m en t o th e carpu s. Cou n tless variation s o in ju ry pattern s can be iden ti ed depen din g on w h ich carpal bon es are a ected an d th e direction o an y dislocation or ractu re displacem en t.

194

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.10 Transtrique tral transcaphoid pe rilunate fracture dislocation tre ate d with scre ws

2

In d ica t io n s (co n t )

Gilula’s arcs III Gilula’s arcs II

Greater arcs

Gilula’s arcs I Lesser arcs a

b

As an exam ple, Gilu la’s arcs ou tlin e th e borders o th e proxim al an d distal carpal row s ( a ). A deviation in th e n orm al sm ooth lin e con tou r alon g th e row s in dicates disru ption or dislocation am on g th e carpals. Th is is com m on in cases o perilu n ate ractu re dislocation . Greater arc in ju ries in dicate ractu re dislocation s o th e scaph oid, capitate, h am ate, an d/ or triqu etru m , w h ile lesser arc in ju ries are pu re ligam en tou s in ju ries arou n d th e lu n ate ( b ). Th ese variou s arcs h elp greatly in iden ti yin g th e location o an y carpal in ju ry.

Fig 2.10 -6a –b

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 Modu lar screw set 1.5 or 2.0 1.4 m m to 1.6 m m K-w ires Poin ted redu ction orceps Bon e an ch ors Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.10-7

195

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision .

Fig 2.10 -8a –b

Th e in traoperative im age sh ow s th e dorsal approach to th e carpu s, w h ich allow s redu ction an d stabilization o th e scaph oid ractu re to be clearly seen w h ile en su rin g in tegrity o th e scaph olu n ate ligam en t.

Fig 2.10-9

196

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.10 Transtrique tral transcaphoid pe rilunate fracture dislocation tre ate d with scre ws

5

Re d u ct io n

Sca p h o id re d u ct io n

Use sm all poin ted redu ction orceps to redu ce th e scaph oid ractu re.

Fig 2.10 -10

De t e rm in e s ca p h o id in s e r t io n p o in t a n d in s e r t t h e gu id e w ire

a

b

Th e correct en try poin t or th e gu ide wire is in th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion . Th e gu ide wire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g th e in trodu ction o th e gu ide wire, th e wrist sh ou ld be in f exion oth erwise th e en try poin t can n ot be reach ed ( a ). Do n ot pen etrate th e scaph otrapezial join t with th e gu ide wire. Im age in ten si cation sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e ractu re ( b ).

Fig 2.10-11a –b

197

Pa rt II Case s

6

Fixa t io n

Sca p h o id fixa t io n

a

b

c

Follow in g m easu rin g an d drillin g, an d u sin g im age in ten si cation , a can n u lated h eadless com pression screw w as in trodu ced in to th e scaph oid bon e u n til th e ractu re gap w as closed an d com pressed.

Fig 2.10 -12 a – c

Th e xation procedu re ollow s th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw , in sertin g th e screw , an d advan cin g an d cou n tersin kin g th e screw . For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated w ith a h eadless com pression screw .

a

b

In traoperative im ages sh ow ed th ere w as correct position in g o th e screw .

Fig 2.10 -13 a – b

198

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.10 Transtrique tral transcaphoid pe rilunate fracture dislocation tre ate d with scre ws

6

Fixa t io n (co n t )

Triq u e t ru m fixa t io n

a

b

c

d

Th e triqu etru m h ad been split in to palm ar an d dorsal com pon en ts. Alth ou gh th e palm ar ractu re ragm en t w as th e bigger ragm en t ( a – b ), it w as redu ced an d stabilized by in trodu cin g a 1.5 m m lag screw via th e dorsal aspect o th e bon e ( c– d ).

Fig 2.10 -14 a – d

Us e o f la g s cre w s

a

Co u n t e rs in k in g

b

Be su re to in sert th e screw as a lag screw , w ith a glidin g h ole in th e n ear cortex, an d a th readed h ole in th e ar cortex ( a ). In sertin g a screw across a ractu re plan e th at is th readed in both cortices (position screw ) w ill h old th e ragm en ts apart an d apply n o in ter ragm en tary com pression ( b ).

Fig 2.10 -15 a – b

a

b

Also en su re to cou n tersin k th e screw to redu ce th e risk o so t-tissu e irritation , so th at th e screw h ead h as m axim al con tact area w ith th e bon e.

Fig 2.10 -16 a – b

199

Pa rt II Case s

6

Fixa t io n (co n t )

Th e redu ction an d xation o th e triqu etral ractu re was th en also ch ecked in traoperatively.

Fig 2.10-17

Lu n o t riq u e t ra l liga m e n t re p a ir

a

b

c

Th e palm ar com pon en t o th e lu n otriqu etral ligam en t was redu ced th rou gh a dorsal approach . Th e palm ar com pon en t is th e th icker an d stron ger aspect, an d it is im portan t to en su re its repair. However, as th e ractu re xation s in th is case were m ade by a dorsal approach , an addition al palm ar approach was n ot n ecessary. Th e dorsal portion o th e lu n otriqu etral ligam en t was th en repaired with su tu res. Th e lu n otriqu etral join t was stabilized with a K-wire.

Fig 2.10-18a –c

Co m p le t e t h e fixa t io n

Th e capsu lotom y f ap is th en closed. Th e patien t w as im m ediately im m obilized u sin g a plaster splin t.

200

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.10 Transtrique tral transcaphoid pe rilunate fracture dislocation tre ate d with scre ws

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.8 Perilu n ate dislocation treated w ith K-w ires.

Fig 2.10-19

a

b

For th is patien t, both th e K-w ire an d th e cast w ere rem oved at th e 8-w eek ollow -u p. Th e patien t w as th en re erred or ph ysical th erapy.

Fig 2.10 -20 a – b

8

Ou t co m e

a

b

At th e 1-year ollow-u p, th e x-ray im ages sh owed per ect align m en t o th e carpu s an d com plete h ealin g o both th e scaph oid an d triqu etral ractu res.

Fig 2.10-21a –b

201

Pa rt II Case s

8

Ou t co m e (co n t )

a

b

c

d

e

f

Good radial an d u ln ar deviation o th e w rist w as sh ow n , an d th ere w as an excellen t u n ction al ou tcom e.

Fig 2.10 -22 a – f

Th e patien t h ad ach ieved good grip stren gth com pared w ith th e u n in ju red h an d, allow in g h im to retu rn to h is previou s activities w ith ou t lim itation .

Fig 2.1 0-23 a –b

a

202

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.11

1

Multiple carpal perilunate fracture dislocation and scaphocapitate syndrome treated with screws

Ca s e d e s crip t io n

a

b

c

A 21-year-old sem ipro ession al BMX bicycle rider su stain ed a h igh -en ergy in ju ry to h is dom in an t righ t w rist a ter a all du rin g a racin g com petition . He presen ted to th e em ergen cy departm en t com plain in g o severe pain , w rist de orm ity, an d m edian n erve distribu tion n u m bn ess.

Fig 2.11 -1a –c

Follow in g exam in ation , a w ide ran ge o im ages w ere taken . Th e ollow in g in ju ries w ere in dicated: • Dorsal perilu n ate dislocation o th e carpu s • Fractu re o th e scaph oid proxim al th ird • Fractu re o th e proxim al pole o th e h am ate • Fractu re o th e h ead o th e capitate • Displacem en t o th e capitate ractu re in th e dorsal aspect o th e carpu s an d rotated 90 degrees • Th e lu n ate rem ain ed articu lated w ith th e proxim al pole o th e scaph oid an d w ith th e distal radiu s bu t it w as su blu xed palm arly on th e lu n ate acet • Fractu re o th e u ln ar styloid base.

Th e coron al view 2-D CT scan s sh ow ed greater detail o th is com plex in ju ry, in clu din g th e ractu re o th e scaph oid, th e ractu re o th e h ead o th e capitate, th e ractu re o th e h am ate, an d eviden ce o dissociation betw een th e triqu etru m an d th e lu n ate (arrow ).

Fig 2 .1 1-2 a – b

a

b

203

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

e

b

c

f

d

g

Th e AP view 3-D CT scan ( a ) sh owed th e dorsal dislocation o th e carpu s, wh ile th e lu n ate rem ain ed articu lated with th e radiu s an d to th e proxim al pole o th e scaph oid. Th e radial view CT scan ( b ) sh owed th e scaph oid ractu re. Th e 3-D im ages also sh owed th at th e proxim al th ird o th e scaph oid was deeply displaced, th e h ead o th e capitate h ad rotated 90 degrees, an d th at th ere were ractu res o th e h am ate an d th e u ln ar styloid ( c–d ). Th e lu n otriqu etral ligam en t disru ption was eviden ced ( e –f). Th e axial view 3-D CT scan s sh owed th e dorsal dislocation o th e carpu s with m ore detail ( g ).

Fig 2.11-3a –g

A ter evalu atin g all th e im ages, it was con clu ded th at th e patien t h ad received a dorsal perilu n ate ractu re dislocation th at in volved scaph oid, capitate, h am ate, an d u ln ar styloid ractu res.

204

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.11  Multiple carpal pe rilunate fracture dislocation and scaphocapitate syndrome tre ate d with scre ws

2

In d ica t io n s

Pe rilu n a t e fra ct u re d is lo ca t io n w it h s ca p h o ca p it a t e s yn d ro m e

As previou sly discu ssed, perilu n ate ractu re dislocation s presen t an exten sive array o in ju ries an d in clu de ractu res o carpal bon es an d ligam en tou s in ju ry adjacen t to th e lu n ate. Wh ile m ost perilu n ate ractu res in volve th e scaph oid, oth er carpal bon es in clu din g th e capitate an d th e h am ate can be in volved. Addition al ractu res can also occu r at th e radial styloid an d, as w ith th is patien t, th e u ln ar styloid.

Fig 2.11 -4

180°

a

b

c

Th e in ju ry to th is patien t also represen ts a speci c variation o m u ltiple carpal perilu n ate ractu re dislocation kn own as scaph ocapitate (or n avicu locapitate) syn drom e, an d is rare. In th is in ju ry, th e h igh -en ergy orce passes th rou gh th e n eck o th e capitate, ractu rin g both th e scaph oid an d th e capitate. Th e resu lt is th at th e proxim al portion o th e capitate can rotate 90 to 180 degrees, with th e articu lar su r ace o th e h ead o th e capitate directed distally. Open redu ction an d in tern al xation is alm ost always requ ired in order to restore carpal stability.

Fig 2.11-5a –c

205

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Headless com pression screw set 2.4 or 3.0 Modu lar screw set 1.3 or 1.5 1.4 m m to 1.6 m m K-w ires A tooth ed orceps Bon e an ch ors Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Pron ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.11-6

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever, on ly th e dorsal approach w as requ ired w ith th is patien t). Th is approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision .

Fig 2.11 -7a –b

206

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.11  Multiple carpal pe rilunate fracture dislocation and scaphocapitate syndrome tre ate d with scre ws

4

Su rgica l a p p ro a ch (co n t )

EPL

CH

Th e w rist w as exposed th rou gh a dorsal approach an d capsu lar in cision . Th e ractu re o th e h ead o th e capitate becam e eviden t (CH), as w as its displacem en t in th e dorsal aspect o th e carpu s w ith 90 degree rotation . Th e exten sor pollicis lon gu s (EPL) w as retracted.

Fig 2 .1 1-8

5

Re d u ct io n

Ca p it a t e re d u ct io n

Hamate

a

b

Usin g a tooth ed orceps, th e displaced proxim al h ead o th e capitate is reapproxim ated to its correct an atom ical location . Th e in traoperative im ages sh ow th e h ead o th e capitate bein g h eld by th e orceps ( a ), w h ich w ere u sed to redu ce th e ractu re. An arrow iden ti es th e h am ate ractu re ( b ).

Fig 2.11 -9a –b

207

Pa rt II Case s

5

Re d u ct io n (co n t )

Ha m a t e re d u ct io n

SL C H

Sca p h o id re d u ct io n

De te rm ine sca phoid inse rtion point a nd inse rt the gu ide wire

Fu rth er traction on th e area perm itted th e scaph oid ractu re to be redu ced. Note th at n o com pression is yet applied (arrow).

Fig 2.11-12

Fig 2.11-11

208

On ce th e capitate is redu ced, th e h am ate is th en stabilized an d redu ced. Th e in traoperative im age sh ows th e redu ction o th e m idcarpal join t, in clu din g th e capitate (C) an d h am ate (H) redu ction . Th e scaph olu n ate ligam en t (SL) rem ain ed u n a ected. Th e scaph oid waist ractu re rem ain ed displaced at th is stage (arrow).

Fig 2.11-10

Th e correct en try poin t or th e gu ide w ire is in th e cen ter o th e proxim al pole, directly adjacen t to th e scaph olu n ate ligam en t in sertion . Th e gu ide w ire is in serted in th e axis o th e sh a t o th e rst m etacarpal, in radial abdu ction . Du rin g th e in trodu ction o th e gu ide w ire, th e w rist sh ou ld be in f exion oth erw ise th e en try poin t can n ot be reach ed. Do n ot pen etrate th e scaph otrapezial join t w ith th e gu ide wire. Im age in ten si cation sh ou ld be u sed to con rm accu rate advan cem en t o th e gu ide wire in th e scaph oid axis an d perpen dicu lar to th e ractu re.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.11  Multiple carpal pe rilunate fracture dislocation and scaphocapitate syndrome tre ate d with scre ws

6

Fixa t io n

Ca p it a t e fixa t io n

Ha m a t e fixa t io n

Fig 2.11 -13

Th e h ead o th e capitate w as devoid o an y attach m en t, so it w as an atom ically redu ced. Th e capitate ragm en t can th en be stabilized w ith eith er a 1.5 m m h eadless com pression screw or a 1.5 m m u lly th readed cortex screw applied as a lag screw . In th is case, a 1.5 m m lag screw w as in serted in an tegrade direction .

Fig 2.11 -14

Us e o f la g s cre w s

Co u n t e rs in k in g

a

b

Be su re to in sert th e screw as a lag screw , w ith a glidin g h ole in th e n ear cortex, an d a th readed h ole in th e ar cortex ( a ). In sertin g a screw across a ractu re plan e th at is th readed in both cortices (position screw ) w ill h old th e ragm en ts apart an d apply n o in ter ragm en tary com pression ( b ).

Fig 2.11 -15 a – b

Th e proxim al pole o th e h am ate w as xed w ith a 1.3 m m lag screw in an tegrade direction . Care w as taken to bu ry both th e capitate an d h am ate screw h eads u n der th e articu lar cartilage.

a

b

Also en su re to cou n tersin k th e screw to redu ce th e risk o so t-tissu e irritation , so th at th e screw h ead h as m axim al con tact area w ith th e bon e.

Fig 2.11 -16 a – b

209

Pa rt II Case s

6

Fixa t io n (co n t )

Sca p h o id fixa t io n

Atten tion w as th en brou gh t to th e scaph oid proxim al th ird ractu re. A ter an atom ical redu ction w as per orm ed, xation w as ach ieved w ith a 3.0 m m h eadless com pression screw . Th e dorsal scaph olu n ate ligam en t w as u n in ju red.

Fig 2.11 -17

Th e xation procedu re ollows th e u su al steps o m easu rin g screw len gth , drillin g, selectin g th e screw, in sertin g th e screw, an d advan cin g an d cou n tersin kin g th e screw. For u rth er in orm ation on th ese steps see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated with a h eadless com pression screw.

Lu n o t riq u e t ra l liga m e n t re p a ir

a

b

A m idsu bstan ce tear o th e lu n otriqu etral ligam en t was n oted an d repaired directly with n on absorbable su tu res ( a ). Th e lu n otriqu etral join t was stabilized with a percu tan eou s K-wire ( b ).

Fig 2.11-18a –b

Th e ligam en t repair procedu re ollows th e u su al steps o determ in in g i th e tear is m idsu bstan ce or bon y avu lsion , determ in in g size o ligam en t rem n an t or bon e an ch ors or direct su tu re, an d in sertion o K-wires. For u rth er in orm ation on th ese steps see ch apter 2.8 Perilu n ate dislocation treated with K-wires.

210

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.11  Multiple carpal pe rilunate fracture dislocation and scaphocapitate syndrome tre ate d with scre ws

6

Fixa t io n (co n t )

Uln a r s t ylo id re p a ir

Th e DRUJ w as stable du rin g in traoperative exam in ation so on th is occasion th e u ln ar styloid ractu re w as n ot xed.

a

b

Th e in traoperative im ages sh ow th e variou s ractu re redu ction s an d xation s.

Fig 2.11 -19 a – b

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow-u p, rem oval o stitch es, an d im m obilization as requ ired. Followin g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 2.8 Perilu n ate dislocation treated with K-wires.

Fig 2.11-20

Th e patien t in th is ch apter was im m ediately placed in to a sh ort arm plaster splin t. Th ere were n o in traoperative or postoperative com plication s, an d m edian n erve distribu tion n u m bn ess resolved com pletely in th e im m ediate postoperative period. Su tu res were rem oved 2 weeks a ter su rgery an d th e splin t was replaced with a rem ovable orth osis. Nin e weeks a ter su rgery th ere was radiograph ic eviden ce o h ealin g o all ractu res th u s th e K-wire was rem oved. Th e patien t was cleared or active an d passive ran ge o m otion exercises at 12 weeks an d retu rn ed to im pact bike ridin g sports at 4 m on th s.

211

Pa rt II Case s

8

Ou t co m e

a

b

At th e 8-m on th ollow -u p, th e x-rays dem on strated h ealin g o all ractu res w ith ou t eviden ce o avascu lar n ecrosis or collapse.

Fig 2.11 -21 a – b

a

b

c

d

e

f

At th is stage, th e patien t dem on strated a u n ction al ran ge o m otion . Note th e f exion lim itation o th e w rist, w h ich can be expected in th is severe type o in ju ry. Th e patien t w en t on to ach ieve excellen t recovery by th e 1-year ollow -u p, even tu ally retu rn in g to prior levels o activity w ith ou t lim itation s.

Fig 2.11 -22 a – f

212

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2.12

1

Trapezium —displaced fracture treated with lag screws

Ca s e d e s crip t io n

A 44-year-old m ale retail w orker in ju red h is le t dom in an t th u m b w h en h e tried to catch a large h eavy object as it ell tow ard h im at w ork. His th u m b w as orcibly h yperexten ded. Th e in itial x-rays revealed a displaced ractu re in th e body o th e trapeziu m .

Fig 2 .1 2-1

2

In d ica t io n s

Tra p e ziu m fra ct u re s

Fractu res o th e trapeziu m are rare an d accou n t or on ly 3–5% o all carpal ractu res. Th e trapeziu m is an im portan t bon e an d con tribu tes to th e stability an d pain - ree u n ction o th e th u m b in pin ch in g an d grippin g. Fractu res o th e trapeziu m are eith er avu lsion ractu res o th e periph eral aspects o th e bon e su stain ed du rin g a carpom etacarpal (CMC) join t dislocation (th e m ost com m on type o trapezial ractu re), or a com pression ractu re a ectin g th e body o th e bon e. Th e latter m ech an ism , illu strated in th is case, is alm ost alw ays th e con sequ en ce o a h igh -en ergy in ju ry. Displaced body ractu res o th e trapeziu m in volve th e CMC join t o th e th u m b an d w ill h eal in articu lar m alu n ion , i n ot adequ ately redu ced an d stabilized.

Fig 2.12 -2

Trapezium

Ch o ice o f im p la n t

Th e bon e qu ality in th e trapeziu m is alm ost always good. As a con sequ en ce, ractu res are su itable or stabilization with lag screws (u su ally 1.5 m m ) u n less th ere are cen tral areas o ragm en tation an d e ective bon e loss. In th ese circu m stan ces, K-wires are a u se u l option i com pression o th e ragm en ts is con train dicated du e to m u lti ragm en tation . 213

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

• Modu lar h an d set 1.3 or 1.5 • Poin ted redu ction orceps • Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Su pin ate th e orearm . A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 2.12 -3

4

Su rgica l a p p ro a ch

Ap p ro a ch Superficial branch of the radial nerve

Radial artery

Th e su rgical approach u sed w as a radiopalm ar approach to th e th u m b (see ch apter 1.4 Radiopalm ar approach to th e th u m b base). Th is approach allow ed access to th e trapeziu m im m ediately proxim al to th e m etacarpal.

Fig 2.12 -4

214

O th e tw o in cision option s available or th is approach , on th is occasion a Wagn er in cision w as u sed, w h ich ollow s th e th en ar em in en ce in a gen tle cu rve tow ard its palm ar aspect.

Fig 2.12 -5

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.12 Trape zium —displace d fracture tre ate d with lag scre ws

5

Re d u ct io n

a

b

As part o th e su rgical approach , th e join t capsu le h as been open ed ( a ). Th is n ow allows or direct in spection o th e articu lar redu ction . Poin ted redu ction orceps are u sed to stabilize th e redu ction tem porarily ( b ).

Fig 2.12-6a –b

6

Fixa t io n

Drillin g

Scre w in s e r t io n

Leavin g th e redu ction orceps in place, drill a glidin g h ole as perpen dicu lar to th e ractu re plan e as possible, u sin g a 1.5 m m drill bit or a 1.5 m m screw . In sert a 1.5 m m drill gu ide in to th e glidin g h ole. Use a 1.1 m m drill bit to drill a th readed h ole in th e opposite ragm en t, ju st th rou gh th e ar cortex. Repeat th e above or a secon d screw .

Fig 2.12 -8

Fig 2.12 -7

A m in im u m o tw o screw s u sed as lag screw s are n ecessary to provide su cien t stability in com pression an d rotation . Wh ile 1.5 m m screw s are recom m en ded, 1.3 m m screw s m ay also be u sed i ragm en t size does n ot perm it.

215

Pa rt II Case s

6

Fixa t io n (co n t )

Us e o f la g s cre w s

a

Co u n t e rs in k in g

b

a

Be su re to in sert th e screw as a lag screw , w ith a glidin g h ole in th e n ear cortex, an d a th readed h ole in th e ar cortex ( a ). In sertin g a screw across a ractu re plan e th at is th readed in both cortices (position screw ) w ill h old th e ragm en ts apart an d apply n o in ter ragm en tary com pression ( b ).

b

Also en su re to cou n tersin k th e screw to redu ce th e risk o so t-tissu e irritation , so th at th e screw h ead h as m axim al con tact area w ith th e bon e.

Fig 2.12 -9a –b

Fig 2.12 -10 a – b

Co m p le t e t h e fixa t io n

Con rm ation o redu ction an d xation sh ou ld be obtain ed u sin g im age in ten si cation or x-rays. It w ill be n ecessary to take several im ages at variou s an gles in order to en su re th ere is n o articu lar pen etration w ith a lag screw tip. Con rm ation o th is can be obtain ed by direct in spection th rou gh th e previou sly created capsu lotom y.

216

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

2 Carpal bone s 2.12 Trape zium —displace d fracture tre ate d with lag scre ws

7

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 2.12 -11

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

As pain an d sw ellin g recede, con trolled f exion an d exten sion exercises or th e th u m b an d h an d gen tly progress. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist. A retu rn to n orm al activities can be en cou raged a ter 6 w eeks.

Fig 2.12 -13

Th e w rist an d th u m b are im m obilized or 4 to 6 w eeks in a sh ort arm splin t. A rem ovable w rist splin t in clu din g th e th u m b to th e in terph alan geal join t can be u sed rom 2 w eeks, du rin g w h ich tim e th e patien t is en cou raged to rem ove th e splin t or sh ort periods du rin g th e day to allow gen tle th u m b m otion .

Fig 2.12 -12

217

Pa rt II Case s

8

Ou t co m e

a

b

Con gru en t redu ction w as con rm ed on review o th e 6-w eek postoperative ollow -u p im ages. Th e patien t w as th en able to retu rn to n orm al retailin g w ork activities.

Fig 2.12 -14 a – b

218

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3

Ulna

Pa rt II Case s

220

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

3.1

1

Ulnar styloid–fracture treated with tension band wiring

Ca s e d e s crip t io n

a

b

c

d

A 38-year-old en gin eer w as in ju red w h ile participatin g in a dirt bike com petition . Wh en h e arrived in th e em ergen cy departm en t h e com plain ed o pain in h is n on dom in an t le t w rist, an d th ere w as eviden ce o edem a an d de orm ity. Th e x-rays an d 3-D CT scan s in dicated a ractu re at th e base o th e u ln ar styloid.

Fig 3.1-1a – d

Th ere was also exten sive m u lti ragm en tation in both th e in term ediate an d radial colu m n s o th e distal radiu s, h owever, treatm en t or th is patien t’s distal radial ractu res are discu ssed in detail in ch apter 4.6 Distal radiu s—m u lti ragm en tary in traarticu lar ractu re treated with a palm ar plate. For th e pu rposes o th is ch apter, on ly th e u ln ar styloid ractu re is discu ssed.

2

In d ica t io n s

Fra ct u re s o f t h e u ln a r s t ylo id

Th e u ln ar styloid can be avu lsed at its tip, th rou gh th e body, or at its base. Th e level at w h ich th e avu lsion occu rred h as im plication s on th e in tegrity o th e attach m en t o th e trian gu lar brocartilage com plex (TFCC) an d th e stability o th e distal radiou ln ar join t (DRUJ). I th e in ju ry in volves th ese stru ctu res th ey m ay also requ ire repair.

Fig 3.1-2

221

Pa rt II Case s

2

In d ica t io n s (co n t )

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

Fractu res o th e u ln ar styloid th at requ ire xation are th ose th at produ ce eviden t DRUJ in stability. Th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e ollow in g tw o m eth ods are recom m en ded to determ in e i in stability exists.

Me t h o d 1: DRUJ b a llo t t e m e n t

a

b

a

Th e elbow is f exed 90 degrees on th e arm table with th e orearm in n eu tral rotation an d displacem en t in a dorsal/ palm ar direction is assessed. Th is is repeated with th e wrist in radial deviation , wh ich stabilizes th e DRUJ, i th e u ln ar collateral com plex is n ot disru pted.

Fig 3.1-3a –b

b

Th is is again repeated w ith th e w rist in u ll su pin ation an d u ll pron ation .

Fig 3.1-4 a – b

Me t h o d 2 : u ln a r co m p re s s io n t e s t

a

b

c

In th is test, th e u ln a is com pressed again st th e radiu s ( a ). Th e orearm is rotated passively th rou gh u ll su pin ation ( b ) an d pron ation ( c ).

Fig 3.1-5 a – c

I th ere is a palpable “clu n k”, in stability o th e DRUJ is presen t. Th is is an in dication to con sider in tern al xation o th e u ln ar styloid ractu re by ten sion ban d w ire, lag screw , or plate. A DRUJ in stability can also resu lt rom so t-tissu e in ju ry to th e TFCC.

222

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.1 Ulnar styloid– fracture tre ate d with tension band wiring

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

0.4 m m cerclage w ire 1.0 m m K-w ires Poin ted redu ction orceps Hypoderm ic n eedle

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

a

b

c

d

Position th e patien t su pin e an d place th e orearm on a h an d table ( a ). Th e elbow is f exed, w h ich h olds th e orearm in n eu tral rotation an d allow s or a direct approach to th e distal u ln a ( b ). In som e ractu res, it m ay also be possible to sim ply rest th e patien ts orearm on th eir ch est ( c ). Altern atively, position in g patien ts on th eir side an d restin g th e a ected orearm in a padded trou gh w ith th e elbow f exed w ill allow th e u ln ar styloid to be per ectly visible w h en th e orearm is rotated in to u ll su pin ation ( d ). A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 3.1-6 a – d

223

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Th e su rgical approach u sed was an u ln ar approach (see chapter 1.10 Uln ar approach to th e distal uln a) ( a ). Care was taken to avoid damagin g the dorsal cu taneou s branch o th e u ln ar n erve du rin g th e approach ( b ).

Fig 3.1-7a –b

5

Re d u ct io n

Re d u ct io n w it h s t a y s u t u re

A stron g stay su tu re can be in serted arou n d th e tip o th e styloid to h elp w ith redu ction in preparation or th e later application o a ten sion ban d w ire.

Fig 3.1-8

224

By pu llin g proxim ally on th is su tu re, th e u ln ar styloid is redu ced.

Fig 3.1-9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.1 Ulnar styloid– fracture tre ate d with tension band wiring

5

Re d u ct io n (co n t )

Dire ct re d u ct io n

Redu ction can also be ach ieved u sin g a den tal pick or a poin ted redu ction orceps.

Fig 3.1-1 0

6

Fixa t io n

Drill h o le

Dorsal branch of ulnar nerve

Drill a h ole th rou gh th e u ln a approxim ately 2 cm proxim al rom th e tip o th e styloid. Care n eeds to be taken to avoid in ju ry to th e dorsal cu tan eou s bran ch o th e u ln ar n erve.

Fig 3.1-1 1

225

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t t h e ce rcla ge w ire

a

b

c

Pass a w ire th rou gh th e h ole m ade proxim al to th e u ln ar styloid ractu re ( a ). Th e clin ical im ages sh ow th e w ire placed th rou gh th e h ole m ade in to th e u ln a ( b – c ).

Fig 3.1-1 2a –c

In s e r t t h e K-w ire s

a

Cre a t e a figu re -o f-e igh t

b

I th ere is en ou gh room , in sert tw o K-w ires rom th e tip o th e styloid in su ch a direction as to en gage th eir tips in th e opposite cortex o th e u ln a, proxim al to th e DRUJ ( a ). Im age in ten si cation sh ou ld be u sed to en su re correct placem en t o th e K-w ires ( b ).

Fig 3.1-1 3a –b

226

Con tin u e th e wire th rou gh th e drill h ole an d, u sin g a h ypoderm ic n eedle as a gu ide, pass th e wire arou n d th e K-wires distally to create a gu re-o -eigh t loop.

Fig 3.1-14

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.1 Ulnar styloid– fracture tre ate d with tension band wiring

6

Fixa t io n (co n t )

Ap p ly t e n s io n t o t h e w ire

Bu r y t h e K-w ire s

A ter creatin g th e gu re-o -eigh t, th e w ire tw ist is begu n , en su rin g th at each en d o th e w ire spirals equ ally. Th e w ire is ten sion ed by pu llin g on th e tw ist u n til th e desired ten sion is ach ieved an d th en tw isted to take u p th e slack created. Cu t th e tw ist an d ben d it tow ard th e bon e so as to n ot irritate th e so t tissu es.

Fig 3 .1 -1 6

Fig 3.1-1 5

a

b

Th e in traoperative im ages sh ow th e location o th e K-w ires ( a ) an d th e cu t K-w ires em bedded in to th e bon e ( b ).

Fig 3.1-1 7a –b

Usin g th e ben din g iron or K-w ires, th e w ires are ben t at th e level o th e tip o th e styloid th rou gh 180 degrees an d cu t sh ort. Th ey are th en im pacted in to th e bon e u sin g a sm all pu n ch or oth er appropriate tool. Con rm u sin g im age in ten si cation to en su re th at th e proxim al tips o th e K-w ires are n ot in th e in terosseou s space.

In traoperative im age in ten si cation also en su res th at th e proxim al tips o th e w ires are n ot in th e in terosseou s space an d th at th ere is per ect redu ction o th e ractu re.

Fig 3.1-1 8

227

Pa rt II Case s

6

Fixa t io n (co n t )

Th e AP an d lateral x-rays (also sh ow in g th e distal radial ractu re) 1 w eek a ter su rgery sh ow s per ect redu ction o th e ractu res an d correct location o th e im plan ts.

Fig 3 .1 -19 a – b

a

7

b

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 3.1-2 0

228

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.1 Ulnar styloid– fracture tre ate d with tension band wiring

7

Re h a b ilit a t io n (co n t )

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

Follow in g su rgery, begin active con trolled ran ge o m otion exercises. Active m otion exercises an d later resistan ce exercises sh ou ld be in itiated based u pon th e su rgeon ’s decision as to tim e a ter su rgery an d patien t com plian ce. Load-bearin g activities are u su ally delayed u n til radiological eviden ce o bon e h ealin g. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist.

Fig 3.1-2 2

Th e type an d du ration o postoperative im m obilization or distal u ln ar ractu res depen ds on a n u m ber o actors in clu din g th e qu ality o th e in tern al xation as w ell as patien t activity an d reliability. It m ay be n ecessary to rest th e w rist or several w eeks in a cast or rem ovable splin t. Du rin g th at tim e, th e patien t is en cou raged to rem ove th e im m obilization or sh ort periods to allow gen tle w rist m otion .

Fig 3.1-2 1

8

Ou t co m e

a

b

a

b

Th e x-rays at th e 1-year ollow -u p con rm ed an atom ical h ealin g.

Fig 3.1-2 3a –b

c

d

Th e patien t h ad n o pain an d cou ld ach ieve u ll ran ge o m otion . He h ad retu rn ed to n orm al w ork an d sportin g activities.

Fig 3.1-2 4a –d

229

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e

Alt e rn a t ive fixa t io n w it h a s cre w

As s e s s m e n t o f DRUJ

Wh ile redu ction is m ain tain ed by pu llin g on th e su tu re, or by pressu re with a den tal pick, th e styloid can also be xed with an appropriate sized screw in trodu ced rom th e tip o th e styloid in to th e lateral cortex o th e u ln ar sh a t.

Fig 3.1-2 6

Fig 3.1-25

Stable reattach m en t o th e u ln ar styloid w ith correct ten sion o th e TFCC sh ou ld be ach ieved w ith th is sin gle screw . Th e stability o th e radiou ln ar join t is tested a ter in sertion o th e screw . Th e su tu re can n ow be w ith drawn .

Th e u ln ar styloid n eeds to be overdrilled or th e screw to h ave a lag screw e ect.

230

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3.2

1

Ulna, head and neck—multifragmentary fracture treated with a hook plate

Ca s e d e s crip t io n

a

b

c

d

A 62-year-old salesm an in ju red h is le t w rist in a m otor veh icle acciden t. He su ered a type II Gu stillo ractu re th at in volved both th e u ln a an d distal radiu s. Th e AP an d lateral x-rays an d coron al CT scan dem on strated com plex u ln ar h ead an d n eck ractu res w ith m arked displacem en t an d a m u lti ragm en tary ractu re o th e distal radiu s.

Fig 3.2-1a – d

a

b

c

d

Fu rth er 2-D axial CT scan s dem on strated su bstan tial m etaph yseal ragm en tation w ith in both th e u ln a an d distal radiu s, w h ile 3-D CT recon stru ction s iden ti ed th e exten t o displacem en t o each ractu re. How ever, or th e pu rposes o th is ch apter, on ly th e u ln ar ractu res are discu ssed.

Fig 3.2-2a – d

231

Pa rt II Case s

2

In d ica t io n s

Fra ct u re s o f t h e d is t a l u ln a

Ch o ice o f im p la n t

Mu lti ragm en tary ractu res o th e distal u ln a can be treated with bridge or h ook platin g or with a m in icon dylar plate. Hook platin g with a lockin g com pression plate (LCP) distal u ln a plate allows better con trol o sm aller distal ragm en ts an d was selected or th is patien t.

In m u lti ragm en tary u ln ar ractu res th ere is in stability an d sh orten in g. An atom ical restoration o th e u ln ar h ead an d n eck is essen tial to restore n orm al distal radiou ln ar join t (DRUJ) u n ction . Restoration o th e DRUJ creates in trin sic stability.

Fig 3.2-3

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• LCP distal u ln a plate 2.0 • 1.1 m m K-w ire • Im age in ten si er

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

a

b

Position th e patien t su pin e an d place th e orearm on a h an d table ( a ). Th e elbow can also be f exed, w h ich h olds th e orearm in n eu tral rotation an d allow s or a direct approach to th e distal u ln a ( b ). A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 3.2-4 a – b

232

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.2 Ulna, he ad and ne ck—multifragme ntary fracture tre ate d with a hook plate

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was an u ln ar approach (see ch apter 1.10 Uln ar approach to th e distal u ln a).

Fig 3.2-5

5

Re d u ct io n

Re d u ce t h e u ln a r h e a d

Un der direct vision , th e u ln ar h ead is redu ced to th e u ln ar sh a t u sin g a sm all periosteal elevator or a den tal pick. In m u lti ragm en tary su bcapital ractu res, correct align m en t an d correct rotation al align m en t o th e h ead is veri ed. A redu ction orceps is u su ally n ot applicable du e to th e sm all ragm en ts an d th e so t bon e qu ality at th is level.

Fig 3.2-6

Tem porary stabilization w ith a sm all K-w ire m ay be n ecessary, especially i th ere is a separate u ln ar styloid ragm en t.

Fig 3.2-7

233

Pa rt II Case s

6

Fixa t io n

Se le ct t h e p la t e

Ap p ly t h e p la t e

a

b

Th e distal u ln a plate is a precon tou red plate th at ts to th e su r ace o th e distal u ln a an d allow s graspin g o th e u ln ar styloid w ith th e poin ted h ooks.

Th e poin ted h ooks are placed arou n d th e tip o th e u ln ar styloid an d th e plate is align ed on th e u ln ar sh a t. I a K-w ire h as been in serted, it w ou ld ideally sit betw een th e distal h ooks o th e plate.

Fig 3.2-8 a – b

Fig 3.2-9

In s e r t t h e firs t s cre w

Han dlin g o th e plate m ay be acilitated u sin g th e LCP drill gu ide in serted in on e o th e LCP plate h oles. Im age in ten si cation can be u sed to veri y correct plate position .

Fig 3.2-1 0

234

An LCP drill gu ide is u sed to drill a h ole or a lockin g screw in th e u ln ar h ead. Avoid drillin g th rou gh th e opposite cortex, as th e screw tip w ou ld pen etrate in to th e distal radiou ln ar join t. Screw len gth is m easu red pu sh in g th e h ook o th e depth gau ge again st th e opposite cortex. A sligh tly sh orter screw is th en ch osen .

Fig 3.2-1 1

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.2 Ulna, he ad and ne ck—multifragme ntary fracture tre ate d with a hook plate

6

Fixa t io n (co n t )

Th e rst lockin g h ead screw is in serted in to th e u ln ar h ead.

Fig 3.2-1 2

A stan dard screw is in serted th rou gh th e oblon g plate h ole to redu ce th e sh a t ragm en t to th e plate. At th is poin t redu ction is veri ed u n der im age in ten si cation an d u n restricted pron ation an d su pin ation is ch ecked.

Fig 3.2-1 3

In s e r t a d d it io n a l s cre w s

Addition al lockin g h ead screw s are in serted in to th e u ln ar h ead an d xation at th e sh a t ragm en t is com pleted u sin g stan dard or lockin g h ead screw s. Th e m u ltiple option s or screw in sertion in th e plate allow a w ide ran ge o ractu re pattern s to be secu rely stabilized.

Op t io n 1 : fra ct u re s re q u irin g le n g t h a d ju s t m e n t

a

b

c

In ractu res th at requ ire len gth adju stm en t, place on e or tw o 2.0 m m lockin g screw s in th e u ln ar h ead to secu rely x th e im plan t distally, th en place a 2.0 m m cortex screw in th e oblon g h ole o th e sh a t an d obtain th e correct len gth o redu ction ( a ). Use a com bin ation o cortex an d lockin g screw s in th e su rrou n din g h oles to stabilize th e ractu re secu rely, as dictated by bon e qu ality ( b –c ).

Fig 3.2-1 4a –c

235

Pa rt II Case s

6

Fixa t io n (co n t )

Op tio n 2 : fra ctu re s re q u irin g s t a b ilit y o f th e u ln a r s t ylo id

a

a

b

Fig 3.2-1 5a –b

In th e case o u n stable ractu res o th e base o th e u ln ar styloid, a 2.0 m m lockin g screw can be applied th rou gh th e m ost distal h ole in th e plate. A lockin g screw does n ot n eed to reach th e ar cortex or stable xation .

Fig 3.2-1 6a –b

Pit fa ll: lo ck in g h e a d s cre w t o o lo n g

Pe a rl: re t a in in g t h e K-w ire

In u n stable ractu res o th e tip o th e u ln ar styloid, th e distal plate h ole is le t em pty. Rem ove th e K-w ire i u sed or prelim in ary xation . Overdrill th e n ear ragm en t w ith a 1.5 m m drill bit. In sert a 1.5 m m cortex screw in lag m ode betw een th e arm s o th e distal h ooks.

a

I a screw pen etrates th e opposite cortex o th e u ln ar h ead, th e screw tip w ill dam age th e cartilage o th e radiou ln ar join t.

Fig 3.2-1 7

236

b

b

I a K-w ire h as been u sed or xation o th e u ln ar styloid, an d h as n ot been rem oved or distal screw placem en t, it m ay be le t in place i it en ters th e u ln ar styloid betw een th e poin ted h ooks. Th e K-w ire is th en ben t an d cu t sh ort.

Fig 3.2-1 8a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

3 Distal ulna 3.2 Ulna, he ad and ne ck—multifragme ntary fracture tre ate d with a hook plate

6

Fixa t io n (co n t )

Th e in traoperative im age sh ow s th e u ln ar ractu res stabilized u sin g th e LCP distal u ln a plate.

Fig 3.2-1 9

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 3.1 Uln ar styloid– ractu re treated w ith ten sion ban d w irin g.

Fig 3.2-20

237

Pa rt II Case s

8

Ou t co m e

At th e 6-m on th ollow -u p, th ere w as h ealin g o th e u ln ar ractu res in good position .

Fig 3.2-2 1a – b

a

b

a

b

c

d

Fig 3.2-2 2a –d

Th ere w as a su ccess u l u n ction al resu lt sh ow in g good ran ge o m otion .

Vid e o

Th is video dem on strates a distal u ln a su bcapital ractu re with diaph yseal com m in u tion an d styloid ractu re treated with an LCP distal u ln a plate.

Vid e o 3.2-1

238

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4

Radius

Pa rt II Case s

240

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

4.1

1

Radial styloid—fracture treated with a radial column plate

Ca s e d e s crip t io n

A 23-year-old em ale u n iversity stu den t su ered an in ju ry to h er righ t wrist in a tra c acciden t an d was in itially treated or a wrist sprain by cast im m obilization . Sh e retu rn ed to th e h an d clin ic or cast rem oval 3 weeks later, h owever, th e ollow-u p PA an d lateral x-rays sh owed an apparen tly ben ign n on displaced ractu re o th e radial styloid. As th ere was su spicion o in traarticu lar displacem en t in th e lateral view, a CT scan was requ ested.

Fig 4.1-1a –b

a

a

b

b

c

Th e CT scan s revealed a displaced in traarticu lar ractu re w ith a step-o o th e dorsal aspect o th e radial styloid.

Fig 4.1-2a – c

A displaced ractu re o th e u ln ar styloid w as also eviden t; h ow ever, or th e pu rposes o th is ch apter, on ly th e radial styloid is discu ssed. For u rth er in orm ation on treatin g u ln ar styloid ractu res see ch apter 3.1 Uln ar styloid– ractu re treated w ith ten sion ban d w irin g.

241

Pa rt II Case s

2

In d ica t io n s

Ra d ia l s t ylo id fra ct u re s

As s o cia t e d m e d ia n n e r ve co m p re s s io n

Median nerve

Sim ple radial styloid ractu res are ractu res w ith ou t m u lti ragm en tation . Th ey can occu r as a resu lt o sh earin g or com pression orces. As th ey in volve an articu lar split o th e radial styloid, th ey are partial articu lar ractu res. Th ese ractu res dem an d accu rate redu ction sin ce th ey in volve th e articu lar su r ace. O ten th e ractu re exists in th e sagittal plan e.

Fig 4.1-3

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Fig 4.1-4

As s o cia t e d ca rp a l in ju rie s

Th ese in ju ries m ay be associated w ith sh earin g in ju ries o th e articu lar cartilage, scaph oid ractu res, an d ru ptu res o th e scaph olu n ate ligam en t. Every patien t sh ou ld be assessed or th ese in ju ries.

Fig 4.1-5

242

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

2

In d ica t io n s (co n t )

As s o cia t e d u ln a r in ju rie s

Co n t ra in d ica t io n s

Th rou gh ou t th e ch apters in th e rem ain in g two section s o th e book, patien t treatm en t m ostly in volves open redu ction an d in tern al xation with a variety o plate an d screw tech n ology. Th e reader is rem in ded th at in som e in stan ces su rgical treatm en t or a distal radial ractu re is n ot recom m en ded, an d th ese can in clu de bu t are n ot lim ited to th e type o displacem en t o th e ractu re, n erve com prom ise, severe swellin g, poor state o so t tissu es, an d th e patien t n ot bein g t or su rgery.

Th ese in ju ries can also be accom pan ied by avu lsion o th e u ln ar styloid an d/ or disru ption o th e distal radiou ln ar join t (DRUJ). I th ere is gross in stability a ter th e xation o th e radial ractu re, it is recom m en ded th at th e u ln ar styloid an d/ or th e trian gu lar brocartilage disc (TFC) is reattach ed. Th is is n ot com m on in sim ple ractu res bu t can occu r in som e h igh -en ergy in ju ries. Th e u n in ju red side sh ou ld be tested as a re eren ce or th e in ju red side. How ever, it m ay n ot be possible to assess DRUJ stability u n til th e ractu re h as been stabilized.

Fig 4.1-6

Ch o ice o f im p la n t

a Radial colum n plate

b

c L-plate

Lag scre w

A variety o plate an d screw option s are available or radial styloid ractu res depen din g on ractu re pattern , th e state o th e a ected so t tissu es, an d stability. Plates w ith variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t, a straigh t radial colu m n plate w as selected an d u rth er su pported w ith an addition al lag screw .

Fig 4.1-7 a – c

243

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA LCP distal radiu s set VA LCP radial colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires 2.4 m m cortex screw Osteotom e Poin ted redu ction orceps Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.1-8

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was a dorsoradial approach between th e rst an d secon d exten sor com partm en ts (see ch apter 1.5 Dorsoradial approach to th e distal radiu s).

Fig 4.1-9

244

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

4

Su rgica l a p p ro a ch (co n t )

To im prove visibility o th e join t su r ace, an arth rotom y o th e dorsal capsu le w as per orm ed. Th is revealed a bigger ragm en t th an su spected rom th e x-rays. Addition ally, becau se th e su rgery w as per orm ed 3 w eeks a ter th e in itial trau m a, open in g o th e early callu s w ith an osteotom e w as requ ired.

Fig 4.1-1 0

5

Fu rth er exam in ation o th e su r ace revealed th at th e articu lar ractu re w as orien ted in th e sagittal an d in th e coron al plan e.

Fig 4.1-1 1

Re d u ct io n

Pro vis io n a l re d u ct io n

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale, a tem porary extern al xator m ay be h elp u l.

Pro vis io n a l fixa t io n

Fig 4.1-1 2

In sert a K-w ire th rou gh th e tip o th e radial styloid to provision ally h old th e ragm en ts. Con rm u sin g im age in ten si cation .

Fig 4.1-1 3

245

Pa rt II Case s

6

Fixa t io n

Co n t o u r t h e p la t e

a

b

Fig 4.1-1 4a –b

Plates u sed in treatin g radial an d in term ediate colu m n in ju ries are available precon tou red. How ever, som e addition al con tou rin g m ay be n ecessary to accom m odate th e in dividu al an atom y o th e patien t.

Fig 4.1-1 5

Variable an gle lockin g plates en able precise position in g o th e distal screw s in desired direction s becau se th ere is 30 degrees o reedom or each screw in side th e plate h ole in order to address th e in dividu al ractu re pattern s.

Pit fa ll: s cre w h o le d is t o r t io n

Fixa t io n o f ra d ia l co lu m n Se le ct a n d a p p ly t h e p la t e Extensor pollicis longus Radial artery

a

b Superficial branch of radial nerve

Avoid con tou rin g th e plate th rou gh th e lockin g h oles, oth erw ise th e lockin g h ead screw m igh t n o lon ger t.

Fig 4.1-1 6a –b

Extensor pollicis brevis

Th e appropriate plate is selected accordin g to th e ractu re con gu ration an d con tou red i n ecessary. Slide th e plate u n dern eath th e rst com partm en t an d apply it on to th e radial colu m n .

Fig 4.1-1 7

246

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

6

Fixa t io n (co n t )

St a b ilize t h e ra d ia l co lu m n

Pit fa ll: in co rre ct p la ce m e n t

a

Ideally wh ile applyin g th e plate, th e n otch in th e distal tip o th e im plan t is placed again st th e tem porary K-wire.

Fig 4.1-18

b

Placem en t o th e plate on th e dorsal aspect o th e radial colu m n is to be avoided, as it w ill n ot bu ttress th e redu ction adequ ately again st axial sh ear orces.

Fig 4.1-1 9a –b

In s e r t t h e firs t s cre w

a

b

In sert a stan dard cortex screw in to th e oblon g plate h ole proxim al to th e ractu re ( a ). It is pre erable th at th e screw sh ou ld en gage th e ar cortex, bu t in th is case th is w ou ld resu lt in pen etration o th e DRUJ. Th e den se su bch on dral bon e in th is region allow s secu re xation i bon e qu ality is good. Th e position o th e plate m ay be adju sted be ore th e screw is tigh ten ed. Tigh ten in g th is screw w ill redu ce th e radial styloid ( b ).

Fig 4.1-2 0a –b

247

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t t h e firs t lo ck in g h e a d s cre w

a

b

To preven t rotation o th e plate du rin g distal su bch on dral lockin g screw xation , th e plate sh ou ld be secu red to th e bon e by in sertin g th e m ost proxim al screw . To avoid overtigh ten in g th e lockin g screw a torqu e lim itin g device sh ou ld be u sed.

Fig 4.1-2 1a –b

In s e r t t h e d is t a l lo ck in g h e a d s cre w

X-ray beam

I a K-wire was u sed, it is n ow rem oved. In sert a lockin g h ead screw in to th e distal lockin g h ole o th e plate. Th e screw sh ou ld be placed in a su bch on dral position .

Fig 4.1-22

248

Con rm th at th e screw does n ot protru de in to th e join t u sin g th e im age in ten si er, w ith th e beam an gled 20 degrees rom th e tru e lateral. Th is projection w ill pro le th e radial articu lar su r ace an d sh ow an y en croach m en t o th e screw in to th e join t.

Fig 4.1-2 3

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

6

Fixa t io n (co n t )

Co m p le t e t h e fixa t io n

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e ollow in g tw o m eth ods are recom m en ded to determ in e i in stability exists.

To com plete th e xation , it m ay be n ecessary to in sert a lag screw . In order to obtain th e lag e ect, u se eith er partially th readed screw s or prepare a glidin g h ole in th e radial styloid. Use a drill gu ide to en su re th at th e so t tissu es are protected du rin g drillin g.

Fig 4.1-2 4

Me t h o d 1: DRUJ b a llo t t e m e n t

a

b

Th e elbow is f exed 90 degrees on th e arm table with th e orearm in n eu tral rotation an d displacem en t in a dorsal/ palm ar direction is assessed. Th is is repeated with th e wrist in radial deviation , wh ich stabilizes th e DRUJ, i th e u ln ar collateral com plex is n ot disru pted.

Fig 4.1-25a –b

a

b

Th is is again repeated w ith th e w rist in u ll su pin ation an d u ll pron ation .

Fig 4.1-2 6a –b

249

Pa rt II Case s

6

Fixa t io n (co n t )

Me t h o d 2 : u ln a co m p re s s io n t e s t

a

b

c

In th is test, th e u ln a is com pressed again st th e radiu s ( a ). Th e orearm is rotated passively th rou gh u ll su pin ation ( b ) an d pron ation ( c ). I th ere is a palpable “clu n k”, in stability o th e DRUJ is presen t. Th is is an in dication to con sider in tern al xation o an u ln ar styloid ractu re by ten sion ban d w ire, lag screw , or plate. A DRUJ in stability can also resu lt rom so t-tissu e in ju ry to th e trian gu lar brocartilage com plex (TFCC).

Fig 4.1-2 7a –c

a

b

c

With th e poin ted redu ction orceps u sed to redu ce th e ractu re, th e plate w as placed on th e radial colu m n an d th e screw s in serted ( a ). In traoperative im age in ten si cation sh ow ed th e displacem en t o th e ractu re an d h elped to determ in e th e righ t location or th e plate ( b – c ).

Fig 4.1-2 8a –c

250

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

6

Fixa t io n (co n t )

a

b

Follow in g plate xation , a 2.4 m m lag screw w as in serted perpen dicu lar to th e ractu re in th e coron al plan e to u rth er stabilize th e ractu re ( a ). Th e poin ted redu ction orceps w as th en rem oved ( b ).

Fig 4.1-2 9a –b

a

b

In traoperative im agin g sh owed th e ractu re redu ction with th e VA LCP straigh t plate actin g as a bu ttress to th e join t su r ace an d th e lag screw placed th rou gh th e plate in to th e su bch on dral bon e.

Fig 4.1-30a –b

251

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 4.1-3 1

Im m o b iliza t io n

Fu n ct io n a l e xe rcis e s

Follow in g su rgery, begin active con trolled ran ge o m otion exercises. Active m otion exercises an d later resistan ce exercises sh ou ld be in itiated based u pon th e su rgeon ’s decision as to tim e a ter su rgery an d patien t com plian ce. Load-bearin g activities are u su ally delayed u n til radiological eviden ce o bon e h ealin g. Th e im portan ce o m obilization m u st be em ph asized to th e patien t an d reh abilitation sh ou ld be su pervised by a ph ysical th erapist.

Fig 4.1-3 3

Th e type an d du ration o postoperative im m obilization depen ds on a n u m ber o actors in clu din g th e qu ality o th e in tern al xation as well as patien t activity an d reliability. It m ay be n ecessary to rest th e wrist or several weeks in a plaster or rem ovable splin t. Du rin g th at tim e, th e patien t is en cou raged to rem ove th e splin t or sh ort periods to allow gen tle wrist m otion .

Fig 4.1-32

252

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

8

Ou t co m e

a

a

b

At th e 3-m on th ollow -u p, th e PA an d lateral x-rays sh ow ed h ealin g o th e ractu re.

Fig 4.1-3 4a –b

b

Th ere w as also n orm al u ln ar an d radial deviation o th e w rist.

Fig 4.1-3 5a –b

a

b

c

d

Fig 4.1-3 6a –d

Th ere w as an excellen t u n ction al resu lt.

253

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e

Ra d ia l s t ylo id fra ct u re t re a t e d w it h p e rcu t a n e o u s fixa t io n

a

b Extensor carpi radialis longus

Extensor carpi radialis brevis

Extensor pollicis Extensor pollicis longus brevis

Superficial branch of radial nerve Radial artery

c

In som e cases o sim ple radial styloid ractu re ( a ), it can be possible to redu ce an d x th e ractu re th rou gh a sm all percu tan eou s approach over th e tip o th e styloid ( b ). Th e advan tages o percu tan eou s treatm en t in clu de preservin g so t tissu e an d redu cin g im m obilization tim e. However, care m u st still be taken to avoid dam agin g im portan t stru ctu res in th is region ( c ).

Fig 4.1-37a –c

254

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.1 Radial styloid—fracture tre ate d with a radial column plate

9

Alt e rn a t ive t e ch n iq u e (co n t )

Clo s e d re d u ct io n

Redu ce th e ractu re u sin g percu tan eou s poin ted redu ction orceps, in serted th rou gh sm all stab in cision s, or th e m ain sm all in cision over th e styloid process. Con rm th e redu ction u sin g im age in ten si cation .

Fig 4.1-38

Fixa t io n

a

b

In sert a gu ide w ire in to th e styloid ragm en t as perpen dicu lar as possible to th e ractu re site ( a ). Pass th e w ire across th e ractu re site, gain in g pu rch ase in th e u ln ar cortex o th e radiu s. I th e ragm en t is large en ou gh , place a secon d gu ide w ire as parallel to th e join t su r ace as possible ( b ).

Fig 4.1-3 9a –b

255

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e (co n t )

a

b

Drill over th e gu ide w ires an d in sert th e appropriate screw s. Fractu re treatm en t can in volve screw an d/ or K-w ire xation .

Fig 4.1-4 0a –b

256

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.2

1

Distal radius—dorsally displaced extraarticular fracture treated with a palmar plate

Ca s e d e s crip t io n

a

b

c

A 76-year-old w om an su ered a all on to h er ou tstretch ed righ t h an d. Sh e w en t to th e em ergen cy departm en t h avin g severe pain , n u m bn ess o th e n gers, an d gross de orm ity o th e w rist. Th e PA an d lateral 3-D CT scan sh ow ed dorsal displacem en t o a n on articu lar distal radial ractu re w ith som e dorsal m etaph yseal m u lti ragm en tation ( a – b ). Th ere w as also a displaced ractu re o th e u ln a n eck. An axial view 3-D CT scan m ore clearly dem on strated th e m arked ractu re displacem en t ( c ).

Fig 4.2-1a – c

For th is patien t, both th e distal u ln a an d radiu s w ere in volved, w ith th e u ln a bein g treated u sin g a distal u ln a (h ook) plate. How ever, or th e pu rposes o th is ch apter, on ly th e distal radiu s is discu ssed. For u rth er in orm ation on treatin g distal u ln ar ractu res see ch apter 3.2 Uln a, h ead an d n eck—m u lti ragm en tary ractu re treated w ith a h ook plate.

257

Pa rt II Case s

2

In d ica t io n s

Ext ra a r t icu la r fra ct u re s

As s o cia t e d m e d ia n n e r ve co m p re s s io n

Median nerve

a

b

Fractu res o th e distal radiu s can in volve a dorsally displaced extraarticu lar ractu re o th e distal m etaph ysis (proxim al to bu t n ot in clu din g th e articu lar su r ace). Th is is th e m ost com m on type o w rist ractu re.

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Fig 4.2-2 a – b

Fig 4.2-3

Extraarticu lar distal radial ractu res are com m on am on g elderly patien ts w ith lesser qu ality bon e w h ereas stron ger you n ger patien ts ten d to su er th ese on ly a ter h igh en ergy im pact, o ten in volvin g in traarticu lar ractu res as w ell. Fractu res an gu lated dorsally at > 25 degrees an d associated w ith osteoporosis or residu al void a ter redu ction can prove u n stable. Th ere ore, prim ary palm ar platin g is o ten th e best treatm en t option . Be ore palm ar platin g becam e a com m on ly u sed treatm en t, m ost o th ese ractu res w ere treated w ith closed redu ction , w h ich w as th en m ain tain ed w ith eith er K-w ires or a plaster cast. Man y su rgeon s n ow treat m ost th ese ractu res w ith a palm ar plate an d o ten u se th e plate as an aid to redu ction .

258

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.2 Distal radius—dorsally displace d   e xtraarticular fracture tre ate d with a palmar plate

2

In d ica t io n s (co n t )

As s o cia t e d u ln a r in ju rie s

Head, n eck, an d m u lti ragm en tary ractu res o th e distal u ln a o ten occu r in com bin ation w ith distal radial ractu res. With th ese u ln ar ractu res th ere is in stability an d sh orten in g, so th e distal u ln ar h ook plate can be u sed to h old th e ractu re. Atten tion sh ou ld be paid to restorin g correct rotation an d len gth in relation to th e radiu s. Com plete dislocation o th e radiocarpal join t is o ten associated w ith disru ption o th e distal radiou ln ar join t (DRUJ).

Ch o ice o f im p la n t

Fig 4.2-4

3

b

2-column plate

Extraarticular plate

A variety o plate option s are available or extraarticu lar distal radial ractu res. Advan ces in plate design h ave provided an gu lar stable xation , w h ich allow s en h an ced stability an d ease o application even in th e presen ce o osteoporotic bon e. Plates w ith variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t, a VA lockin g com presion plate (LCP) 2-colu m n palm ar plate w as selected.

Fig 4.2-5 a – b

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

a

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA LCP distal radiu s set VA LCP 2-colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.2-6

259

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 4.2-7

5

Re d u ct io n a n d fixa t io n

Pro vis io n a l re d u ct io n

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.2-8

260

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.2 Distal radius—dorsally displace d   e xtraarticular fracture tre ate d with a palmar plate

5

Re d u ct io n a n d fixa t io n (co n t )

Re d u ct io n u s in g t h e p la t e

Alt e rn a t ive re d u ct io n

Select an d apply th e plate to th e distal ragm en t. Th e distal en d o th e plate sh ou ld en d at th e an atom ical watersh ed lin e o th e distal radiu s. In sert a K-wire th rou gh a screw h ole as close to th e su bch on dral bon e as possible an d parallel to th e articu lar su r ace. Th e resu ltan t an gle o th e plate to th e sh a t sh ou ld equ al th e an gle o th e displacem en t. Con rm u sin g im age in ten si cation .

Fig 4.2-1 0

Fig 4.2-9

Som e su rgeon s believe th at u sin g th e plate or redu ction in patien ts w ith osteoporosis m ay cau se th e screw s to loosen in th e bon e. In su ch cases, m an u al redu ction an d prelim in ary xation w ith K-w ires m ay be pre erable.

In s e r t t h e firs t d is t a l s cre w

20° X-ray beam a

b

Th e in itial screw is in serted in th e m ost u ln ar screw h ole. Th e reason is th at i th e in itial screw is placed on th e radial side it w ill block accu rate im agin g o th e u ln ar screw placem en t. Ch oose a lockin g h ead screw 2–4 m m sh orter th an m easu red. Provided th e screw is parallel to th e K-w ire it sh ou ld n ot en ter th e radiocarpal join t.

Fig 4.2-1 1a –b

Con rm screw position w ith a lateral view u n der im age in ten si cation , w ith th e beam aim ed at an an gle o 20 degrees to th e tru e lateral, clearly sh ow in g th e join t su r ace.

Fig 4.2-1 2

261

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

In s e r t a d d it io n a l lo ck in g h e a d s cre w s

Pit fa ll: s cre w t ip p ro t ru s io n

a

b

Du e to th e prom in en ce o Lister tu bercle, as seen on th e lateral im age projection , a screw placed on eith er side o th e tu bercle m ay appear n ot to protru de th rou gh th e ar cortex. Protru sion o su ch a screw m ay resu lt in exten sor ten don irritation an d ru ptu re.

Fig 4.2-1 4 Fig 4.2-1 3a –b

In sert at least tw o oth er distal lockin g h ead

screw s.

Ap p ly t h e p la t e t o t h e s h a ft

In s e r t t h e firs t p ro xim a l s cre w

Th e im plan t is th en u sed to redu ce th e ragm en ts by pu sh in g it on to th e su r ace o th e radiu s. Brin g th e plate on to th e sh a t an d h old it with a orceps. Ch eck correct placem en t with im agin g an d adju st th e position o th e distal ragm en t i n ecessary by m ovin g th e plate.

Fig 4.2-16

Fig 4.2-15

262

On ce satis actory redu ction is con rm ed, in sert an appropriate cortex screw th rou gh th e oblon g plate h ole.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.2 Distal radius—dorsally displace d   e xtraarticular fracture tre ate d with a palmar plate

5

Re d u ct io n a n d fixa t io n (co n t )

Co m p le t e t h e fixa t io n

a

b Fig 4.2-1 7a –b

In sert u rth er proxim al screw s to com plete

th e xation .

In traoperative pictu re o th e redu ced ractu re xed with th e VA LCP 2-colu m n palm ar plate 2.4.

Fig 4.2-18

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a

b

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.2-1 9a –b

263

Pa rt II Case s

6

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.2-20

7

Ou t co m e

a

b

At th e 1-year ollow-u p, th e x-rays revealed u ll h ealin g with an atom ical redu ction o both th e distal radial an d u ln ar n eck ractu res.

Fig 4.2-21a –b

264

a

b

c

d

Th ere w as an excellen t u n ction al resu lt w ith u ll orearm an d w rist m otion possible.

Fig 4.2-2 2a –d

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.3

1

Distal radius—lunate facet fracture treated with a buttress plate

Ca s e d e s crip t io n

a

d

b

c

e

A 48-year-old m ale en gin eer su ered a polytrau m a in a m otor veh icle in ju ry su stain in g em oral ractu res, ractu res o th e distal h u m eru s, an d a ractu re o th e sh a t o th e le t u ln a. All ractu res were treated su rgically. However, th e patien t was seen in th e h an d clin ic 2 m on th s a ter th e in ju ry h avin g pain , sign s o m edian n erve com pression , an d u n ction al lim itation o th e righ t wrist. New PA an d lateral x-rays th en in dicated a previou sly u n detected lu n ate acet ractu re o th e radiu s ( a –b ). Sagittal an d coron al 2-D scan s alon g with a 3-D CT scan clearly sh owed th e displaced lu n ate acet ractu re as an isolated distal radial in ju ry ( c–e ).

Fig 4.3-1a –e

265

Pa rt II Case s

2

In d ica t io n s

Lu n a t e fa ce t fra ct u re s

As s o cia t e d m e d ia n n e r ve co m p re s s io n

Median nerve

a

b

Fig 4.3-2a –b

Followin g h igh -en ergy impact a lu n ate acet ractu re can occur, wh ich is a partial articu lar ractu re where the rim o th e distal radiu s at th e radiocarpal join t is sh eared o . Th is o ten occurs at th e palmar rim, as th e palmar lunate acet projects anteriorly to th e f at palmar su r ace o the distal radiu s an d is there ore relatively vu ln erable to in ju ry. Th e resu lt o the in ju ry is join t in con gru ity an d palmar subluxation o the carpus. Displaced lunate acet ractu res a ect both radiocarpal an d radiou ln ar alignmen t an d u n ction . Bu ttress platin g is the recommen ded treatmen t option .

Fig 4.3-3

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Im a gin g

Ch o ice o f im p la n t

As sh ow n w ith th is case, th e ractu re pattern m ay n ot alw ays be clear on stan dard x-rays, so addition al CT scan n in g is stron gly recom m en ded.

a

b L-plate s

c 2-colum n plate

A variety o plate option s are available or palm ar bu ttress platin g, an d th e size o th e palm ar rim ragm en t/ s will in f u en ce th e ch oice o plate. Plates with variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t, a VA lockin g com pression plate (LCP) L-sh aped plate with two h oles in th e distal lim b was selected to redu ce an d bu ttress th e ractu re.

Fig 4.3-4a –c

266

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.3   Distal radius—lunate face t fracture tre ate d with a buttre ss plate

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA LCP distal radiu s set VA LCP L-plate 2.4 Poin ted redu ction orceps Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.3-5

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as an u ln ar palm ar approach (see ch apter 1.7 Uln ar palm ar approach to th e distal radiu s).

Fig 4.3-6

On ce th e ractu re w as exposed it w as n oted th at th e ractu re lin e exten ded to th e m iddle o th e distal radial su r ace.

Fig 4.3-7

267

Pa rt II Case s

5

Re d u ct io n

Hyp e re xt e n d t h e w ris t

a

To assist in th e approach an d to h elp redu ce th e ractu re, place a rolled tow el or bolster u n der th e w rist an d h yperexten d it. Per ect an atom ical redu ction can be ach ieved by direct m an ipu lation o th e distal ragm en t u sin g a den tal pick or a n e h ook. Redu ction can be m ain tain ed u sin g a poin ted redu ction orceps.

Fig 4.3-8

b

Th e ractu re w as disim pacted to de n e th e articu lar in ju ry. Th e redu ced ractu re w as h eld w ith a poin ted redu ction orceps. Note th at a carpal tu n n el release w as also per orm ed th rou gh a separate in cision .

Fig 4.3-9 a – b

6

Fixa t io n

Co n t o u r t h e p la t e

a

b

Th e distal en d o th e plate sh ou ld en d at th e an atom ical w atersh ed zon e o th e distal radiu s ( a ). On ce position ed, en su re th at th e plate is con tou red so th at its distal lim b exerts even pressu re over th e ragm en t or ragm en ts o th e palm ar rim o th e radiu s ( b ).

Fig 4.3-1 0a –b

268

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.3   Distal radius—lunate face t fracture tre ate d with a buttre ss plate

6

Fixa t io n (co n t )

Ap p ly t h e p la t e in b u t t re s s m o d e

In s e r t s e co n d s cre w

Attach th e plate to th e distal radial sh a t u sin g an appropriate cortex screw th rou gh th e oblon g plate h ole. Be ore u lly tigh ten in g it, ch eck th e plate position u sin g in traoperative im agin g, adju stin g th e position o th e plate as n ecessary so as to provide an optim al bu ttress e ect.

Fig 4.3-12

Fig 4.3-11

Now tigh ten th e rst screw an d in sert a secon d cortex screw . Ch eck or adequ ate bu ttress pressu re on th e palm ar rim ragm en t(s).

In s e r t d is t a l s cre w s a n d co m p le t e t h e fixa t io n

a

b

Secu re th e distal ragm en t(s) with at least two screws th rou gh th e appropriate distal h oles, as dictated by th e ractu re pattern . Th e screws m u st n ot pen etrate th e dorsal radial cortex. I a plate is selected with th readed h oles in th e distal lim b, th en lockin g h ead screws are u sed. Con rm redu ction u sin g im age in ten si cation .

Fig 4.3-13a –b

a

b

De n itive xation w as ach ieved w ith a VA LCP L-plate 2.4.

Fig 4.3-1 4a –b

269

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.3-15

8

Ou t co m e

a

b

At th e 12-m on th ollow -u p, th e x-rays sh ow ed e ective h ealin g h ad been ach ieved.

Fig 4.3-1 6a –b

270

a

b

c

d

Th e patien t h ad n early u ll h an d, w rist, an d orearm ran ge o m otion .

Fig 4.3-1 7a –d

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.3   Distal radius—lunate face t fracture tre ate d with a buttre ss plate

8

Ou t co m e (co n t )

Vid e o

Th is video dem on strates a reverse Barton (ie, palm ar) distal radial ractu re treated u sin g an LCP 2-colu m n plate.

Vid e o 4 .3 -1

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

Lu n a t e fa ce t fra ct u re t re a t e d w it h s cre w s

a

b

A classical con cert gu itarist h ad a all on to h is le t h an d w h ile ridin g h is bicycle w h en it becam e stu ck in tram w ay lin es. He presen ted to th e em ergen cy departm en t th e ollow in g day w ith con cern s abou t h is playin g u tu re an d asked or a per ect u n ction al resu lt. Th e PA an d lateral x-rays in dicated a sh earin g type o lu n ate acet ractu re.

Fig 4.3-1 8a –b

271

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

a

b

c

Axial an d sagittal 2-D CT scan s ( a –b ) sh ow ed th e displacem en t o th e isolated lu n ate acet ractu re. A 3-D CT scan m ore clearly sh ow ed th e m orph ology o th e acet ractu re ( c ).

Fig 4.3-1 9a –c

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n

a

b

As th e patien t w as a pro ession al gu itarist, an d ollow in g discu ssion o poten tial perioperative an d postoperative problem s, h e w as con sidered reliable or receivin g treatm en t w ith less stable xation . Th ere ore, ju st a ew days a ter presen tation , h e w as treated w ith th ree can n u lated 2.7 m m screw s. Screw s rarely in ter ere w ith so t tissu es, especially f exor ten don s, w h ich allow ed th e patien t to resu m e gu itar playin g qu ickly an d w ith con sideration th at im plan t rem oval w as u n likely to be n ecessary in th e u tu re.

Fig 4.3-2 0a –b

272

Th e h igh ly m otivated patien t u n dertook im m ediate u n ction al a ter-treatm en t in th e h an d th erapy departm en t an d qu ickly regain ed u ll m obility to h is wrist join t. He was soon able to play the gu itar again with ou t pain an d per orm ed h is n ext con cert 8 weeks postoperatively.

Fig 4.3-21

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.4

1

Distal radius—shearing fracture treated with a buttress plate

Ca s e d e s crip t io n

A 35-year-old sales con su ltan t su ered a all rom h is m otorcycle wh ile ridin g to work. He was seen in th e em ergen cy departm en t h avin g pain an d swellin g o th e righ t wrist. Th e PA an d lateral x-rays dem on strated a sh earin g ractu re o th e distal radiu s with palm ar displacem en t, with th e carpu s also su blu xated rom its n orm al position .

Fig 4.4-1a –b

a

b

a

b

c

Th ree 2-D CT ron tal plan e im ages dem on strated m u lti ragm en tation o th e palm ar articu lar su r ace. Th ere w as a ractu re o th e radial styloid, m u lti ragm en tation o th e scaph oid acet, an d partial in volvem en t o th e lu n ate acet. On th e u ln a th ere w as a displaced avu lsion ractu re o th e u ln ar styloid.

Fig 4.4-2a – c

273

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

c

a

Th e 2-D sagittal CT scan s sh ow ed th e palm ar su blu xation o th e carpu s w ith a palm ar sh earin g ractu re an d a cen trally im pacted articu lar ragm en t o th e scaph oid acet.

Fig 4.4-3 a – c

b

Th e 3-D CT scan s sh ow ed th at th e sigm oid n otch an d th e u ln ar corn er o th e lu n ate acet w ere n ot in ju red an d rem ain ed in con tin u ity w ith th e m etaph ysis.

Fig 4.4-4 a – b

For th is patien t, a sm all u ln ar styloid ractu re was eviden t in addition to th e radiu s in ju ry, h owever, or th e pu rposes o th is ch apter, on ly th e distal radiu s is discu ssed. For u rth er in orm ation on treatin g u ln ar styloid ractu res see ch apter 3.1 Uln ar styloid— ractu re treated with ten sion ban d wirin g.

2

In d ica t io n s

Sh e a rin g fra ct u re s

Fractu res are described as sh earin g wh en th e opposite cortex rem ain s in tact. Th ese partial in traarticu lar ractu res can in volve ragm en tation an d can occu r on eith er th e palm ar (as in th is case) or th e dorsal side (see th e altern ative tech n iqu e later in th is ch apter). Sh earin g ractu re in ju ries resu lt in join t in con gru ity an d su blu xation o th e carpu s an d are best sh own in CT scan s. Most sh earin g ractu res are u n stable an d displaced an d or th at reason requ ire operative treatm en t to restore an atom y an d stability. An in tact opposite cortex allows a bu ttress platin g tech n iqu e to be u sed as th e treatm en t o ch oice.

Fig 4.4-5a –b

a

274

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

2

In d ica t io n s (co n t )

As s o cia t e d m e d ia n n e r ve co m p re s s io n

As s o cia t e d u ln a r in ju rie s

Median nerve

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Fig 4.4-6

Th ese in ju ries can also be accom pan ied by avu lsion o th e u ln ar styloid an d/ or disru ption o th e distal radiou ln ar join t (DRUJ). I th ere is gross in stability a ter th e xation o th e radial ractu re, it is recom m en ded th at th e u ln ar styloid an d/ or th e trian gu lar brocartilage disc (TFC) is reattach ed. Th is is n ot com m on in sim ple ractu res bu t can occu r in som e h igh -en ergy in ju ries. Th e u n in ju red side sh ou ld be tested as a re eren ce or th e in ju red side. How ever, it m ay n ot be possible to assess DRUJ stability u n til th e ractu re h as been stabilized.

Fig 4.4-7

Ch o ice o f im p la n t

A variety o plate option s are available to treat sh earin g ractu res w ith bu ttress platin g, an d th e size o th e palm ar rim ragm en t(s) w ill in f u en ce th e ch oice o plate. Plates w ith variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t, a 2-colu m n palm ar plate w ith a 7-h ole h ead w as selected.

Fig 4.4-8 a – c

a

b 2-column plates

c Palmar rim plate

275

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA lockin g com pression plate (LCP) distal radiu s set VA LCP 2-colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Poin ted redu ction orceps Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan es o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.4-9

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a m odi ed Hen ry palm ar approach (see Ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 4.4-1 0

276

Th e m odi ed Hen ry palm ar approach was per orm ed with th e f exor carpi radialis an d th e f exor pollicis lon gu s bein g separated u ln arly, protectin g th e m edian n erve an d th e radial artery separated radially. Th e pron ator qu adratu s m u scle was in cised on its radial border an d was stripped o th e distal radiu s togeth er with th e periosteu m . Th is m ade th e ractu re m ore visible.

Fig 4.4-11

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

5

Re d u ct io n

Hyp e re xt e n d t h e w ris t

To assist in th e approach an d to h elp redu ce th e ractu re, place a rolled tow el or bolster u n der th e w rist an d h yperexten d it. Per ect an atom ical redu ction can be ach ieved by direct m an ipu lation o th e distal ragm en t u sin g a den tal pick or a n e h ook. Redu ction can be m ain tain ed u sin g a poin ted redu ction orceps.

Fig 4.4-1 2

6

Fixa t io n

Co n t o u r t h e p la t e

Ap p ly t h e p la t e in b u t t re s s m o d e

a

b

Th e distal en d o th e plate sh ou ld en d at th e an atom ical w atersh ed zon e o th e distal radiu s ( a ). On ce position ed, en su re th at th e plate is con tou red so th at its distal lim b exerts even pressu re over th e ragm en t or ragm en ts o th e palm ar rim o th e radiu s ( b ).

Fig 4.4-1 3a –b

Attach th e plate to th e distal radial sh a t u sin g an appropriate cortex screw th rou gh th e oblon g plate h ole. Be ore u lly tigh ten in g it, ch eck th e plate position u sin g in traoperative im agin g, adju stin g th e position o th e plate as n ecessary so as to provide an optim al bu ttress e ect.

Fig 4.4-14

277

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t s e co n d s cre w

In s e r t d is t a l s cre w s a n d co m p le t e t h e fixa t io n

Now tigh ten th e rst screw an d in sert a secon d cortex screw . Ch eck adequ ate bu ttress pressu re on th e palm ar rim ragm en t(s).

a

Fig 4.4-1 5

b

Secu re th e distal ragm en t(s) with at least two screws th rou gh th e appropriate distal h oles, as dictated by th e ractu re pattern . Th e screws m u st n ot pen etrate th e dorsal radial cortex. I a plate is selected with th readed h oles in th e distal lim b, th en lockin g h ead screws are u sed. Con rm redu ction u sin g im age in ten si cation .

Fig 4.4-16a –b

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a

b

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.4-1 7a –b

278

Th e VA LCP 2.4 w as applied to th e palm ar aspect o th e radiu s. Care w as taken n ot to exten d past th e w atersh ed lin e w ith th e plate.

Fig 4.4-1 8

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.4-19

8

Ou t co m e

a

a

b

At th e 12-m on th ollow -u p, th e AP an d lateral x-rays sh ow ed u ll h ealin g in an atom ical position .

Fig 4.4-2 0a –b

b

Th ere w as n orm al radial an d u ln ar deviation 12 m on th s a ter th e in itial trau m a.

Fig 4.4-2 1a –b

279

Pa rt II Case s

8

Ou t co m e (co n t )

a

b

c

d

Fig 4.4-2 2a –d

By th is stage, th e patien t h ad also obtain ed u ll w rist ran ge

o m otion .

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

Do rs a l s h e a rin g fra ct u re t re a t e d w it h d o rs a l p la t e s

a

b

c

Ju st as palm ar sh earin g distal radial ractu res can occu r, so too can su ch ractu res occu r on th e dorsal side. A 24-year-old en gin eer h ad a w ork-related m otor veh icle acciden t su stain in g gross de orm ity, severe pain an d sw ellin g, an d m u ltiple skin abrasion s alon g th e palm ar aspect o h is le t w rist, th u m b, an d orearm . A ter w ou n d clean in g an d sedation , th e patien t w as im m obilized in a padded su gar-ton g splin t. Ten days a ter th e in ju ry, w h en sw ellin g h ad su bsided an d in ection w as ru led ou t, h e w as taken to th e operatin g room . New PA an d lateral x-rays dem on strated a dorsal sh earin g articu lar ractu re.

Fig 4.4-2 3a –c

280

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

a

b

c

a

Th ree 2-D lateral view CT scan s revealed th e radial styloid an d th e dorsal rim o th e distal radiu s w ere displaced w ith th e proxim al carpal row .

Fig 4.4-2 4a –c

Do rs a l s h e a rin g fra ct u re s

b

Th e 3-D CT scan s u rth er sh ow ed th e m u lti ragm en tary dorsal sh earin g ractu re in th e le t w rist.

Fig 4.4-2 5a –b

Ch o ice o f im p la n t

I th e distal radial ragm en ts are predom in an tly dorsal, th ey can be h eld w ith dorsally applied plates, bu t i th ere is a sign i can t radial styloid ragm en t, it is stabilized m ore e ectively w ith a radial plate.

a

b

Dorsal sh earin g ractu res are less com m on th an palm ar sh earin g ractu res bu t are also o ten th e resu lt o h igh -en ergy trau m a. Th ey are typically m u lti ragm en tary ractu res an d associated with dorsal su blu xation o th e carpu s. Th ere can be a spectru m o in ju ry types with variation in th e size o th e dorsal ragm en ts.

Fig 4.4-26a –b

281

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

Ap p ro a ch

Ar t h ro t o m y

I direct vision o th e articu lar su r ace is n eeded, a lim ited tran sverse radiocarpal arth rotom y is per orm ed.

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 4.4-27

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n Pro vis io n a l re d u ct io n

Pro vis io n a l in t e rm e d ia t e co lu m n fixa t io n

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed with in a reason able tim e scale, a tem porary extern al xator m ay be h elp u l.

Fig 4.4.28

282

I th e dorsal rim ragm en ts are large en ou gh , obtain provision al xation w ith K-w ires.

Fig 4.4-2 9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Pro vis io n a l ra d ia l s t ylo id fixa t io n

Superficial branch of radial nerve

I th e ragm en t are too sm all th ey can be h eld w ith su tu re an ch ors or tran sosseou s su tu res.

Th e radial styloid ragm en ts are redu ced u n der direct vision w ith eith er a K-w ire on th e dorsoradial aspect or percu tan eou sly. In th e latter case, in order n ot to in ju re th e sen sory bran ch o th e radial n erve, m ake a sm all in cision over th e tip o th e radial styloid an d u se a protective drill gu ide to in sert tw o K-w ires. Con rm u sin g im age in ten si cation .

Fig 4.4-3 0

Fig 4.4-3 1

In t e rm e d ia t e co lu m n fixa t io n

a

b

c

Follow in g redu ction o th e dorsal rim ractu res, th e distal radiu s w as su pported by xation o a VA L-plate 2.4.

Fig 4.4-3 2a –c

Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g th e plate, an d in sertin g proxim al an d distal screw s. For u rth er in orm ation on th ese steps see ch apter 4.11 Distal radiu s—radiocarpal ractu re dislocation treated w ith dou ble platin g.

283

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Ra d ia l co lu m n fixa t io n

a

b

c

Th e radial colu m n plate w as placed u n dern eath th e rst com partm en t an d applied. In traoperative im agin g sh ow s th e com pleted dou ble plate xation .

Fig 4.4-3 3a –c

Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g th e plate, stabilizin g th e radial colu m n , in sertin g proxim al an d distal screw s, an d con rm in g screw placem en t w ith im agin g or x-rays. For u rth er in orm ation on th ese steps see ch apter 4.11 Distal radiu s—radiocarpal ractu re dislocation treated w ith dou ble platin g.

Pa lm a r liga m e n t o u s a vu ls io n re a t t a ch m e n t

a

Ad d it io n a l e xt e rn a l fixa t io n

b

Dorsal carpal su blu xation m ay be associated w ith avu lsion o th e palm ar w rist capsu le rom th e distal radiu s ( a ).

Fig 4 .4 -3 4 a – b

I th e dorsal rim ragm en ts are large en ou gh , th ey m ay be h eld in place w ith a bu ttress plate. I th ey are too sm all, K-w ires m ay be th e de n itive xation , in w h ich case, an extern al xator sh ou ld be applied.

Fig 4.4-3 5

A ter dorsal xation , ch eck th e carpal position an d stability u n der image in ten si cation . I th ere is carpal u ln ar an d/ or palm ar tran slation , con sider an addition al palm ar approach to repair so t tissu es. Th e capsu le can be reattach ed u sin g m u ltiple su tu re an ch ors or tran sosseou s su tu res ( b ).

284

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.4 Distal radius—she aring fracture tre ate d with a buttre ss plate

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Ou t co m e

a

b

Th e x-rays at th e 6-m on th ollow -u p sh ow th e redu ction h ad been m ain tain ed u n til bon e h ealin g.

Fig 4.4-3 6a –b

a

b

c

d

Fig 4.4-3 7a –d

Th ere w as an excellen t n al u n ction al resu lt

285

Pa rt II Case s

286

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.5

1

Distal radius—dorsally displaced intraarticular fracture treated with double plating

Ca s e d e s crip t io n

a

b

A 57-year-old m an ell on h is ou tstretch ed righ t h an d wh ile carryin g groceries, su stain in g a closed wrist in ju ry. Th e x-rays in dicated an in traarticu lar, dorsally displaced distal radial ractu re.

Fig 4.5-1a –b

a Fig 4.5-2a – d

b

c

d

Th e 2-D CT im ages also sh ow ed a dorsal lu n ate acet com pon en t w ith im paction .

287

Pa rt II Case s

2

In d ica t io n s Prin cip le o f co lu m n s

o c

l t

n

e

d

i

r

a

r

a

b

I

R

n

U

l

a

a

m

c

e

c

o

l

o

d

l

i

u

a

u

t

m

e

m

n

n

l

u

m

n

Co m p le t e in t ra a r t icu la r fra ct u re s

Com plete in traarticu lar ractu res o th e distal radiu s occu r wh en th ere is n o part o th e articu lar su r ace in con tin u ity with th e diaph ysis. Th is case in volves a com plete in traarticu lar ractu re with a dorsou ln ar posterom edial articu lar ragm en t associated with m etaph yseal displacem en t. As with all in traarticu lar ractu res, it sh ou ld be treated with an atom ical redu ction an d absolu te stability in order to m in im ize th e risk o su bsequ en t degen erative ch an ges in th e join t. An atom ical redu ction an d stabilization o th ese ractu res is also essen tial becau se o th e u n ction al im plication s o th e in volvem en t o th e distal radiou ln ar join t (DRUJ).

Fig 4.5-3a –b

Dorsally displaced ractu res m ay in volve loss o radial len gth an d a displaced coron al split in th e lu n ate ossa. Optim u m h old an d stability is best obtain ed with separate platin g o both th e radial an d in term ediate colu m n s. Th e xation o sm all distal ragm en ts is m ore secu re with lockin g plates.

288

Th e distal orearm can be th ou gh t o in term s o th ree colu m n s. Th e u ln a orm s on e colu m n (th e u ln ar colu m n ) wh ile th e radiu s can be separated in to two (th e in term ediate colu m n an d th e radial colu m n ). Th e 3-colu m n prin ciple h elps in describin g th e location o wrist in ju ries an d is u rth er explain ed in th e in dication s topic in ch apter 1.8 Dorsal approach to th e distal radiu s.

Fig 4.5-4

In dorsal dou ble platin g, u n derstan din g th e prin ciple o colu m n s is im portan t as th e in term ediate an d radial colu m n s are each stabilized with a separate plate. Th e radial colu m n is stabilized by a plate placed radially, deep to th e rst exten sor com partm en t. Th e in term ediate colu m n is stabilized with a separate precon tou red plate on th e dorsal aspect o th e in term ediate colu m n .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.5  Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating

2

In d ica t io n s (co n t )

As s o cia t e d m e d ia n n e r ve co m p re s s io n

As s o cia t e d ca rp a l in ju rie s

Median nerve

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Fig 4.5-5

Th ese in ju ries m ay be associated w ith sh earin g in ju ries o th e articu lar cartilage, scaph oid ractu res, an d ru ptu res o th e scaph olu n ate ligam en t. Every patien t sh ou ld be assessed or th ese in ju ries.

Fig 4.5-6

Ch o ice o f im p la n t

a

b

c

Dorsal plates

A selection o plates u sed or stabilizin g th e radial an d in term ediate colu m n s is available. Plates w ith variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t VA straigh t an d L-plates w ere u sed, w ith th e in term ediate colu m n bein g treated rst.

Fig 4.5-7 a – c

289

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA lockin g com pression plate (LCP) distal radiu s set VA LCP radial colu m n plate 2.4 VA LCP in term ediate colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan es o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.5-8

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 4.5-9

290

b

Followin g th e dorsal approach , th e exten sor pollicis lon gu s was elevated ( a ). Th e term in al bran ch o th e posterior in terosseou s n erve was iden ti ed ( b ).

Fig 4.5-1 0a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.5  Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating

4

Su rgica l a p p ro a ch (co n t )

Th rou gh th e dorsal exposu re, th e in term ediate an d radial colu m n in ju ries were clearly visible.

Fig 4.5-11

5

Re d u ct io n

Pro vis io n a l re d u ct io n

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed with in a reason able tim e scale, a tem porary extern al xator m ay be h elp u l.

Pro vis io n a l fixa t io n

Fig 4.5-12

In sert a K-w ire th rou gh th e tip o th e radial styloid to provision ally h old th e ragm en ts. Con rm u sin g im age in ten si cation .

Fig 4.5-1 3

291

Pa rt II Case s

6

Fixa t io n

Co n t o u r t h e p la t e s

a

b

Fig 4.5-14a –b

Plates u sed in treatin g radial an d in term ediate colu m n in ju ries are available precon tou red. However, som e addition al con tou rin g m ay be n ecessary to accom m odate th e in dividu al an atom y o th e patien t.

Fig 4.5-1 5

Pit fa ll: s cre w h o le d is t o r t io n

Fixa t io n o f in t e rm e d ia t e co lu m n Ar t h ro t o m y

a

Variable an gle lockin g plates en able precise position in g o th e distal screw s in desired direction s becau se th ere is 30 degrees o reedom or each screw in side th e plate h ole in order to address th e in dividu al ractu re pattern s.

b

Avoid con tou rin g th e plate th rou gh th e lockin g h oles oth erw ise th e lockin g h ead screw m igh t n o lon ger t.

Fig 4.5-1 6a –b

I direct vision o th e articu lar su r ace is n eeded, a lim ited tran sverse radiocarpal arth rotom y is per orm ed. Th e join t su r ace is n ow visible. Ch eck th e proxim al carpal row or addition al ligam en t in ju ries. Th e radial in sertion o th e trian gu lar brocartilage com plex can also be ch ecked.

Fig 4.5-1 7

292

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.5  Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating

6

Fixa t io n (co n t )

Re d u ce t h e u ln a r a r t icu la r fra gm e n t

Se le ct a n d a p p ly t h e p la t e

Th e in term ediate colu m n m u st n ow be restored. Th e u ln ar ragm en t m ay be ou n d im pacted in to th e m etaph ysis. Th is m u st be levered u p to th e level o th e join t. An atom ically redu ce th e en tire radiocarpal join t u n der direct vision . Prelim in ary xation w ith K-w ires is an option .

Fig 4.5-1 9

Fig 4.5-1 8

a

b

Th e appropriate plate is selected accordin g to th e ractu re con gu ration . Th e plate sh ou ld t exactly th e an atom y o th e in term ediate colu m n an d con tou red i n ecessary. Th e plate is position ed so th at it bu ttresses th e in term ediate colu m n an d su pports th e recon stru cted radiocarpal join t su r ace. Fix th e plate provision ally to th e bon e w ith a stan dard cortex screw in serted th rou gh th e oblon g plate h ole. Be ore u lly tigh ten in g it, ch eck th e plate position u sin g in traoperative im agin g, adju stin g th e position o th e plate as n ecessary.

c

For th is patien t, ollow in g placem en t o a sm all n eedle in to th e radiocarpal join t or orien tation , a VA L-plate 2.4 w as position ed an d h eld w ith a 1.2 m m K-w ire ( a ). In traoperative im agin g con rm ed th e position o th e plate an d redu ction o th e in term ediate colu m n ( b – c ).

Fig 4.5-2 0a –c

293

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t p ro xim a l s cre w s

In s e r t d is t a l s cre w s

X-ray beam

a Fig 4.5-21

In sert proxim al screws as n ecessary to com plete th e xation o th e in term ediate colu m n plate.

Fig 4.5-2 2a –b

Fixa t io n o f ra d ia l co lu m n Se le ct a n d a p p ly t h e p la t e

St a b ilize t h e ra d ia l co lu m n

b

Follow in g in sertion o th e distal lockin g screw s, an gled lateral im ages are taken to con rm extraarticu lar placem en t. I th e screw s appear to en ter th e radiocarpal join t, th ey can be reposition ed i a VA LCP h as been u sed.

Ideally wh ile applyin g th e plate, th e n otch in th e distal tip o th e im plan t is placed again st th e tem porary K-wire.

Fig 4.5-24

Th e appropriate plate is selected accordin g to th e ractu re con gu ration an d con tou red i n ecessary. Slide th e plate u n dern eath th e rst com partm en t an d apply it on to th e radial colu m n .

Fig 4.5-2 3

294

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.5  Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating

6

Fixa t io n (co n t )

Pit fa ll: in co rre ct p la ce m e n t

70°–90° a

b

c

To optim ally stabilize th e radial styloid, th e plates m u st be position ed correctly at 70–90 degrees to each oth er. Avoid placem en t o th e radial plate on th e dorsal aspect o th e radial colu m n , as it will n ot bu ttress th e redu ction adequ ately again st axial sh ear orces.

Fig 4.5-25a –c

In s e r t t h e firs t s cre w in t h e ra d ia l co lu m n p la t e

In s e r t t h e firs t lo ck in g h e a d s cre w

In sert a stan dard cortex screw in to th e oblon g plate h ole proxim al to th e ractu re. Th e screw sh ou ld en gage th e ar cortex. Th e position o th e plate m ay be adju sted be ore th e screw is tigh ten ed. Tigh ten in g th is screw w ill redu ce th e radial styloid.

Fig 4.5-2 7

Fig 4.5-2 6

To preven t rotation o th e plate du rin g distal lockin g screw xation , th e plate sh ou ld be secu red to th e bon e by in sertin g th e m ost proxim al screw .

295

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t d is t a l lo ck in g h e a d s cre w s a n d co m p le t e t h e fixa t io n

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a a

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.5-2 9a –b

b

I a K-w ire w as u sed, it is n ow rem oved. Distal lockin g h ead screw (s) are in serted to su pport th e radial styloid. Con rm screw position in g u sin g th e im age in ten si er.

Fig 4.5-2 8a –b

a

b

b

In traoperative view o th e dou ble plate xation . Th e in traoperative im age con rm ed an an atom ical redu ction an d stable in tern al xation .

Fig 4.5-30a –b

296

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.5  Distal radius—dorsally displace d intraarticular fracture tre ate d with double plating

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.5-31

8

Ou t co m e

a

b

Th e 4-m on th ollow-u p x-rays sh owed com plete ractu re u n ion .

Fig 4.5-32a –b

a

b

c

d

Fig 4.5-3 3a –d

Th ere was excellen t pain - ree m otion an d

recovery.

297

Pa rt II Case s

8

Ou t co m e (co n t )

Vid e o

Th is video dem on strates an in traarticu lar distal radial ractu re treated u sin g dorsal dou ble plate xation .

Vid e o 4 .5 -1

298

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.6

1

Distal radius—multifragmentary intraarticular fracture treated with a palmar plate

Ca s e d e s crip t io n

a

b

c

d

A 38-year-old en gin eer w as in ju red w h ile participatin g in a dirt bike com petition . Wh en h e arrived at th e em ergen cy departm en t h e com plain ed o pain in h is n on dom in an t le t w rist, an d th ere w as eviden ce o edem a an d de orm ity. Th e x-rays an d CT scan s in dicated exten sive m u lti ragm en tation in both th e in term ediate an d radial colu m n s o th e distal radiu s, an d on th e coron al plan e, th e articu lar com pon en t an d cen tral im paction ragm en ts w ere apparen t.

Fig 4.6-1a – d

a

b

c

Th e 3-D CT scan s dem on strated th e palm ar an d dorsal m u ltiragm en tation as w ell as an u ln ar styloid ractu re.

Fig 4.6-2 a – c

299

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

A view o th e join t su r ace o th e radiu s in th e 3-D CT scan sh owed th e severity o th e articu lar com pon en t.

Fig 4.6-3

In addition to th e obviou s distal radial in ju ries th ere was also a ractu re at th e base o th e u ln ar styloid, so all th ree colu m n s were in volved. Treatm en t or th is patien t’s u ln ar styloid ractu re h as already been discu ssed in detail in ch apter 3.1 Uln ar styloid— ractu re treated with ten sion ban d wirin g, so or th e pu rposes o th is ch apter, on ly th e m u lti ragm en tary distal radial ractu re is discu ssed.

2

In d ica t io n s

Mu lt ifra gm e n t a r y co m p le t e in t ra a r t icu la r fra ct u re s

a

b

Com plete in traarticu lar ractu res o th e distal radiu s occu r w h en th ere is n o part o th e articu lar su r ace in con tin u ity w ith th e diaph ysis, an d th ey requ ire an atom ical redu ction except in low dem an d patien ts. Wh en th e ractu re is m u lti ragm en tary it can be classi ed accordin g to th e exten t o th e m etaph yseal ragm en tation , varyin g rom th ose in volvin g ragm en tation o th e articu lar su r ace bu t w ith a sim ple m etaph yseal ractu re, as seen on th e le t h an d o th is patien t, to th ose in volvin g severe ragm en tation in th e m etaph ysis, or th e m ost com plex w ith ractu re lin es exten din g w ell in to th e diaph ysis.

Fig 4.6-4 a – b

Plate xation is appropriate or th ese ractu res. As lon g as th e articu lar su r ace is accu rately redu ced an d is xed in th e correct position in relation to th e radial sh a t, it is n ot n ecessary to x all th e m etaph yseal ragm en ts an d th e plate can be u sed in a bridgin g m ode.

300

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.6 Distal radius—multifragmentary intraarticular fracture tre ate d with a palmar plate

2

In d ica t io n s (co n t )

As s o cia t e d u ln a r in ju rie s

Im a gin g

It is n ot possible to m ake an accu rate assessm en t o th e details o th ese in ju ries w ith ou t a CT scan .

Ch o ice o f im p la n t

Th ese in ju ries can also be accom pan ied by avu lsion o th e u ln ar styloid an d/ or disru ption o th e distal radiou ln ar join t (DRUJ). I th ere is gross in stability a ter th e xation o th e radial ractu re, it is recom m en ded th at th e u ln ar styloid an d/ or th e trian gu lar brocartilage (TFC) disc is reattach ed. Th is is n ot com m on in sim ple ractu res bu t can occu r in som e h igh -en ergy in ju ries. Th e u n in ju red side sh ou ld be tested as a re eren ce or th e in ju red side. How ever, it m ay n ot be possible to assess DRUJ stability u n til th e ractu re h as been stabilized.

Fig 4.6-5

a Palm ar plate

b 2-colum n plate

c Volar colum n plate

In m ost com plete in traarticu lar ractu res w ith m u lti ragm en tation o th e articu lar su r ace, stan dard palm ar lockin g plates are lon g en ou gh to obtain adequ ate proxim al h old. How ever, i th ere is m u lti ragm en tation in volvin g a sign i can t len gth o th e m etaph ysis, stan dard palm ar plates m ay be too sh ort to provide adequ ate stabilization . Specially design ed lon ger an gu lar stable plates an d plates w ith larger m u ltiple-h ole h eads an d variable an gle (VA) lockin g screw option s h ave been developed to h elp stabilize th e distal an d proxim al ragm en ts. For th is patien t, a volar colu m n distal radiu s plate w as selected.

Fig 4.6-6 a – c

301

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

• VA lockin g com pression plate (LCP) distal radiu s set • VA LCP volar colu m n plate 2.4 • 1.1 m m or 1.2 m m K-w ires

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.6-7

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a m odi ed Hen ry palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 4.6-8

302

Th e radiu s was exposed th rou gh th e m odi ed Hen ry approach wh ere severe ractu re ragm en tation becam e apparen t.

Fig 4.6-9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.6 Distal radius—multifragmentary intraarticular fracture tre ate d with a palmar plate

5

Re d u ct io n

Pro vis io n a l re d u ct io n

a

b

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.6-1 0a –b

6

Fixa t io n

Se le ct t h e p la t e

a

b

A volar colu m n distal radiu s plate w as u sed to stabilize th e ractu re in th is case. Volar colu m n plates (VCP) are precon tou red or an atom ical t on th e palm ar aspect o th e distal radiu s. Mu ltiple lockin g screw h oles in th e h ead o th e plate provide addition al xation o th e radial an d in term ediate colu m n s, w ith screw trajectories design ed to address a w ide variety o ractu re types.

Fig 4.6-1 1a –f

c

d

e

f

303

Pa rt II Case s

6

Fixa t io n (co n t )

Ap p ly t h e p la t e a n d in s e r t t h e firs t s cre w

Apply th e VCP to th e bon e so th at th e distal en d o th e plate en ds at th e an atom ical w atersh ed zon e o th e distal radiu s. In sert an appropriate cortex screw th rou gh th e oblon g plate h ole in to th e proxim al radial ragm en t. Select a screw th at is lon g en ou gh to en gage both cortices. Be ore u lly tigh ten in g it, ch eck th e plate position u sin g in traoperative im agin g, adju stin g th e position o th e plate as n ecessary.

Fig 4.6-1 2

Th is sagittal view MRI sh ow s h ow close th e f exor ten don s are to th e radiu s (yellow arrow s), m akin g it clear th at th e plate sh ou ld be placed proxim ally to th e an atom ical w atersh ed zon e to avoid ten don irritation an d ru ptu res.

Fig 4.6-1 3

In s e r t t h e firs t d is t a l s cre w

Th e in itial distal screw sh ou ld be placed th rou gh th e u ln ar sided screw h oles to stabilize th e in term ediate colu m n . Th is distal screw sh ou ld be placed ju st in th e su bch on dral bon e to bu ttress th e articu lar ragm en ts an d to avoid later displacem en t.

Fig 4.6-1 4

304

a

b

Th e in traoperative im ages sh ow th e plate bein g applied to th e bon e. On ce th e rst screw was in trodu ced th rou gh th e proxim al oblon g plate h ole, th e im age in ten si er was u sed to evalu ate th e direction o th e m ost u ln ar distal screw.

Fig 4.6-1 5a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.6 Distal radius—multifragmentary intraarticular fracture tre ate d with a palmar plate

6

Fixa t io n (co n t )

In s e r t a d d it io n a l d is t a l s cre w s

a

a

b

Precise m easu rem en t is requ ired to avoid an y screw tip protru din g th rou gh th e dorsal aspect o th e radiu s (red lin e) to avoid ten don ru ptu res. Screws placed in th e radial styloid sh ou ld reach th e tip o th e radial styloid or th e best pu rch ase. Th is can be evalu ated u sin g th e im age in ten si er.

Fig 4.6-17a –b

b

In sert distal lockin g h ead screw s to secu re articu lar redu ction .

Fig 4.6-1 6a –b

Co n firm s cre w p o s it io n in g

90°

a

b

A sagittal im age w ith th e an gle o th e x-ray beam directed 20 degrees obliqu ely to th e radiu s can con rm th at th e screw is n ot pen etratin g th e radiocarpal join t. With th is view , th e su bch on dral position in g o th e distal screw s is accu rately evalu ated. I th e screw is ou n d to pen etrate th e articu lar su r ace, it m u st be rem oved an d reposition ed. Fig 4.6-18 a –d

c

d

305

Pa rt II Case s

6

Fixa t io n (co n t ) In s e r t p ro xim a l s cre w s a n d co m p le t e t h e fixa t io n

a

Th is in traoperative im age dem on strates h ow placin g th e drill gu ide in to th e distal h oles o th e plate assists in evalu atin g th e direction o th e screws.

Fig 4.6-1 9

b

In sert u rth er proxim al screw s as requ ired an d com plete th e xation .

Fig 4.6-2 0a –b

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

Fu rth er screw s w ere in serted an d th e distal radiu s xation later com pleted.

a

b

Fig 4 .6 -21

306

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.6-2 2a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.6 Distal radius—multifragmentary intraarticular fracture tre ate d with a palmar plate

6

Fixa t io n (co n t )

a

b

AP an d lateral x-rays were taken 1 week a ter su rgery to con rm per ect redu ction o th e ractu res an d correct location o im plan ts.

Fig 4.6-23a –b

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.6-24

307

Pa rt II Case s

8

Ou t co m e

a

b

At th e 1-year ollow -u p, th ere w as an excellen t radiological ou tcom e.

Fig 4.6-2 5a –b

a

b

c

d

Th ere w as also an excellen t u n ction al ou tcom e w ith n o pain . Th e patien t h ad retu rn ed to h is n orm al w ork an d m otor bike sportin g activities.

Fig 4.6-2 6a –d

308

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.7

1

Distal radius—multifragmentary intraarticular fracture with defect treated with a palmar plate

Ca s e d e s crip t io n

a

a

b

c

A 57-year-old pro ession al h ou sekeeper tripped an d ell on to h er ou tstretch ed righ t wrist wh ile walkin g a dog. Sh e presen ted to th e em ergen cy departm en t with a swollen wrist bu t with a n orm al n eu rovascu lar exam in ation . Th e AP, lateral, an d obliqu e x-rays dem on strated a m u ltiragm en tary com plete in traarticu lar ractu re o th e distal radiu s with exten sion in to th e m etaph ysis as well as a com plex ractu re o th e distal u ln a exten din g in to th e u ln ar h ead.

Fig 4.7-1a –c

b

Th e axial 2-D CT scan s clearly sh owed th e articu lar in ju ry with im paction an d rotation o articu lar ragm en ts.

Fig 4.7-2a –b

Th e exten sion o th e radial ractu re in to th e distal diaph yseal-m etaph yseal ju n ction is sh own in th e 3-D CT scan s.

Fig 4.7-3a –b

a

b

For th is patien t, both th e distal u ln a an d radiu s su stain ed m u lti ragm en tary ractu res requ irin g open redu ction an d in tern al xation . However, or th e pu rposes o th is ch apter, on ly th e distal radiu s is discu ssed. For u rth er in orm ation on treatin g distal u ln ar ractu res see ch apter 3.2 Uln a, h ead an d n eck—m u lti ragm en tary ractu re treated with a h ook plate.

309

Pa rt II Case s

2

In d ica t io n s

Mu lt ifra gm e n t a r y co m p le t e in t ra a r t icu la r fra ct u re s w it h m e t a p h ys e a l d e fe ct

a

As s o cia t e d u ln a r in ju rie s

b

In som e in stan ces, com plete in traarticu lar ractu res o th e distal radiu s can in volve severe ragm en tation in th e m etaph ysis resu ltin g in a m etaph yseal de ect. Th ere are o ten sm all articu lar ragm en ts an d im pacted ragm en ts. An atom ical redu ction an d stabilization o th ese in traarticu lar ractu res is essen tial becau se o th e u n ction al im plication s o th e in volvem en t o th e distal radiou ln ar join t (DRUJ). Plate xation is appropriate provided th e distal ragm en ts are large en ou gh to be h eld w ith screw s. As lon g as th e articu lar su r ace is accu rately redu ced an d is xed in th e correct position in relation to th e radial sh a t it is n ot n ecessary to x all th e m etaph yseal ragm en ts.

Fig 4.7-4 a – b

Head, n eck, an d m u lti ragm en tary ractu res o th e distal u ln a o ten occu r in com bin ation w ith distal radial ractu res. With th ese u ln ar ractu res th ere is in stability an d sh orten in g, so th e distal u ln a h ook plate can be u sed to h old th e ractu re. Atten tion sh ou ld be paid to restorin g correct rotation an d len gth in relation to th e radiu s. Com plete dislocation o th e radiocarpal join t is o ten associated w ith disru ption o th e distal radiou ln ar join t (DRUJ).

Fig 4.7-5

Im a gin g

It is n ot possible to m ake an accu rate assessm en t o th e details o th ese in ju ries w ith ou t a CT scan .

310

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.7 Distal radius—multifragmentary intraarticular fracture with de fe ct tre ate d with a palmar plate

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

In m ost com plete in traarticu lar ractu res w ith m u lti ragm en tation o th e articu lar su r ace, stan dard palm ar lockin g plates are lon g en ou gh to obtain adequ ate proxim al h old. How ever, i th ere is m u lti ragm en tation in volvin g a sign i can t len gth o th e m etaph ysis, stan dard palm ar plates m ay be too sh ort to provide adequ ate stabilization . Specially design ed lon ger an gu lar stable plates an d plates w ith larger m u ltiple-h ole h eads an d variable an gle (VA) lockin g screw option s h ave been developed to h elp stabilize th e distal an d proxim al ragm en ts. For th is patien t, a 2-colu m n palm ar plate w ith th e lon ger 3-h ole sh a t w as selected.

Fig 4 .7 -6a –c

a

b Palm ar plate

3

2-colum n plate

c Volar colum n plate

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA lockin g com pression plate (LCP) distal radiu s set VA LCP 2-colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Poin ted redu ction orceps Sm all extern al xator or th e distal radiu s Ball tip redu ction orceps Lam in ar spreader Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.7-7

311

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a m odi ed Hen ry palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 4.7-8

5

Th rou gh th e m odi ed Hen ry approach , th e palm ar ractu re lin es w ere exposed.

Fig 4.7-9

Re d u ct io n

Pro vis io n a l re d u ct io n

a

b

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.7-1 0a –b

312

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.7 Distal radius—multifragmentary intraarticular fracture with de fe ct tre ate d with a palmar plate

5

Re d u ct io n (co n t )

Pro vis io n a l fixa t io n w it h K-w ire s

Re d u ct io n w it h a s p re a d e r/ m a n u a l t ra ct io n

In cases o m oderate ragm en tation on th e dorsal an d palm ar cortex, it is di cu lt to m ain tain tem porary redu ction w ith K-w ires. Redu ction w ith th e h elp o a spreader an d/ or m an u al traction is th en recom m en ded.

In sert a K-wire across th e ractu re, th rou gh th e radial styloid, to provide provision al stabilization . Th e m ajor articu lar ragm en ts can be redu ced with th e aid o a poin ted redu ction orceps. Tem porary xation o th e m ajor articu lar ragm en ts with K-wires is also an option . Th e aim is to ach ieve an accu rate an atom ical redu ction o th e articu lar ragm en ts be ore th e plate is applied.

Fig 4.7-11

Pro vis io n a l re d u ct io n w it h a n e xt e rn a l fixa t o r

In cases o exten sive m etaph yseal an d/ or diaph yseal com m in u tion , redu ction can be ach ieved an d m ain tain ed w ith th e h elp o an extern al xator.

Fig 4.7-1 2

313

Pa rt II Case s

5

Re d u ct io n (co n t )

Re d u ct io n u s in g a b a ll t ip re d u ct io n fo rce p s

a

b

An altern ate m eth od to en su re redu ction is by u sin g a ball tip redu ction orceps ( a ). Usin g a bolster or towel to assist with f exin g th e wrist can som etim es m ake it di cu lt to access th e distal segm en ts o th e radiu s, yet lyin g th e wrist f at on th e table can m ake access easier bu t ractu re redu ction m ore di cu lt. With th e ball tip redu ction orceps, th e th ick ru bber on th e dorsal side h elps to redu ce th e dorsal aspect o th e ractu re with ou t pu ttin g stress on th e ten don s or th e skin ( b –c).

Fig 4.7-13a –c

c

314

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.7 Distal radius—multifragmentary intraarticular fracture with de fe ct tre ate d with a palmar plate

6

Fixa t io n

Se le ct a n d a p p ly t h e p la t e a n d in s e r t d is t a l s cre w s

Th e lockin g plate is rst position ed distally on th e f at redu ced palm ar su r ace o th e distal radiu s at th e an atom ical w atersh ed zon e an d xed w ith distal lockin g screw s parallel to th e articu lar su r ace w ith at least on e bu t pre erably tw o screw (s) in each articu lar ragm en t, depen din g on th e qu ality o bon e stock. Th e rst screw in serted is th e u ln ar on e an d its position sh ou ld be ch ecked u n der im age in ten si cation w ith th e h an d elevated 20–30 degrees o th e table, in lu n ate acet view . On ce th e articu lar block is secu rely h eld to th e plate an y K-w ire(s) can be rem oved.

Fig 4.7-1 4a –b

a

b

a

b

In traoperative im ages con rm ed th e placem en t o th e plate an d prelim in ary screw placem en t.

Fig 4.7-1 5a –b

315

Pa rt II Case s

6

Fixa t io n (co n t )

De t e rm in e co rre ct b o n e le n g t h

In s e r t firs t p ro xim a l s cre w

a

b

Th e correct len gth o th e radiu s in relation to th e u ln a sh ou ld be establish ed preoperatively by takin g x-rays o th e opposite w rist. Th e len gth o th e radiu s in relation to th e u ln a is th en ach ieved by in sertin g a u n icortical screw , ju st proxim al o th e proxim al en d o th e plate, an d th en u sin g a spreader as illu strated to m ove th e plate gen tly distally.

Fig 4.7-1 6

In s e rt p ro xim a l lo ckin g s cre w s a n d co m p le te th e

On ce th e correct len gth is ach ieved, th e plate is provision ally xed proxim ally w ith an appropriate cortex screw th rou gh th e oblon g h ole.

Fig 4.7-1 7a –b

xa tio n

a

b

Th e relation sh ip o th e radiu s to th e distal u ln a is ch ecked u n der im age in ten si cation be ore th e plate is xed w ith addition al proxim al lockin g screw s.

Fig 4.7-1 8a –b

316

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.7 Distal radius—multifragmentary intraarticular fracture with de fe ct tre ate d with a palmar plate

6

Fixa t io n (co n t )

a Fig 4.7-19a –b

b

Two views o th e VA LCP palm ar plate 2.4 in position a ter placem en t o th e rem ain in g screws.

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a

b

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.7-2 1a –b

In traoperative im age ollow in g xation o th e distal radiu s.

Fig 4.7-2 0

317

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.7-22

8

Ou t co m e

a

a

b

At th e 6-m on th ollow-u p, th e AP an d lateral x-rays dem on strated u ll h ealin g in an an atom ical position .

Fig 4.7-23a –b

318

b

c

By th is stage, n early u ll w rist an d orearm m otion h ad been ach ieved.

Fig 4.7-2 4a –c

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.8

1

Distal radius—multifragmentary intraarticular fracture treated with triple plating

Ca s e d e s crip t io n

a

b

c

A 48-year-old o ce m an ager ell on to h er dom in an t ou tstretch ed le t h an d wh en sh e tripped over a box in h er o ce. Sh e su stain ed a m u lti ragm en tary in traarticu lar ractu re o th e le t distal radiu s. Th e PA an d lateral x-rays revealed th e com plex n atu re o th e distal radial ractu re. Axial 2-D CT scan s u rth er dem on strated th e in volvem en t o th e articu lar su r aces o both colu m n s o th e distal radiu s an d th e articu lar su r ace o th e distal radiou ln ar join t.

Fig 4.8-1a –c

a

b

c

d

Addition al sagittal an d coron al 2-D CT scan s revealed th e im pacted an d displaced in traarticu lar com pon en t o th e radial ractu re in both radial an d in term ediate colu m n s ( a ), as well as th e com m in u ted n atu re o th e articu lar ragm en ts ( b ), th e palm ar displacem en t o th e lu n ate acet com pon en t ( c ), an d th e im pacted an d u n stable n atu re o th e scaph oid acet com pon en t ( d ).

Fig 4.8-2a –d

319

Pa rt II Case s

2

In d ica t io n s

Co m p le t e in t ra a r t icu la r fra ct u re s w it h im p a ct io n

a

b

c

A stron g orce or all can be en ou gh to cau se a com plete in traarticu lar ractu re o th e distal radiu s w ith n o part o th e articu lar su r ace in con tin u ity w ith th e diaph ysis. Mu lti ragm en tation can resu lt, as can ractu re lin es exten din g in to th e diaph ysis. Addition ally, th e in ju ry can in volve im paction , w h ich can occu r in th e m ore osteoporotic bon e o an elderly patien t or in you n ger patien ts typically as a resu lt o h igh -en ergy trau m a. As th ese are in traarticu lar ractu res, w h ere possible, th ey sh ou ld be treated w ith an atom ical redu ction an d absolu te stability to m in im ize th e risk o su bsequ en t degen erative ch an ges in th e join t. Use o CT scan s can be h elp u l or treatm en t decision s.

Fig 4 .8 -3 a –c

320

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.8 Distal radius—multifragmentary intraarticular fracture tre ate d with triple plating

2

In d ica t io n s (co n t )

I

R

n

U

l

a

t

n

e

d

i

r

a

r

a

l

m

c

e

c

o

l

o

d

l

i

u

a

u

t

m

e

m

n

n

c

o

l

u

m

n

Prin cip le o f co lu m n s

Th e distal orearm can be th ou gh t o in term s o th ree colu m n s. Th e u lna orm s on e colu m n (th e u ln ar colu m n ) wh ile th e radiu s can be separated in to two (th e in term ediate colu m n an d th e radial colu m n ). Th e 3-colu m n prin ciple h elps in describin g th e location o wrist in ju ries an d is u rth er explain ed in th e in dication s topic in ch apter 1.8 Dorsal approach to th e distal radiu s.

Fig 4.8-4

In in ju ry types sim ilar to th is patien t, u n derstan din g o th e 3-colu m n prin ciple is particu larly h elp u l in preparin g a plan or su rgical redu ction an d stabilization an d will assist in in terpretation o th e im agin g. It m u st be rem em bered th at th e in term ediate colu m n provides articu lar su r aces or both th e radiocarpal an d th e distal radiou ln ar join ts, so in ju ries to th is colu m n dem an d atten tion to recon stru ct both com pon en ts. Wh en acin g in ju ries o th is n atu re, open redu ction an d a com bin ation o palm ar an d dorsal in tern al xation are likely to be requ ired. Th e ration ale or u sin g both palm ar an d dorsal approach es in clu des: th e displaced palm ou ln ar ragm en t (in term ediate colu m n ) an d th e rotated radial styloid (radial colu m n ) requ irin g a palm ar approach ; an d th e displaced an d u n stable dorsal ragm en t with cen tral im paction (in term ediate colu m n ) requ irin g a dorsal approach an d arth rotom y. Appreciation o in ju ries to each colu m n assists in plan n in g th e order o xation .

321

Pa rt II Case s

2

In d ica t io n s (co n t )

As s o cia t e d m e d ia n n e r ve co m p re s s io n

Ch o ice o f im p la n t

Median nerve

a

I th ere is den se sen sory loss, or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed rom th e level o th e ractu re in to th e palm , releasin g th e carpal tu n n el.

Dorsal plate s

Fig 4.8-5

3

c 2-colum n plate

Th is case in volves treatm en t o both th e dorsal an d palm ar aspect, an d so speci c palm ar an d dorsal plates w ere selected in clu din g variable an gle lockin g com pression plate (VA LCP) dorsal distal radiu s plates an d a VA LCP 2-colu m n plate on th e palm ar side.

Fig 4.8-6 a – c

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • •

b

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA LCP distal radiu s set VA LCP 2-colu m n plate 2.4 VA LCP radial colu m n plate 2.4 VA LCP in term ediate colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Th e palm ar approach will requ ire th e orearm to be placed in su pin ation . A dorsal approach requ ires th e orearm to be pron ated. Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.8-7

322

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.8 Distal radius—multifragmentary intraarticular fracture tre ate d with triple plating

4

Su rgica l a p p ro a ch

Pa lm a r a n d d o rs a l a p p ro a ch e s

a

b

Th e in itial su rgical approach w as a m odi ed Hen ry palm ar approach (see ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s). Su bsequ en tly, a dorsal approach w as requ ired to redu ce an d stabilize th e dorsal com pon en ts w ith dorsal im plan ts an d to per orm an arth rotom y to assess articu lar redu ction an d to in spect th e in tegrity o th e in trin sic ligam en ts (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 4.8-8 a – b

5

Re d u ct io n a n d fixa t io n

Pro vis io n a l re d u ct io n

a

b

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.8-9 a – b

Redu ction is ach ieved by rst recreatin g a stable palm ar cortex so th at th e dorsal an d articu lar ractu res can be redu ced again st it in bu ttress m ode.

323

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

A h ypoderm ic n eedle w as placed in to th e radiolu n ate join t u n der im age in ten si cation to accu rately de n e th e distal lim it o th e distal radiu s or placem en t o th e im plan t.

Fig 4.8-1 0

Re d u ct io n u s in g t h e p la t e

a

b

Select an d apply th e palm ar plate to th e distal ragm en t ( a ). In sert tem porary K-w ires to stabilize th e im plan t an d to secu re th e correct position or im plan t placem en t. Th e n om in al an gle drill gu ide block is u sed to preven t in adverten t in traarticu lar screw pen etration . Con rm u sin g im age in ten si cation . A VA LCP 2-colu m n plate w as applied to th e palm ar su r ace o th e distal radiu s u n der im age in ten si cation ( b ).

Fig 4.8-1 1a –b

324

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.8 Distal radius—multifragmentary intraarticular fracture tre ate d with triple plating

5

Re d u ct io n a n d fixa t io n (co n t )

In s e r t d is t a l s cre w s

Ap p ly t h e p la t e t o t h e s h a ft

Th e im plan t is th en u sed to redu ce th e ragm en ts by pu sh in g it on to th e su r ace o th e radiu s. Brin g th e plate on to th e sh a t an d h old it with a orceps. Ch eck correct placem en t with im agin g an d adju st th e position o th e distal ragm en t i n ecessary by m ovin g th e plate.

Fig 4.8-13

a

b

Sh ort n om in al an gle lockin g screw s are in serted in to th e palm ar ragm en ts on ly.

Fig 4.8-1 2a –b

In s e r t p ro xim a l s cre w s

a

On ce satis actory redu ction is con rm ed, in sert an appropriate cortex screw th rou gh th e oblon g plate h ole.

Fig 4.8-14

b

Usin g th e palm ar su rgical approach , xation o th e palm ar ragm en ts o th e in term ediate colu m n (lu n ate acet) w as ach ieved u sin g th e VA LCP 2-colu m n plate 2.4 w ith sh ort lockin g screw s. Th e palm ar bu ttress w as th en reestablish ed.

Fig 4.8-1 5a –b

325

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

a

b

Th e procedu re restores th e palm ar bu ttress th at h ad been lost du e to th e ractu re pattern . In traoperative im ages con rm th e redu ction an d stabilization o th e displaced palm ar ragm en ts o th e in term ediate colu m n .

Fig 4.8-16a –b

It m u st be appreciated th at n eith er th e dorsal ragm en ts o th e in term ediate colu m n n or th e ragm en ts o th e radial colu m n h ave yet been redu ced or stabilized. However, th e restoration o an in tact an d stable palm ar bu ttress allows th ese com pon en ts o th e ractu re to be treated.

Do rs a l p la t e s fixa t io n

a

b

c

Th e dorsal su rgical approach allow s placem en t o VA LCP dorsal distal radiu s plates. In itially, th e dorsal ragm en ts o th e in term ediate colu m n (an d th ere ore also th e distal radiou ln ar join t) w ere redu ced by bu ttressin g again st th e n ew ly stabilized palm ar su r ace/ im plan t. Th e in term ediate colu m n can th en be redu ced an d stabilized. Th e lu n ate acet o th e distal radiu s an d th e distal radiou ln ar join t su r aces w ere restored.

Fig 4.8-1 7a –c

326

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.8 Distal radius—multifragmentary intraarticular fracture tre ate d with triple plating

5

Re d u ct io n a n d fixa t io n (co n t )

a

b

d

c

e

f

Fin ally, th e radial colu m n is stabilized by th e application o a radial VA LCP dorsal distal radiu s plate th at also acts in bu ttress m ode, th is tim e bu ttressin g again st th e redu ced an d stabilized in term ediate colu m n . Th e total com bin ation o plates provides per ect redu ction o all ragm en ts an d stable xation . In traoperative im ages an d illu stration s sh ow th e com pleted triple platin g o th e distal radial ractu re. For u rth er in orm ation on th e steps or dorsal platin g see ch apter 4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re treated with dou ble platin g.

Fig 4.8-18a –f

6

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow-u p, rem oval o stitch es, an d im mobilization as requ ired. Followin g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated with a radial colu m n plate.

Fig 4.8-19

327

Pa rt II Case s

7

Ou t co m e

a

b

At th e 2-year ollow -u p, x-rays con rm ed th e ractu res h ad h ealed an atom ically.

Fig 4.8-2 0a –b

a

a

b

c

d

Th e patien t retu rn ed to n orm al u n ction with n o pain an d a m in or degree o restriction o f exion .

Fig 4.8-21a –d

b

Th e in ju red side (th e dom in an t le t h an d) was n ow dem on stratin g greater grip stren gth th an th e u n in ju red n on dom in an t side.

Fig 4.8-22a –b

328

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.9

1

Distal radius—multifragmentary intraarticular fracture with associated scaphoid fracture treated with triple plating and screw

Ca s e d e s crip t io n

a

b

c

d

A 32-year-old salesm an ell on to h is ou tstretch ed le t h an d w h ile ru n n in g du rin g a soccer m atch . He su stain ed a m u lti ragm en tary in traarticu lar distal radial ractu re an d an associated ractu re o th e proxim al pole o th e scaph oid. Th e PA an d lateral x-rays o th e le t h an d revealed th e com plex n atu re o th e ractu res in th e radiu s an d th e scaph oid. Axial 2-D CT scan s u rth er dem on strated th e m ajor articu lar in volvem en t o th e distal radiu s scaph oid acet.

Fig 4.9-1a – d

a

b

c

Addition al sagittal 2-D CT scan s m ade clear th e distal radial an d scaph oid ractu res, sh ow in g th e dorsal displacem en t ( a ), th e cen trally im pacted in traarticu lar com pon en t o th e radial ractu re ( b ), an d th e proxim al pole ractu re o th e scaph oid ( c ).

Fig 4.9-2a – c

329

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

c

Th e 3-D CT im ages iden ti ed both palm ar an d dorsal m etaph yseal aspects o th e radial ractu re an d th e m u lti ragm en tation o th e articu lar su r ace.

Fig 4.9-3 a – c

2

In d ica t io n s

Co m p le t e in t ra a r t icu la r fra ct u re s w it h a s s o cia t e d ca rp a l in ju rie s

a

b

Wh en com plete in traarticu lar ractu res o th e distal radiu s occu r, m u lti ragm en tation can o ten resu lt, as can ractu re lin es exten din g in to th e diaph ysis, an d treatm en t m u st in volve an atom ical redu ction an d stabilization . Yet an y patien t wh o su ers h igh -en ergy im pact on to an ou tstretch ed h an d can also su stain in tercarpal ligam en t in ju ries an d carpal ractu res. Th ese can easily be m issed on in itial clin ical assessm en t. Use o CT scan s can be h elp u l or treatm en t decision s.

Fig 4.9-4a –b

For in ju ries described above, open redu ction an d a com bin ation o palm ar an d dorsal in tern al xation m ay be requ ired. Th e ration ale or u sin g both palm ar an d dorsal approach es in clu des: th e h yperexten ded palm ou ln ar ragm en t (in term ediate colu m n ) an d th e rotated radial styloid (radial colu m n ) requ irin g a palm ar approach ; an d a displaced dorsal ragm en t an d th e im pacted cen tral articu lar ragm en t (in term ediate colu m n ) requ irin g a dorsal approach an d arth rotom y, an d in th is case a dorsal approach to treat th e scaph oid proxim al pole ractu re.

330

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.9  Distal radius—multifragme ntary intraarticular fracture with associate d scaphoid fracture tre ate d with triple plating and scre w

2

In d ica t io n s (co n t )

As s o cia t e d m e d ia n n e r ve co m p re s s io n

As s o cia t e d s ca p h o id in ju rie s

Median nerve

Fig 4.9-5

I th ere is den se sen sory loss, or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

Fig 4.9-6

With h igh -en ergy distal radial in ju ries o th is n atu re, associated carpal ligam en t in ju ries an d ractu res in clu din g th e scaph oid can occu r. Th e scaph oid proxim al pole relies largely on a retrograde blood f ow an d so it relies on distal-to-proxim al in traosseou s blood su pply or h ealin g. Th is m akes th ese ractu res h igh ly pron e to avascu lar bon e n ecrosis, delayed u n ion , an d n on u n ion . I th e proxim al ragm en t is large en ou gh , a 2.4 m m or 3.0 m m im plan t u sin g an tegrade in sertion is advisable.

An a t o m ica l a n d va s cu la rit y co n s id e ra t io n s

Ch o ice o f im p la n t

Th e scaph oid’s u n iqu e an atom y an d vascu larity are critically im portan t in cases in volvin g th e proxim al pole. Re er to th e in dication s topic in ch apter 2.1 Scaph oid— n on displaced ractu re treated percu tan eou sly w ith a h eadless com pression screw or m ore in orm ation .

a

b Dorsal plate s

c 2-colum n plate

d He adle ss com pre ssion scre w

Th is case in volves treatm en t o both th e dorsal an d palm ar aspect, an d so speci c palm ar an d dorsal plates were selected in clu din g variable an gle lockin g com pression plate (VA LCP) dorsal distal radiu s plates an d a VA LCP 2-colu m n plate on th e palm ar side. A 3.0 m m h eadless com pression screw was u sed to treat th e scaph oid ractu re.

Fig 4.9-7a –d

331

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA LCP distal radiu s set VA LCP 2-colu m n plate 2.4 VA LCP radial colu m n plate 2.4 VA LCP in term ediate colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires 2.4 m m or 3.0 m m h eadless com pression screw Poin ted redu ction orceps Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. As th e rst step in volves a palm ar approach , su pin ate th e orearm . I a dorsal approach is also requ ired, pron ate th e orearm at th at stage. Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.9-8

4

Su rgica l a p p ro a ch

Pa lm a r a n d d o rs a l a p p ro a ch e s

Th e su rgical approach in itially u sed was a m odi ed Hen ry palm ar approach (see ch apter 1.6 Modied Hen ry palm ar approach to th e distal radiu s). Later, a dorsal approach was requ ired to apply dorsal platin g an d to treat th e scaph oid ractu re (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 4.9-9a –b

a

332

b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.9  Distal radius—multifragme ntary intraarticular fracture with associate d scaphoid fracture tre ate d with triple plating and scre w

5

Re d u ct io n

Pro vis io n a l re d u ct io n

a

b

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Man ipu lative redu ction is u sed to provision ally h old th e ragm en ts. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed w ith in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.9-1 0a –b

Pro vis io n a l fixa t io n w it h K-w ire s

In sert a K-w ire across th e ractu re th rou gh th e radial styloid to provide provision al stabilization . Th e m ajor articu lar ragm en ts can be redu ced w ith th e aid o a poin ted redu ction orceps. Tem porary xation o th e m ajor articu lar ragm en ts w ith K-w ires is also an option . Th e aim is to ach ieve as accu rate an an atom ical redu ction as possible o th e articu lar ragm en ts be ore th e plate is applied.

Fig 4.9-1 1

Altern atively, u se o a poin ted redu ction orceps or an extern al xator to ach ieve redu ction m ay be requ ired.

333

Pa rt II Case s

6

Fixa t io n

Pa lm a r p la t e fixa t io n

a

b

Usin g a palm ar approach , xation o th e distal radial ragm en ts w as rst attem pted u sin g a VA LCP 2-colu m n plate 2.4.

Fig 4.9-1 2a –b

Th e xation procedu re ollow s th e u su al steps o selectin g an d applyin g th e plate, in sertin g distal screw s, determ in in g correct bon e len gth , in sertin g proxim al screw s, an d in traoperative im agin g. For u rth er in orm ation on th ese steps see ch apter 4.7 Distal radiu s—m u lti ragm en tary in traarticu lar ractu re treated w ith a palm ar plate.

Do rs a l p la t e fixa t io n

a

b

Un ortu n ately, th e dorsal ragm en ts were n ot redu ced solely with th e palm ar plate, so addition al dorsal im plan ts were requ ired. Th ese ragm en ts were th en stabilized u sin g VA LCP dorsal distal radiu s plates, on e in th e radial colu m n , wh ich was able to be in serted th rou gh th e existin g palm ar approach , an d th e oth er in th e in term ediate colu m n u sin g a dorsal L-plate to bu ttress th e ragm en ts (bu t with n o distal screws in serted in to th e h ead o th e plate), an d wh ere a n ew dorsal approach was requ ired. Th e total com bin ation o plates provided per ect redu ction o all ragm en ts an d stable xation . For u rth er in orm ation on th e steps or dorsal platin g see ch apter 4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re treated with dou ble platin g.

Fig 4.9-13a –b

334

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.9  Distal radius—multifragme ntary intraarticular fracture with associate d scaphoid fracture tre ate d with triple plating and scre w

6

Fixa t io n (co n t )

Sca p h o id re d u ct io n a n d fixa t io n

a

b

Follow in g redu ction an d in sertion o a gu ide w ire in to th e scaph oid, th e scaph oid proxim al pole ractu re xation w as ach ieved u sin g a 3.0 m m h eadless com pression screw . For u rth er in orm ation on treatin g scaph oid proxim al pole ractu res see ch apter 2.4 Scaph oid, proxim al pole— ractu re treated w ith a h eadless com pression screw .

Fig 4.9-1 4a –b

335

Pa rt II Case s

6

Fixa t io n (co n t )

a

b

c

d

e

Im m ediate postoperative x-rays ( a –b ) an d illu strated version s ( c– e ) sh ow th e com pleted triple platin g o th e distal radial ractu re an d th e in tern al screw xation o th e scaph oid.

Fig 4.9-1 5a –e

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow-u p, rem oval o stitch es, an d im mobilization as requ ired. Followin g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated with a radial colu m n plate.

Fig 4.9-16

336

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.9  Distal radius—multifragme ntary intraarticular fracture with associate d scaphoid fracture tre ate d with triple plating and scre w

8

Ou t co m e

At th e 20-m on th ollow-u p, x-rays were taken with u ln ar deviation o th e wrist, an d lateral view. Th e ractu res were sh own to h ave h ealed in n ear an atom ical position .

Fig 4.9-17a –b

a

b

a

b

c

d

e

f

Th e patien t cou ld per orm n ear u ll w rist an d orearm ran ge o m otion an d th ere h ad been an excellen t u n ction al resu lt.

Fig 4 .9 -1 8a – f

337

Pa rt II Case s

8

Ou t co m e (co n t )

a

b

Excellen t grip stren gth h ad retu rn ed w h en com pared w ith th e u n in ju red side.

Fig 4.9-1 9a –b

338

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.10

1

Distal radius—displaced intraarticular fracture treated with a bridge plate

Ca s e d e s crip t io n

a

b

c

d

A 29-year-old pro ession al m otorcyclist w as in volved in a h igh -speed crash w h ile com petin g, su stain in g an isolated righ t w rist in ju ry. Upon adm ission to th e em ergen cy departm en t h e h ad m edian n erve dys u n ction , w h ich resolved w ith lon gitu din al traction u sin g n ger traps an d closed redu ction . Th e in itial obliqu e an d lateral x-rays dem on strated m arked dorsal displacem en t o th e articu lar su r ace w ith ragm en ts th at w ere sm all an d close to th e join t ( a – b ). Later AP an d lateral x-rays w ere taken ollow in g plaster splin t application , yet w h ile th e m edian n erve sym ptom s w ere resolved an d redu ction im proved, th e redu ction rem ain ed u n satis actory ( c–d ).

Fig 4.10 -1a –d

Given th e u n stable ractu re pattern in an d arou n d th e articu lar su r ace, an d th e proxim ity o th e ractu res to th e join t, it w as decided th at in tern al xation w as in dicated u sin g a bridgin g plate tech n iqu e. (Note: som e addition al in traoperative im ages rom a 46-year-old w om an w ith a sim ilar ractu re h ave been u sed in th is case or u rth er illu strative su pport).

339

Pa rt II Case s

2

In d ica t io n s

In t ra a r t icu la r w ris t fra ct u re s re q u irin g b rid ge p la t in g

a

b

Th e patien t in th is case h ad su ered displacem en t o th e articu lar su r ace w ith ragm en tation th at w as sm all an d close to th e join t. In som e in traarticu lar distal radial ractu res, th e u se o an exten ded su rgical approach an d a lon ger plate th at bridges (or span s) th e en tire join t m u st be con sidered. Th e cu rren t in dication s or u sin g th is treatm en t tech n iqu e in clu de: • Extrem ely ragm en ted in traarticu lar ractu res in w h ich ragm en t speci c xation m ay be u n attain able du e to th e sm all size o th e ragm en ts • Distal ractu res th at are so close to th e join t th at xation w ith plates becom es extrem ely di cu lt or im possible • High -en ergy in ju ries in polytrau m atized patien ts w h ere early w eigh tbearin g on th e u pper extrem ities is deem ed n ecessary to h elp m obilize th e patien t in th e early postoperative period, or w h ere w eigh tbearin g w as th ou gh t n ot as reliable w h en u sin g oth er con stru cts • Patien ts w ith osteoporotic ractu res w ith sign i can t ragm en tation th at m igh t lead to collapse o th e ractu re i th e com pressive orces at th e w rist are n ot properly n eu tralized • High -en ergy m u lti ragm en tary ractu res w ith exten sion in to th e m etaph yseal-diaph yseal region o th e distal radiu s in w h ich distal xation w ith diaph yseal/ m etaph yseal plates m ay be ten u ou s or im possible.

Fig 4.10 -2a –b

By span n in g th e w rist join t, th e bridge plate acts as a bridgin g in tern al xator an d as a tem porary m eth od o xation . It requ ires rem oval abou t 8–12 w eeks a ter placem en t. Th e dorsal bridge plate provides both in tern al distraction an d bu ttress su pport to th e dorsal part o th e ractu re. Un like extern al xation , th e bridge plate can be le t in place w ith ou t th e risk o pin loosen in g or in ection .

Co n t ra in d ica t io n s o f b rid ge p la t in g

Relative con train dication s o bridge platin g in clu de ractu res in you n g in dividu als th at are am en able to palm ar platin g or ragm en t speci c xation . It is also im portan t to rem em ber th at bridge platin g requ ires a secon d su rgery or im plan t rem oval an d carries th e addition al risks o w rist sti n ess an d exten sor ten don irritation .

340

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

a

b

c

A n u m ber o im plan ts are available to u n ction as a bridge plate in clu din g a stan dard lim ited con tact dyn am ic com pression plate (LC-DCP), th e specialized plates or distal radiu s total arth rodesis, or speci cally design ed plates u sin g 2.7 m m screws. Plate selection is based on th e size o th e patien t an d th e proxim al exten t o ragm en tation alon g th e distal radiu s. Lay th e plate on th e skin over th e radial diaph ysis to th e m etadiaph ysis o th e secon d or th ird m etacarpal an d u se th e im age in ten si er to en su re th at a m in im u m o th ree cortex screws can be placed both proxim al to th e ractu re an d distal in to th e m etacarpal. Plates can be precon tou red with a ben d or sim ply in serted straigh t. A straigh t plate 2.7 was u sed or th is patien t.

Fig 4.10-3a –c

Im a gin g

It is n ot possible to m ake an accu rate assessm en t o th e details o th ese in ju ries w ith ou t a CT scan . Im age in ten si cation is requ ired th rou gh ou t th e procedu re.

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Bridge plate 2.7 1.1 or 1.2 m m K-w ires Fin ger trap traction system Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al. For th is patien t th e h an d was su pported with a rolled towel.

Fig 4.10-4

341

Pa rt II Case s

4

Clo s e d re d u ct io n

Pro vis io n a l re d u ct io n

a

b

c

d

In th is in ju ry type, redu ction is requ ired prior to per orm in g th e su rgical approach . A closed redu ction m an eu ver is per orm ed th at in volves a com bin ation o lon gitu din al traction an d palm ar tran slation to restore radial len gth , radial in clin ation , an d palm ar an gu lation . Redu ction is ach ieved by applyin g lon gitu din al traction u sin g n ger traps to th e in dex an d m iddle n gers ( a –b ). Usin g th e im age in ten si er or gu idan ce, radial len gth is restored ( c ). Lon gitu din al traction is also u sed to assist in th e redu ction o th e articu lar su r ace ( d ). Th is m an eu ver w ill determ in e th e in tegrity o th e palm ou ln ar corn er o th e radiu s. Fin ally, pron ate th e h an d to correct th e su pin ation de orm ity.

Fig 4.10 -5a –d

342

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

5

Su rgica l a p p ro a ch

De t e rm in e p la t e p o s it io n in g

Th e rst step in con siderin g th e su rgical approach is to decide w h ich m etacarpal (eith er th e secon d or th ird) w ill be u sed or plate xation . Note th at a m in im u m o th ree screw s sh ou ld be able to be placed in th e m etacarpal. Th e determ in in g actor is th e position th at provides best redu ction . Th e m eth od or determ in in g w h ich m etacarpal to u se is as ollow s: 1. Provision ally redu ce th e ractu re 2. Place th e plate on to th e dorsal su r ace o th e w rist 3. Usin g th e im age in ten si er, m ake sm all adju stm en ts in radial-u ln ar deviation allow in g th e optim al plate location to be determ in ed over eith er th e secon d or th ird m etacarpal On ce th is im portan t step is accom plish ed th e in cision s are m ade.

a

b

Wh en th e th ird m etacarpal is selected, th e carpu s is in sligh t radial deviation an d th e plate lies obliqu ely over th e radiu s with th e proxim al en d o th e plate on th e u ln ar side o th e diaph ysis ( a ).

Fig 4.10-6a –b

Wh en th e secon d m etacarpal is selected, th e carpu s is in sligh t u ln ar deviation an d th e plate lies obliqu ely over th e radiu s with th e proxim al en d o th e plate on th e radial side o th e diaph ysis ( b ). Th is allows better correction o radial h eigh t an d in clin ation , h owever, th e decision always depen ds on ractu re align m en t as seen via im age in ten si cation . It is acceptable or th e plate to lie obliqu ely on th e radial sh a t as lon g as th e screws en gage both cortices.

343

Pa rt II Case s

5

Su rgica l a p p ro a ch (co n t )

Ap p ro a ch

Distal extension

Dorsal approach

Proximal extension a

b

Th e su rgical approach u sed w as an exten ded dorsal approach ( a ) (see ch apter 1.9 Exten ded dorsal approach to th e distal radiu s). In m ost cases, th is tech n iqu e requ ires th ree in cision s ( b ). For th is patien t, a th ree-in cision tech n iqu e w as u sed in volvin g a dorsal approach w ith both proxim al an d distal addition al in cision s.

Fig 4.10 -7a –b

Th e plate is placed on th e dorsal su r ace an d assists in determ in in g wh ich m etacarpal sh ou ld be u sed or xation . Th is tech n iqu e is u lly explain ed in th e approach ch apter 1.9 Exten ded dorsal approach to th e distal radiu s.

Fig 4.10-8

344

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

6

Op e n re d u ct io n

Align m en t alon g th e th ird m etacarpal w as ch osen as providin g th e best redu ction an d th ree in cision lin es w ere draw n ( a ). Th e rst 3 cm in cision w as m ade at th e base o th e th ird m etacarpal an d con tin u ed over th e sh a t. Th e secon d in cision o 2 cm w as th en m ade directly over Lister tu bercle ( b ). Th e exten sor pollicis lon gu s (EPL) w as released an d retracted u ln arly. Mobilizin g th e EPL h elped w ith plate in sertion an d redu ction o th e articu lar su r ace an d assisted w ith slidin g th e plate u n der th e secon d com partm en t ten don s. Wh ile th e th ird (m ost proxim al) in cision lin e w as draw n , it w as n ot m ade u n til a ter plate in sertion .

Fig 4.10 -9a –b

a

b

7

Fixa t io n

De t e rm in e p la t e in s e r t io n d ire ct io n Retrograde

a

Antegrade

b

Con sider th e direction o th e ractu re displacem en t be ore in sertin g th e plate to h elp avoid catch in g th e plate on ractu re ragm en ts as it is advan ced. With redu ction ach ieved by traction applied th rou gh th e n ger traps, th e plate is placed u n der th e secon d dorsal com partm en t th rou gh eith er retrograde or an tegrade in sertion . Retrograde in sertion is recom m en ded in dorsal displacem en t o ragm en ts ( a ). An tegrade in sertion is recom m en ded in palm ar displacem en t o ragm en ts ( b ). Th e plate is in serted u n dern eath th e ten don s an d m u scle bellies an d advan ced in th e ch osen direction .

Fig 4.10-10a –b

345

Pa rt II Case s

7

Fixa t io n (co n t )

Ap p ly t h e d rill gu id e

Th e drill gu ide can be screw ed in to on e o th e distal h oles o th e plate so it can be u sed as a h an dle to acilitate th e slidin g o th e plate.

Fig 4.10 -11

In s e r t t h e p la t e

EPL ECRL ECRB a

EPB APL b

Th e plate is passed proxim ally u n der th e secon d com partm en t ten don s. Th e m iddle in cision is recom m en ded to avoid an y dam age to th e EPL. Th e in traoperative im age sh ow s th e plate in sertion in retrograde ash ion .

Fig 4.10 -12 a – b

346

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

7

Fixa t io n (co n t )

Ma ke t h e p ro xim a l in cis io n

A 3 cm radial sh a t in cision is m ade over th e dorsal aspect o th e radiu s ju st proxim al to th e m u scle bellies o th e abdu ctor pollicis lon gu s (APL) an d th e exten sor pollicis brevis (EPB), in lin e w ith th e exten sor carpi radialis lon gu s (ECRL) an d exten sor carpi radialis brevis (ECRB) ten don s. Th is in cision w as previou sly m arked du rin g in itial im agin g w ith th e plate over th e dorsal su r ace bu t con rm atory im ages can be taken be ore in cision .

Fig 4.10 -13

An option al tooth ed orceps can be placed in th e sh a t to preven t th e plate rom m ovin g too u ln arly or radially. Du rin g drillin g, th e u n iversal drill gu ide can also h elp stabilize th e plate’s position as requ ired.

Fig 4.10 -14

Th e exact location o th e in cision m ay depen d on w h eth er th e plate will attach distally at th e secon d or th ird m etacarpal. As th is plate w as attach ed to th e th ird m etacarpal, th e in terval betw een th e rst an d secon d com partm en ts w as developed an d th e diaph ysis o th e radiu s exposed. Care was taken to avoid in ju ry to th e su per cial bran ch o th e radial n erve. Retract th e rst com partm en t m u scles u ln arly an d th e secon d com partm en t radially. Th e proxim al h oles o th e plate sh ou ld be visible at th is poin t.

347

Pa rt II Case s

7

Fixa t io n (co n t )

In s e r t d is t a l s cre w s

2

In s e r t p ro xim a l s cre w s

1 3

a

6

5 4

6

5 4

a 2

1 3

b

b

Th e m etacarpal sh a t is n arrow an d does n ot tolerate lateral sh i tin g o th e plate. For th is reason , it is recom m en ded to in sert th e th ree m etacarpal screw s rst (w ith recom m en ded sequ en ce o screw in sertion sh ow n ). Care m u st be taken to cen ter th e plate to en su re all screw s en gage both cortices.

Fig 4.10 -16 a – b

Fig 4.10 -15 a – b

It is recom m en ded to u se at least on e lockin g screw in both th e m etacarpal an d th e radiu s. Th is allow s th e plate to be u sed as an in tern al xator. Th e u se o lockin g screw s in th e m etacarpal is also ben e cial becau se th e screw h eads lie f u sh w ith th e plate an d avoid exten sor ten don irritation .

Be ore secu rin g th e plate proxim ally, con rm th at u ll passive m otion o all digits is possible. I u ll n ger f exion is n ot possible, plate im pin gem en t o th e exten sor ten don s is th e likely cau se, an d th ese m u st be released. Fix th e plate to th e radiu s w ith th ree or ou r screw s proxim al to th e ractu re. On ce radial sh a t xation is com pleted, appropriate len gth an d redu ction o th e ractu re sh ou ld be ach ieved w ith n o m ore th an 5 m m o distraction at th e radiocarpal join t.

Re d u ce t h e a r t icu la r s u r fa ce

With th e plate in its n al position an d radial len gth restored, th e su rgeon can n ow ocu s on redu ction o th e articu lar su r ace.

348

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

7

Fixa t io n (co n t )

Op t io n : b o n e gra ft in g

Op t io n : s cre w in s e r t io n

Bone graft a

a

b

b

Fig 4.10 -17 a – b

An y m etaph yseal voids can be lled by u sin g bon e gra t in serted th rou gh th e m iddle in cision . Th e prim ary objectives o bon e gra tin g are to take advan tage o th e m ech an ical e ect o bu ttressin g th e articu lar ragm en ts an d to accelerate th e process o h ealin g.

Fig 4.10 -18 a – b

Op t io n : K-w ire in s e r t io n

Ad d it io n a l p a lm a r p la t in g

Som e ragm en ts th at requ ire redu ction m igh t be too sm all or screw pu rch ase. In th is in stan ce, 1.1 or 1.2 m m K-w ires sh ou ld be u sed to redu ce an d stabilize th ese ragm en ts. Th is is o ten th e case w ith radial styloid an d in term ediate colu m n ragm en ts.

Fig 4.10 -20

Fig 4.10 -19

Fu rth er bu ttressin g o th e lu n ate acet can be provided by a 3.5 m m lockin g screw in serted th rou gh th e m id-portion o th e plate ju st u n der th e su bch on dral bon e o th e lu n ate acet. Altern atively, a 2.7 m m cortex screw can be u sed bu t m u st en gage both cortices.

Som e displaced palm ar lu n ate acet ragm en ts can n ot be redu ced solely by ligam en totaxis or dorsal bridge platin g. In th ese cases, an addition al palm ar approach is recom m en ded, an d a sm all bu ttress plate is u sed or su pplem en tal xation o th e ragm en t.

349

Pa rt II Case s

7

Fixa t io n (co n t )

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a

b

a

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.10 -21 a – b

8

b

Follow in g xation o th e bridgin g plate on to th e patien t’s th ird m etacarpal, an d w ith a screw su pportin g th e lu n ate acet th rou gh th e m idsection o th e plate, in traoperative im ages w ere u sed to con rm good align m en t an d redu ction o th e radial ractu re.

Fig 4.10 -22 a – b

Re h a b ilit a t io n

Aft e rca re

Fo llo w -u p

See th e patien t a ter 2–5 days to ch an ge th e dressin g. A ter 10 days, rem ove th e su tu res an d con rm w ith x-rays th at n o secon dary displacem en t h as occu rred.

Wh ile th e patien t is in bed, u se pillow s to keep th e h an d elevated above th e level o th e h eart to redu ce sw ellin g.

Fig 4.10 -23

350

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

8

Re h a b ilit a t io n (co n t )

Im m o b iliza t io n

Im p la n t re m o va l

Th e K-w ires m ay be rem oved at approxim ately 6 w eeks, bu t th e plate is le t in place u n til bon e h ealin g h as been radiologically con rm ed, u su ally betw een 3–4 m on th s. At tim e o rem oval, exten sor ten olysis is recom m en ded ollow ed by an active reh abilitation program .

Th e type an d du ration o postoperative im m obilization depen ds on a n u m ber o actors in clu din g th e qu ality o th e in tern al xation as w ell as patien t activity an d reliability. It m ay be n ecessary to rest th e w rist or several w eeks in a plaster or rem ovable splin t.

Fig 4.10 -24

Fu n ct io n a l e xe rcis e s a n d p a t ie n t m o b iliza t io n

Follow in g su rgery, begin active con trolled ran ge o m otion exercises. Weigh tbearin g is perm itted on th e orearm an d elbow a ter su rgery. Addition ally, a ter th e patien t is stabilized, a plat orm cru tch can be u sed. Th ree to 4 w eeks ollow in g th e su rgery, th e plat orm is rem oved an d w eigh tbearin g is allow ed th rou gh th e h an d grip o regu lar cru tch es. It is recom m en ded to restrict li tin g an d carryin g to n o m ore th an 5 kg u n til th e ractu re h as h ealed.

Fig 4.10 -25

Th e protocol w ill be di eren t w h en th ere is associated DRUJ in stability. A lon g arm splin t is applied or 3 w eeks ollow in g su rgery, a ter w h ich DRUJ stability an d active su pin ation o th e orearm is assessed. I th e patien t’s arm can be u lly su pin ated, splin tin g is discon tin u ed. Axial loadin g th rou gh th e extrem ity is allow ed or tran s ers an d all w eigh tbearin g n eeds. How ever, i su pin ation is di cu lt or i th e DRUJ requ ired recon stru ction , th en a rem ovable lon g arm splin t is provided. I th e DRUJ w as tran s xed w ith K-w ires, th en th e w ires are rem oved a ter 6 w eeks an d DRUJ stability is reassessed. 351

Pa rt II Case s

9

Ou t co m e

a

b

At th e 2-week ollow-u p th e postoperative im ages o th e bridgin g plate sh owed m ain tain ed align m en t an d redu ction . Th e bridgin g plate was rem oved 12 weeks a ter su rgery.

Fig 4.10-26a –b

a

b

At a u rth er ollow-u p 5 m on th s a ter plate rem oval, PA an d lateral x-rays sh owed h ealin g o th e ractu re an d per ect con gru en cy an d align m en t o th e join t.

Fig 4.10-27a –b

Th e patien t h ad ach ieved a n ear u ll ran ge o m otion an d w as able to recon tin u e h is m otorbike ridin g activities w ith ou t di cu lties.

Fig 4.10 -28

352

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.10 Distal radius—displace d intraarticular fracture tre ate d with a bridge plate

10 Alt e rn a t ive t e ch n iq u e Us in g a 2 -in cis io n t e ch n iq u e

Fig 4.10 -29

As an altern ative, th e approach can be m ade u sin g proxim al an d distal in cision s on ly. Th e 2-in cision approach m igh t be con sidered w h en th ere is gross com m in u tion an d m u ltiple sm all bon e ragm en ts. A ter closed redu ction , u se th e im age in ten si er to determ in e w h ich m etacarpal to u se or xation . With th e plate sittin g on th e skin , m ark th e skin at th e level o th e proxim al an d distal screw h oles. Make a 3 cm distal in cision an d in sert th e plate.

Fig 4.10 -30

By blu n t dissection , th e in terval betw een th e ECRL/ ECRB an d th e APL/ EPB is developed, an d th e plate can be seen over th e diaph ysis o th e radiu s. Care m u st be taken to avoid in ju ry to th e su per cial bran ch o th e radial n erve.

Fig 4.10 -32

Fig 4.10 -31

In sert a drill gu ide in to on e o th e distal screw h oles or u se as a h an dle. On ce th e plate h as been in serted an d is in position over th e radiu s proxim al to th e ractu re, a secon d in cision m easu rin g approxim ately 3 cm is m ade over th e dorsal aspect o th e radiu s ju st proxim al to th e m u scle bellies o th e APL an d EPB, in lin e w ith th e ECRL an d ECRB ten don s.

A drill gu ide, u sed as a secon d h an dle, is in serted in to on e o th e proxim al h oles o th e plate to acilitate th e align m en t o th e plate over th e radiu s. Fixation is com pleted in th e stan dard w ay.

353

Pa rt II Case s

354

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4.11

1

Distal radius—radiocarpal fracture dislocation treated with double plating

Ca s e d e s crip t io n

a

b

c

d

A 30-year-old bu ildin g su pervisor w as seen in th e em ergen cy departm en t in severe pain 2 h ou rs a ter allin g rom a h eigh t. On clin ical exam in ation th ere w as eviden ce o gross de orm ity an d sw ellin g o th e h an d an d w rist exten din g to th e orearm ( a –b ). Th e PA an d lateral x-rays revealed a com plex radiocarpal ractu re dislocation o h is righ t w rist ( c–d ).

Fig 4.11 -1a –d

a

b

c

Sagittal 2-D CT scan s dem on strated com plete dislocation dorsally o th e carpu s as w ell as a sm all sh earin g ractu re o th e dorsal aspect o th e distal radiu s.

Fig 4.11 -2a –c

355

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

c

d

Mu ltiple 3-D CT scan s sh ow th e dorsal sh earin g ractu re ragm en ts bu t th e palm ar rim o th e radiu s w as still in tact.

Fig 4.11 -3a –d

2

In d ica t io n s

Ra d io ca rp a l fra ct u re d is lo ca t io n s

a

b

Radiocarpal ractu re dislocation s are th e resu lt o h igh er-en ergy trau m a, can h ave associated so t-tissu e in ju ries, an d are o ten ou n d in polytrau m a cases. Th e in ju ry is ch aracterized by m u lti ragm en tary dorsal rim ractu res an d dorsal dislocation o th e carpu s. In th ese ractu res, th e ractu re o th e dorsal rim is associated w ith a radial styloid ractu re as well, w ith greater m arked in stability. As th ese are partial in traarticu lar in ju ries, w ith an existin g or a h igh risk o later radiocarpal su blu xation , th ey sh ou ld n orm ally be treated w ith open redu ction an d in tern al xation .

Fig 4.11 -4a –b

I th e distal radial ragm en ts are predom in an tly dorsal, redu ction an d xation is per orm ed u sin g dorsally applied plates bu t i th ere is a sign i can t radial styloid ragm en t th is is h elped m ore e ectively w ith a radial colu m n plate. Large ragm en ts can be treated w ith platin g or even lag screw s w h ile sm aller ragm en ts m ay requ ire xation w ith K-w ires or su tu re an ch ors, alth ou gh redu ction an d stabilization by extern al xation m ay be n eeded in itially becau se o m arked sw ellin g.

356

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

2

In d ica t io n s (co n t )

In it ia l a s s e s s m e n t

Me d ia n n e r ve co m p re s s io n

Dorsal lunate facet

Median nerve

Fig 4.11 -5

Un der direct vision , approach th e radial styloid an d dorsal lu n ate acet ragm en ts. Usu ally th e dorsal capsu le is torn , bu t i it is in tact, a dorsal arth rotom y is m ade parallel to th e dorsal rim to in spect th e articu lar su r ace an d look or an y associated carpal in ju ries.

Fig 4.11 -6

I th ere is den se sen sory loss or oth er sign s o m edian n erve com pression , th e m edian n erve sh ou ld be decom pressed.

As s o cia t e d ca rp a l in ju rie s

Im a gin g

Usin g CT scan s can be h elp u l or treatm en t decision s w ith th is in ju ry.

Ch o ice o f im p la n t

Th ese in ju ries m ay be associated w ith sh earin g in ju ries o th e articu lar cartilage, scaph oid ractu res, an d ru ptu res o th e scaph olu n ate ligam en t. Every patien t sh ou ld be assessed or th ese in ju ries.

Fig 4.11 -7

a

b

c

Dorsal plates

A selection o plates can be u sed to stabilize dorsal radiocarpal ractu re dislocation s by stabilizin g th e radial an d in term ediate colu m n s. Plates w ith variable an gle (VA) lockin g screw option s can be u se u l. For th is patien t, VA straigh t an d L-plates w ere u sed, w ith th e in term ediate colu m n bein g treated rst.

Fig 4.11 -8a –c

357

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

VA lockin g com pression plate (LCP) distal radiu s set VA LCP radial colu m n plate 2.4 VA LCP in term ediate colu m n plate 2.4 1.1 m m or 1.2 m m K-w ires Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 4.11 -9

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 4.11 -10

358

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

4

Su rgica l a p p ro a ch (co n t )

a

b

Th e dorsal su rgical approach w as m arked. A ter th e in cision , th e exten sor pollicis lon gu s w as elevated rom th e exten sor retin acu lu m .

Fig 4.11 -11 a – b

a

b

Th e sm all dorsal rim ractu res th en becam e visible. Th e approach allow ed access to both th e radial an d in term ediate colu m n s.

Fig 4.11 -12 a – b

Ar t h ro t o m y

I direct vision o th e articu lar su r ace is n eeded, a lim ited tran sverse radiocarpal arth rotom y is per orm ed.

359

Pa rt II Case s

5

Re d u ct io n

Pro vis io n a l re d u ct io n

Redu ction is ach ieved by applyin g lon gitu din al traction eith er m an u ally or u sin g n ger traps. Th e redu ction is m ain tain ed by a tem porary splin t. I de n itive su rgery is plan n ed bu t can n ot be per orm ed with in a reason able tim e scale a tem porary extern al xator m ay be h elp u l.

Fig 4.11-13

a

b

c

In traoperative redu ction w as ch ecked u sin g th e im age in ten si er.

Fig 4.11 -14 a – c

Pro vis io n a l fixa t io n

I th e dorsal rim ragm en ts are large en ou gh , obtain provision al xation w ith K-w ires.

Fig 4.11 -15

360

I th ey are too sm all th ey can be h eld w ith su tu re an ch ors or tran sosseou s su tu res.

Fig 4.11 -16

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

5

Re d u ct io n (co n t )

Pro vis io n a l ra d ia l s t ylo id fixa t io n

Superficial branch of radial nerve

Th e radial styloid ragm en ts are redu ced u n der direct vision w ith eith er a K-w ire on th e dorsoradial aspect or percu tan eou sly. In th e latter case, in order n ot to in ju re th e sen sory bran ch o th e radial n erve, m ake a sm all in cision over th e tip o th e radial styloid an d u se a protective drill gu ide to in sert tw o K-w ires. Con rm u sin g im age in ten si cation .

Fig 4.11 -17

a

Th e radial styloid ractu re com pon en t w as redu ced an d h eld w ith a K-wire. A dorsal w rist arth rotom y h ad been per orm ed or direct vision o th e articu lar redu ction .

Fig 4.11-18

b

Th e articu lar redu ction w as con rm ed u sin g in traoperative im agin g.

Fig 4.11 -19 a – b

361

Pa rt II Case s

6

Fixa t io n

Co n t o u r t h e p la t e

Plates u sed in treatin g radial an d in term ediate colu m n in ju ries are available precon tou red. How ever, becau se o th e sh ape o th e dorsal distal m etaph ysis, th e plate m ay n eed to be con tou red to t th e bon e su r ace an d th e proxim al lim b m ay requ ire som e torsion al adaptation . I th e distal tran sverse lim b o th e plate does n ot exert su cien t com pression on th e distal ragm en ts, rem ove th e plate an d overben d th e tran sverse distal lim b.

Fig 4.11 -20

Pit fa ll: s cre w h o le d is t o r t io n

a

Variable an gle lockin g plates en able precise position in g o th e distal screws in desired direction s becau se th ere is 30 degrees o reedom or each screw in side th e plate h ole to address th e in dividu al ractu re pattern s.

Fig 4.11-21

Fixa t io n o f in t e rm e d ia t e co lu m n Se le ct a n d a p p ly t h e p la t e

b

Avoid con tou rin g th e plate th rou gh th e lockin g h oles oth erw ise th e lockin g h ead screw m igh t n o lon ger t.

Fig 4.11 -22 a – b

a

b

Th e appropriate plate is selected accordin g to th e ractu re con gu ration . Th e plate sh ou ld be applied as distally as possible over th e dorsal rim ragm en ts ( a ). I th e provision al K-w ires con f ict w ith th e optim al plate position , th e plate can be slipped over th e w ires, or th e w ires can be reposition ed ( b ).

Fig 4.11 -23 a – b

362

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

6

Fixa t io n (co n t )

In s e r t p ro xim a l s cre w s

a

b

Fix th e plate provision ally to th e bon e w ith a stan dard cortex screw in serted th rou gh th e oblon g plate h ole ( a ). Be ore u lly tigh ten in g it, ch eck th e plate position u sin g in traoperative im agin g, adju stin g th e position o th e plate as n ecessary. On ce th e plate position is satis actory, it sh ou ld be secu red w ith a lockin g screw in th e proxim al screw h oles ( b ).

Fig 4.11 -24 a – b

In s e r t d is t a l s cre w s 20° X-ray beam

a

b

Screw s are in serted th rou gh th e distal plate h oles be ore or a ter rem oval o th e K-w ire(s), as appropriate ( a ). With im age in ten si cation , con rm th at th e distal screw s h ave n ot pen etrated th e articu lar su r ace. To h ave a view in lin e w ith th e articu lar su r ace, th e beam sh ou ld be an gled 20 degrees rom th e tru e lateral ( b ).

Fig 4.11 -25 a – b

363

Pa rt II Case s

6

Fixa t io n (co n t )

Fixa t io n o f ra d ia l co lu m n Se le ct a n d a p p ly t h e p la t e

St a b ilize t h e ra d ia l co lu m n

EPL

ECRB

Fig 4.5-2 6

Th e appropriate plate is selected accordin g to th e ractu re con gu ration an d con tou red i n ecessary. Slide th e plate u n dern eath th e rst com partm en t an d apply it on to th e radial colu m n . Exten sor carpi radialis brevis (ECRB); exten sor pollicis lon gu s (EPL).

Fig 4.11-27

Pit fa ll: in co rre ct p la ce m e n t

In s e r t t h e firs t s cre w in t h e ra d ia l co lu m n p la t e

a

b

Avoid placem en t o th e radial plate on th e dorsal aspect o th e radial colu m n as it will n ot bu ttress th e redu ction adequ ately again st axial sh ear orces.

Fig 4.11-28a –b

364

Ideally, wh ile applyin g th e plate th e n otch in th e distal tip o th e im plan t is placed again st th e tem porary K-wire.

In sert a stan dard cortex screw th rou gh th e oblon g plate h ole proxim al to th e ractu re. Th e screw sh ou ld en gage th e ar cortex. Th e position o th e plate m ay be adju sted be ore th e screw is tigh ten ed. Tigh ten in g th is screw w ill redu ce th e radial styloid.

Fig 4.11 -29

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

6

Fixa t io n (co n t )

In s e r t firs t lo ck in g h e a d s cre w

In s e r t d is t a l lo ck in g h e a d s cre w s

To preven t rotation o th e plate du rin g distal lockin g screw xation , th e plate sh ou ld be secu red to th e bon e by in sertin g th e m ost proxim al screw .

Fig 4.11 -31

Fig 4.11 -30

I a K-w ire w as u sed, it is n ow rem oved. Distal lockin g h ead screw (s) are in serted to su pport th e radial styloid. Usin g VA screw s allow optim al direction o xation . Th e position o th e m ost distal screw sh ou ld be ju st u n der th e su bch on dral bon e.

Pit fa ll: p e n e t ra t io n o f s igm o id n o t ch 20° X-ray beam

Con rm th at th e screw does n ot protru de in to th e join t u n der direct vision an d u sin g an im age in ten si er, with th e beam an gled 20 degrees rom th e tru e lateral. Th is projection will pro le th e radial articu lar su r ace an d visu alize an y en croach m en t o th e screw in to th e join t.

Fig 4.11-32

Bew are o th e tip o th e screw pen etratin g in to th e sigm oid n otch . It is sa er to leave th e screw a little sh ort an d it sh ou ld n ot be drilled in to th e opposite cortex.

Fig 4.11 -33

365

Pa rt II Case s

6

Fixa t io n (co n t )

Co m p le t e t h e fixa t io n

I n ecessary, in sert addition al screw s an d com plete th e xation .

Fig 4.11 -34

Th e de n itive xation w as ach ieved u sin g a radial colu m n plate an d a dorsal L-plate 2.4.

Fig 4.11 -35

Pa lm a r liga m e n t o u s a vu ls io n re a t t a ch m e n t

a

b

In traoperative im agin g con rm ed th e plate position an d th e an atom ical redu ction o th e ractu re dislocation .

Fig 4.11 -36 a – b

366

a

b

Radiocarpal ractu re dislocation s m ay be associated w ith avu lsion o th e palm ar w rist capsu le rom th e distal radiu s. A ter dorsal xation , ch eck th e carpal position an d stability u n der im age in ten si cation . I th ere is carpal u ln ar an d/ or palm ar tran slation , con sider an addition al palm ar approach to repair so t tissu es. Th e capsu le can be reattach ed u sin g m u ltiple su tu re an ch ors or tran sosseou s su tu res.

Fig 4.11 -37 a – b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

4 Distal radius 4.11 Distal radius—radiocarpal fracture dislocation tre ate d with double plating

6

Fixa t io n (co n t )

Ad d it io n a l e xt e rn a l fixa t io n

I th e dorsal rim ragm en ts are large en ou gh , th ey m ay be h eld in place with a bu ttress plate. I th ey are too sm all, K-wires m ay be th e de n itive xation , in wh ich case, a n eu tralization extern al xation sh ou ld be applied.

Fig 4.11-38

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 4.11-39

367

Pa rt II Case s

8

Ou t co m e

a

b

a

Th e ollow -u p x-rays at 6 w eeks sh ow ed th ere w as m ain tain ed redu ction an d early bon e h ealin g.

Fig 4.11 -40 a – b

a

b

c

d

e

f

Th e patien t h ad close to n orm al ran ge o m otion com pared w ith th e u n in ju red side.

Fig 4.11 -42 a – f

368

b

Th e 12-m on th ollow -u p x-rays sh ow ed good h ealin g.

Fig 4.11 -41 a – b

a

b

Th ere w as an excellen t overall u n ction al resu lt.

Fig 4 .1 1 -4 3 a – b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5

Reconstructions and treatment of complications

Pa rt II Case s

370

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Ha n d  Je sse  B  Jupite r

5.1

1

Distal radius—dorsal extraarticular malunion treated with osteotomy and double plating

Ca s e d e s crip t io n

a

b

A 54-year-old m an su ered a dorsally displaced distal radial ractu re o th e righ t h an d w ith a sm all dorsal lu n ate in traarticu lar com pon en t, or wh ich h e received n on operative treatm en t. Th e PA an d lateral x-rays taken in th e plaster cast sh ow ed th e in itial displaced ractu re.

Fig 5.1-1a – b

a

b

c

At th e 4-m on th ollow -u p a ter th e in ju ry, 2-D CT scan s sh ow ed a m arked de orm ity existed w h ile also in dicatin g im m atu re callu s.

Fig 5.1-2a – c

371

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

c

d

Addition al 3-D CT scan s clearly sh owed th e eviden t de orm ity. Th e de orm ity in volved con siderable sh orten in g o th e radiu s, loss o th e wrist’s n orm al radial an d palm ar in clin ation , an d dorsal displacem en t o th e distal ragm en t with dorsal ragm en tation .

Fig 5.1-3a –d

372

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

2

In d ica t io n s

Do rs a l e xt ra a r t icu la r ra d iu s m a lu n io n

a

b Loss of radial inclination

c Dorsal angulation

d

e

Oblique vie w with norm al angulation

Oblique vie w with dorsal angulation

Supination of distal fragm e nt

Malu n ion is a com m on com plication o distal radial ractu res an d occu rs w h en th e h ealed distal radiu s deviates rom its origin al an atom ical align m en t. Th e m ost com m on de orm ity type in volves dorsal extraarticu lar an gu lation , w ith radial sh orten in g an d su pin ation o th e distal ragm en t. Th e alteration o radial orien tation can m odi y th e loads tran sm itted in th e carpu s an d th e distal radiou ln ar join t (DRUJ), possibly cau sin g th em to ch an ge an d adapt, an d greatly in creasin g th e risk o developin g posttrau m atic osteoarth ritis.

Fig 5.1-4 a – e

Co rre ct ive o s t e o t o m y fo r m a lu n io n

A corrective osteotom y, in volvin g bon e len gth en in g or sh orten in g or to ch an ge align m en t, can o ten be ch osen to treat a m alu n ited distal radial ractu re. Wh en con siderin g th is, th e ollow in g tw o qu estion s m u st be an sw ered: • How m u ch de orm ity can actu ally be tolerated? • Wh en is th e optim al tim e to per orm an osteotom y? Th e qu estion o h ow m u ch de orm ity can be tolerated is n ot alw ays easy to an sw er as it can be di cu lt to qu an ti y an acceptable m alalign m en t an d depen ds on th e n eeds o th e in dividu al. Wh ile som e patien ts rem ain sym ptom ree despite th e de orm ity, oth ers can presen t w ith pain or u n ction al lim itation . Th e exten t o disability m ay depen d on th e am ou n t o radial sh orten in g, th e loss o radial in clin ation , th e am ou n t o dorsal an gu lation , an d an y DRUJ in stability. 373

Pa rt II Case s

2

In d ica t io n s (co n t )

22° normal

1 mm

10° 5 mm 10°

a

b

c

d

How m u ch de orm ity in th e distal radiu s can be accepted? Wh ile eviden ce o adaptive carpal in stability (ch an ge in capitolu n ate or scaph olu n ate align m en t) is in creasin gly seen as an accu rate predictor o ou tcom e, as a gen eral gu ide, th e ollow in g m easu rem en ts h ave been recogn ized as providin g acceptable levels o dorsal de orm ity: a Not greater th an 5 m m o radial sh orten in g b Not less th an 10 degrees o radial in clin ation c Not greater th an 10 degrees o dorsal an gu lation d Not greater th an 1 m m o step-o o th e articu lar su r ace. Fig 5.1-5 a – d

As or th e m ost optim al tim e to per orm th e osteotom y, it is recom m en ded to operate wh en th e so t tissu es dem on strate absen ce o troph ic ch an ges, wh en th e x-rays reveal lim ited or n o appearan ce o low bon e den sity (osteopen ia), an d wh en wrist m obility is adequ ate. Regardless, th ere are advan tages to early operative treatm en t su ch as decreased likelih ood o de orm ity or wh en th e correction is th rou gh an im m atu rely h ealed ractu re site, wh ich is always easier. Th is early approach can lim it th e problem o so t-tissu e con tractu res an d can m in im ize th e econ om ic an d social im pact to th e patien t. Besides u n acceptable de orm ities o th e distal radiu s, oth er in dication s or corrective osteotom y are carpal m alalign m en t, in con gru en ce o th e DRUJ, decreased ran ge o m otion , decreased grip stren gth , th e presen ce o pain with m otion an d activity, an d an u n acceptable clin ical appearan ce by th e patien t.

Im a gin g

Wh en dealin g w ith m alu n ion s, th e correct len gth o th e radiu s in relation to th e u ln a sh ou ld alw ays be establish ed preoperatively by takin g x-rays o th e opposite w rist.

374

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

• Variable an gle (VA) lockin g com pression plate (LCP) distal radiu s set • VA LCP radial colu m n plate 2.4 • VA LCP in term ediate colu m n plate 2.4 • 2.7 m m Sch an z pin s or 1.4 m m to 1.6 m m K-w ires • Con ical drill gu ide • Gon iom eter • Osteotom e • Au togen ou s bon e gra t or bon e su bstitu te • Sm all extern al xation set • Lam in ar spreader • Im age in ten si er Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.1-6

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 5.1-7

b

Du rin g th e approach , th e exten sor pollicis lon gu s (EPL) w as elevated rom th e th ird exten sor com partm en t an d protected.

Fig 5.1-8 a – b

375

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n

Pla n t h e o s t e o t o m y 4 3

1

2

a

b

c Plan

Oste otom y line

Re duction

In preparin g or an osteotom y procedu re th ree types o osteotom ies can be con sidered: In com plete (open in g w edge) Rockin g Com plete ( u ll th ickn ess in terposition al).

Fig 5.1-9 a – c a b c

To determ in e th e type o osteotom y requ ired, su perim pose th e x-ray o th e de orm ity side on to th e x-ray o th e u n in ju red side. In th e sagittal view , draw a lin e betw een th e m ost dorsal poin t o th e n orm al x-ray ( 1 ) to th e dorsal poin t o th e m alu n ion ( 2 ). Create a perpen dicu lar lin e at th e cen ter o th e lin e. Th is is ollow ed by a lin e draw n rom th e m ost palm ar aspect o th e n orm al side ( 3 ) to th e m ost palm ar aspect o th e m alu n ion side ( 4 ) an d a perpen dicu lar lin e is draw n in th e m iddle o th is lin e to con n ect to th e perpen dicu lar lin e draw n rom th e dorsal side. Wh ere th ese tw o perpen dicu lar lin es in tersect w ill de n e w h at type o osteotom y w ill be requ ired. In som e in stan ces, th e perpen dicu lar lin es in tersect directly on or n ear th e palm ar cortex (bu t still w ith in th e radiu s), w h ich dem on strates th at th e osteotom y on ce created does n ot n eed len gth en in g o th e distal ragm en t an d requ ires an in com plete osteotom y or a rockin g m eth od osteotom y. How ever, I th e lin es in tersect beyon d th e palm ar cortex, as w ith th is patien t, it in dicates th at ollow in g th e osteotom y o th e m alu n ion th e distal ragm en t w ill requ ire len gth en in g, creatin g a de ect o both th e dorsal an d palm ar aspects o th e distal radiu s. A com plete osteotom y w ill th ere ore be requ ired ( c ). 376

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

5

Re d u ct io n a n d fixa t io n (co n t )

De t e rm in e d e gre e o f d e fo rm it y

10°

a

b

c

A Sch an z pin is placed perpen dicu larly to th e radiu s bu t proxim al o th e osteotom y site wh ile a secon d pin is placed distally in lin e with th e exten sion de orm ity o th e distal radiu s ( a –b ). A h an dh eld gon iom eter can be u sed to ju dge th e degree o de orm ity an d an ticipated correction ( c). A sm all h ypoderm ic n eedle was placed in th e radiocarpal join t or better orien tation .

Fig 5.1-10a –c

Pe r fo rm t h e o s t e o t o m y

Th e osteotom y is per orm ed by u sin g an osteotom e at th e site o th e de orm ity. Th e m alu n ion with dorsal an gu lation is corrected by a dorsal open wedge osteotom y an d appropriate len gth en in g o th e radiu s.

Fig 5.1-11a –b

a

b

377

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t ) Op t io n : e xt e rn a l fixa t o r

a

b

Th e lateral in traoperative im ages dem on strate th e position o th e Sch an z pin s an d th e in ten ded osteotom y site ( a ). Th e osteotom y was per orm ed by u se o th e osteotom e ( b ). In teroperative im agin g is u sed to determ in e th e exact location o th e osteotom y an d to avoid dam agin g th e m edian n erve an d f exor ten don s.

Fig 5.1-12a –b

a

As an option , an d as u sed in th is case, th e osteotom y an d redu ction can be aided w ith an extern al xator. Attach an extern al xation pin h oldin g clam p to each Sch an z pin . Th en place an addition al Sch an z pin in to th e distal ragm en t rom th e radial direction . Th is is u sed to h elp regain th e an ticipated radial len gth an d an gu lation o th e distal ragm en t.

Fig 5.1-1 3

b

a

In traoperative im ages sh ow th e extern al xation an d th e osteotom y site.

Fig 5.1-1 4a –b

378

b

Th e correction ollowin g th e osteotom y is seen in th e lateral in traoperative im ages, precorrection ( a ) an d a ter correction with a m ore appropriate align m en t ( b ).

Fig 5.1-15a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

5

Re d u ct io n a n d fixa t io n (co n t )

Fixa t io n o f in t e rm e d ia t e co lu m n

a

b

For xation o th e distal radiu s, two con tou red VA LCP dorsal plates 2.4 were sequ en tially applied, startin g with th e plate or th e in term ediate colu m n .

Fig 5.1-16a –b

Fixa t io n o f ra d ia l co lu m n

a

b

c

Th is w as ollow ed by xation o th e radial colu m n . Note th e u se o th e con ical drill gu ide to allow variable direction s or th e lockin g h ead screw s.

Fig 5.1-1 7a –c

Th e dou ble platin g xation procedu re ollow s th e u su al steps o selectin g, preparin g an d applyin g th e plates, stabilizin g th e radial colu m n , en su rin g correct plate position in g, an d in sertin g th e screw s. For u rth er in orm ation on th ese steps see ch apter 4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re treated w ith dou ble platin g.

379

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

a

b

In traoperative im ages ollow in g plate xation en su red correct plate placem en t. Note th at th e de ect created by th e osteotom y is still clearly eviden t.

Fig 5.1-1 8a –b

Bo n e gra ft

Ha r ve s t in g

2–4 cm Iliac crest

Harvest corticocan cellou s gra t m aterial rom th e iliac crest.

Fig 5.1-1 9

380

Make a lon gitu din al in cision over th e lateral aspect o th e palpable iliac crest avoidin g th e an terior aspect an d th e ilio em oral n erve. Mark ou t th e preplan n ed gra t size to be h arvested con siderin g th e sh ape an d size o th e de ect in th e distal radiu s. Harvest th e selected gra t u sin g a sh arp osteotom e.

Fig 5.1-2 0

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

5

Re d u ct io n a n d fixa t io n (co n t )

In s e r t t h e b o n e gra ft

a Fig 5.1-2 1a –c

b

c

Th e de ect created by th e osteotom y w as lled w ith th e iliac crest gra t.

Co m p le t e t h e fixa t io n

a

b

On ce th e bon e gra t w as in place, th e exten sor retin acu lu m w as reapproxim ated an d th e w ou n d irrigated an d closed. Th e EPL ten don is le t above th e retin acu lu m .

Fig 5.1-2 2a –b

381

Pa rt II Case s

6

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.1-23

7

Ou t co m e

a

b

At th e 4-m on th ollow-u p th e postoperative x-rays sh owed th e in tegration o th e bon e gra t an d th e com pleted xation .

Fig 5.1-24a –b

382

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

7

Ou t co m e (co n t )

a

b

c

d

Th e patien t sh ow ed som e lim itation o w rist f exion bu t th e exten sion , pron ation , an d su pin ation w ere good an d th e patien t w as w ith ou t pain .

Fig 5.1-2 5a –d

Vid e o

Th is video dem on strates a corrective osteotom y on a distal radiu s with xation with a m in icon dylar plate 2.0.

Vid e o 5.1-1

383

Pa rt II Case s

8

Alt e rn a t ive t e ch n iq u e

Do rs a l m a lu n io n t re a t e d t h ro u gh a p a lm a r a p p ro a ch

a

b

c

d

Occasion ally, plates placed on th e dorsal aspect o th e radiu s can resu lt in ten don irritation an d ru ptu re becau se o th e in tim ate con tact between th e ten don s an d th e plate. As an altern ative, i th e xation is per orm ed with a plate on th e palm ar aspect o th e radiu s (as sh own , applyin g a palm ar plate to assist with th e osteotom y ( a –b ), correctin g align m en t ( c), an d even tu al xation ( d )), th en th e ten don s an d m edian n erve are protected by th e pron ator qu adratu s.

Fig 5.1-26a –d

With th e u se o an gu lar stable im plan ts su ch as an LCP lockin g plate, m ost corrective osteotom ies can be per orm ed th rou gh th e palm ar approach u sin g can cellou s bon e gra t in stead o a m ore com plex au togen ou s corticocan cellou s gra t. Man y osteotom ies can n ow be per orm ed palm arly, an d in stead o scu lptu red bon e gra t, w h ich is a dem an din g tech n iqu e, su rgeon s can u se can cellou s ch opped ch ips.

384

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .1 Distal radius—dorsal e xtraarticular malunion tre ate d with oste otomy and double plating

8

Alt e rn a t ive t e ch n iq u e (co n t )

a

b

c

As an illu stration , th ese x-rays sh ow a dorsally displaced m alu n ion on a righ t-h an ded patien t ( a –b ). Th e in traoperative im age sh ow s th at th rou gh a palm ar approach th e an gu lar stable im plan t is applied w ith th e proxim al lim b placed o th e palm ar cortex based on th e plan n ed an gu lar correction ( c ).

Fig 5.1-2 7a –c

a

b

c

In traoperative im agin g sh ow s th e strategic placem en t o th e im plan t ( a ) ollow ed by th e osteotom y an d th e plate th en applied to th e sh a t to correct th e de orm ity ( b ) w ith placem en t o can cellou s bon e gra t to com plete th e xation ( c ).

Fig 5.1-2 8a –c

385

Pa rt II Case s

386

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.2

1

Distal radius—palmar extraarticular malunion treated with osteotomy and plate

Ca s e d e s crip t io n

a

b

c

d

A 15-year-old m ale sch ool stu den t su stain ed a displaced ractu re o th e righ t distal radiu s in a m otorcycle in ju ry, or wh ich h e received treatm en t in a region al h ospital with closed redu ction an d percu tan eou s K-wire xation . Th e patien t was in itially im m obilized in a sh ort arm plaster cast, wh ich was rem oved alon g with th e K-wires 15 days a ter su rgery. Th e PA an d lateral x-rays sh ow th e in itial ractu re an d K-wire xation .

Fig 5.2-1a –d

387

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

a

b

a

At th e 5-week ollow-u p, n ew PA an d lateral x-rays sh owed a m alu n ited ractu re o th e distal radiu s. Th ere was sh orten in g o th e radiu s by 5 m m , radial in clin ation o 15 degrees, an d palm ar an gu lation o 40 degrees. On th e lateral view, a trian gle o callu s was sh own on th e palm ar aspect o th e radiu s. Th e growth plate was open in th e u ln a an d partially closed in th e radiu s.

Fig 5.2-2a –b

a

b

Th e patien t retu rn ed 6 m on th s a ter th e in itial trau m a h avin g a m atu re sym ptom atic m alu n ited ractu re o th e distal radiu s. He com plain ed o pain , de orm ity, an d u n ction al lim itation o th e orearm an d w rist. Th e ph ysical exam in ation sh ow ed redu ction o w rist exten sion an d in creased f exion com pared w ith th e opposite lim b. Lim itation o su pin ation o th e orearm w as also dem on strated, an d th ere w as pain du rin g active an d passive m ovem en t an d orearm rotation . Exam in ation o radial in clin ation an d sh orten in g sh ow ed th ere h ad been n o im provem en t. Th e grow th plate w as closed in both th e u ln a an d th e radiu s. In th e lateral view , a com pen satory exten sion o th e capitate w as eviden t becau se o th e f exed position o th e lu n ate as a resu lt o th e in crease in palm ar an gu lation o th e radiu s.

Fig 5.2-3 a – b

b

Th e sagittal view CT scan s sh ow ed th e exact plan e o th e m alu n ited ractu re an d th e apex o th e de orm ity, both elem en ts th at h elp w h en plan n in g an osteotom y. Addition ally, an x-ray o th e n orm al con tralateral w rist w as u sed or preoperative plan n in g.

Fig 5.2-4 a – b

388

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate

2

In d ica t io n s

Pa lm a r e xt ra a r t icu la r ra d iu s m a lu n io n

a

b

c

Loss of radial inclination

d Oblique vie w with norm al angulation

Palmar angulation

Pronation of distal fragm e nt

e Oblique vie w with palmar angulation

Alth ou gh less requ en t th an dorsally displaced m alu n ion s, m alu n ited extraarticu lar ractu res o th e distal radiu s can also occu r w ith in creased palm ar an gu lation , radial sh orten in g, an d pron ation o th e distal ragm en t, w h ich can m odi y th e loads tran sm itted in th e carpu s an d th e distal radiou ln ar join t (DRUJ) w ith in creased risk o developin g posttrau m atic osteoarth ritis.

Fig 5.2-5 a – e

Co rre ct ive o s t e o t o m y fo r m a lu n io n

As discu ssed in th e previou s ch apter, con sideration or a corrective osteotom y to treat distal radial m alu n ion depen ds on h ow m u ch de orm ity can be accepted an d w h en best to operate. Wh ile th ere m ay be som e con train dication s, it is gen erally accepted th at th ere are advan tages to early operative treatm en t, su ch as decreased likelih ood o de orm ity, or w h en th e correction is th rou gh an im m atu rely h ealed ractu re site, w h ich is alw ays easier.

389

Pa rt II Case s

2

In d ica t io n s (co n t )

22° normal

1 mm

10° 5 mm 20°

a

b

c

d

As or th e qu estion o h ow m u ch de orm ity can be accepted, as w ith dorsal m alu n ion , th ere are broad gu idelin es on w h at are acceptable levels o palm ar de orm ity. Th ese are as ollow s: a Not greater th an 5 m m o radial sh orten in g b Not less th an 10 degrees o radial in clin ation c Not greater th an 20 degrees o palm ar an gu lation d Not greater th an 1 m m o step-o o th e articu lar su r ace. Fig 5.2-6 a – d

Regardless o th ese m easu rem en ts, or th e you n g patien t in th is case th e decreased ran ge o m otion , decreased grip stren gth , presen ce o pain w ith m otion an d activity, an d th e u n acceptable clin ical appearan ce by th e patien t m ade or stron g in dicators or a corrective osteotom y.

Im a gin g

Wh en dealin g w ith m alu n ion s, th e correct len gth o th e radiu s in relation to th e u ln a sh ou ld alw ays be establish ed preoperatively by takin g x-rays o th e opposite w rist.

390

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

• Variable an gle (VA) lockin g com pression plate (LCP) distal radiu s set • VA LCP volar colu m n plate 2.4 • Au togen ou s bon e gra t or bon e su bstitu te • Poten tial n eed or extern al xator • Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.2-7

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a m odi ed Hen ry palm ar approach (see Ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 5.2-8

391

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n

Pla n t h e o s t e o t o m y

4 3

1

2

a

b

c Plan

Oste otom y line

Re duction

In preparin g or an osteotom y procedu re th ree types o osteotom ies can be con sidered: • In com plete (open in g w edge) ( a ) • Rockin g ( b ) • Com plete ( u ll th ickn ess in terposition al) ( c ).

Fig 5.2-9 a – c

By an alyzin g th e perpen dicu lar lin es (o n orm al versu s th e m alu n ited align m en t) an d w h ere th ey in tersected it w as determ in ed th at th e osteotom y on ce created did n ot n eed len gth en in g o th e distal ragm en t, th ere ore an in com plete osteotom y tech n iqu e w as selected. Details on h ow to determ in e w h ich osteotom y to per orm are ou tlin ed in th e plan o th e osteotom y topic in ch apter 5.1 Distal radiu s—dorsal extraarticu lar m alu n ion treated w ith osteotom y an d dou ble platin g.

392

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate

5

Re d u ct io n a n d fixa t io n (co n t )

Pe r fo rm t h e o s t e o t o m y

With a distal radial ractu re m alu n ited w ith palm ar an gu lation , th e recom m en ded su rgery is an open w edge osteotom y or correction o th e de orm ity, len gth adju stm en t o th e radiu s, bon e gra t or bon e su bstitu te to ll th e de ect, an d xation u sin g a palm ar plate. I in stead o a regu lar plate an an gu lar stable im plan t is u sed, su ch as th e LCP, th e su rgeon can u se can cellou s ch opped bon e gra t becau se th ose im plan ts provide m u ch better stability.

Fig 5.2-10

Th rou gh th e m odi ed Hen ry palm ar approach , an open w edge osteotom y w as per orm ed th at adju sted radial len gth , corrected th e excessive palm ar an gu lation , an d restored th e n orm al radial in clin ation . Th e osteotom y is per orm ed at th e site o th e m axim u m de orm ity. Provide provision al xation w ith a K-w ire. Th e correction o th e de orm ity is acilitated by u tilizin g th e an atom ical sh ape o th e im plan t.

Fig 5.2-1 1

393

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

In s e r t t h e firs t s cre w

De t e rm in e a n d co rre ct ra d ia l in clin a t io n

Th e rst screw is placed th rou gh th e im plan t proxim al to th e osteotom y. By tigh ten in g th is screw an in direct redu ction o th e de orm ity w ill resu lt.

Fig 5.2-13

Fig 5.2-1 2

Th e de orm ity in th e ron tal plan e is corrected u sin g th e lam in ar spreader to correct th e radial in clin ation .

In s e r t a d d it io n a l s cre w s

a

b

In traoperative im ages sh ow th e correction obtain ed w ith th e per orm ed osteotom y in both th e coron al an d sagittal plan e. Th ese im ages also sh ow th e correct location o th e plate, w h ere care w as taken n ot to exceed th e w atersh ed lin e n or to in ter ere w ith th e provision al xation m ain tain ed by th e K-w ire.

Fig 5.2-1 5a –b

Addition al screw s proxim ally an d distally are u sed to com plete th e xation .

Fig 5.2-1 4

394

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate

5

Re d u ct io n a n d fixa t io n (co n t )

In s e r t b o n e gra ft

a

b

c

Au togen ou s can cellou s bon e gra t was u sed to ll th e space le t by th e osteotom y. Th e bon e was stabilized with an LCP volar colu m n plate 2.4.

Fig 5.2-16a –c

Co m p le t e t h e fixa t io n

a

b

Later in traoperative im ages sh ow th e n al xation w ith th e de orm ities corrected.

Fig 5.2-1 7a –b

a

b

Th e skylin e view dem on strated n o protru sion o th e tip o th e screws on th e dorsal aspect o th e radiu s.

Fig 5.2-18a –b

395

Pa rt II Case s

5

Re d u ct io n a n d fixa t io n (co n t )

Re d u ct io n : o p t io n

Th e osteotom y is u su ally per orm ed at th e site o th e m axim u m de orm ity.

Fig 5.2-1 9

Fig 5.2-2 1

396

As an altern ative, redu ction can be ach ieved with h yperexten sion o th e wrist u sin g a rolled towel or bolster.

Fig 5.2-20

Fixation an d bon e gra t o th e de orm ity.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .2 Distal radius—palmar e xtraarticular malunion tre ate d with oste otomy and plate

6

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.2-22

7

Ou t co m e

a

b

At th e 6-m on th ollow-u p, th e x-rays sh owed th at th e u ln a an d radiu s were equ al in len gth , th ere was 15 degrees o palm ar an gu lation , an d 20 degrees o radial in clin ation . Th e site o th e osteotom y h ad com pletely h ealed.

Fig 5.2-23a –b

397

Pa rt II Case s

7

Ou t co m e (co n t )

a

b

c

d

e

f

At th is stage, th ere w as good u ln ar an d radial deviation , an d th e patien t cou ld ach ieve excellen t ran ge o m otion .

Fig 5.2-2 4a –f

a

b

At a later ollow -u p, th e plate w as rem oved w ith ou t problem s or th e patien t.

Fig 5.2-2 5a –b

398

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.3

1

Distal radius—intraarticular malunion treated with osteotomy and palmar plate

Ca s e d e s crip t io n

A 28-year-old salesm an su stain ed a all on to h is ou tstretch ed h an d. Th e PA an d lateral x-rays taken im m ediately a ter th e all sh ow ed a palm ar articu lar sh earin g ractu re an d palm ar displacem en t w ith an articu lar step-o o 3 m m an d in volvem en t o tw o-th irds o th e articu lar su r ace. Th ere w as articu lar in con gru ity at th e lu n ate acet, an d a distan ce betw een th e palm ar an d dorsal rim o 9 m m , w ith palm ar su blu xation o th e carpu s eviden t. He w as in itially provided w ith n on operative treatm en t o a sh ort cast or 6 w eeks.

Fig 5.3-1 a – b

a

a

b

b

c

d

Fou r m on th s a ter th e in itial trau m a, h e presen ted com plain in g o pain , de orm ity, an d n oticeable lim itation in ran ge o m otion . Th e x-rays taken at th at stage sh ow ed a m alu n ited in traarticu lar ractu re o th e distal radiu s w ith palm ar su blu xation o th e carpu s an d still w ith articu lar step-o o 3 m m .

Fig 5.3-2a – d

399

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

In th e sagittal view CT scan , th e palm ar carpal su blu xation w as eviden t. Th e ractu re w as in com pletely h ealed w ith both articu lar in con gru ity as w ell as brou s u n ion at th e distal m argin . Fig 5 .3 -3

a

b

c

A set o 3-D CT scan s o ered en ou gh in orm ation abou t th e de orm ity to in dicate th e n eed or an osteotom y an d xation .

Fig 5.3-4 a – c

400

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

2

In d ica t io n s

In t ra a r t icu la r ra d iu s m a lu n io n

Wh ile extraarticu lar m alu n ion o th e distal radiu s is m ore com m on , in traarticu lar m alu n ion in volvin g th e radiocarpal join t or distal radiou ln ar join t (DRUJ) can also occu r. Articu lar in con gru ity on th e join t su r ace u ltim ately leads to cartilage degen eration , an d residu al articu lar in con gru ity o greater th an 1 m m will predictably lead to posttrau m atic arth ritis. For th is reason , a corrective osteotom y sh ou ld be con sidered or an y distal radiu s m alu n ion with join t in volvem en t an d associated in con gru en ce.

In d ica t io n s fo r s u rge r y in m a lu n it e d in t ra a r t icu la r d is t a l ra d ia l fra ct u re s

Th e ollow in g are in dication s or su rgery: • An y step-o greater th an 1 m m , as it cau ses articu lar in con gru ity • Carpu s su blu xation , as it a ects carpal kin em atics an d overall w rist u n ction an d is di cu lt to tolerate by th e patien t • Malu n ited ractu res th at h ave a relatively sim ple in traarticu lar com pon en t. Note th at th e osteotom y sh ou ld be per orm ed as early as possible sin ce it can be m ade en tirely th rou gh th e im m atu re callu s ollow in g th e plan es o th e de orm ity, th u s ach ievin g a m ore an atom ical redu ction o th e articu lar su r ace.

a

b

c

d

Exam ples o m alu n ited in traarticu lar distal radial ractu res am en able or corrective osteotom y in clu de: Malu n ited palm ar sh earin g ractu re w ith palm ar su blu xation o th e carpu s Malu n ited dorsal sh earin g ractu re w ith dorsal su blu xation o th e carpu s Dorsal die pu n ch ractu res w ith ran k in con gru ity betw een th e sigm oid n otch an d th e h ead o th e u ln a Malu n ited radial styloid ractu res w ith ran k radiocarpal in con gru ity.

Fig 5.3-5 a – d a b c d

401

Pa rt II Case s

2

In d ica t io n s (co n t )

Co n tra in d ica tio n s fo r su rge ry in m a lu n ite d in tra a rticu la r d is t a l ra d ia l fra ctu re s

Im a gin g

Th e ollowin g are con train dication s or su rgery: • In volves advan ced posttrau m atic arth ritis • Older patien ts with low dem an d an d/ or m in im al sym ptom s • In volves less th an 1 m m articu lar displacem en t • In volves a com plex de orm ity with both distal radial an d carpal in ju ries.

3

In an in traarticu lar distal radial racture m alun ion , obtainin g th e x-ray o th e in itial in ju ry is especially h elp u l to both u nderstan d th e articu lar in ju ry an d in th e preoperative plan n in g o th e osteotom y. Also, a h igh -resolu tion CT with mu ltiplan ar re ormattin g is help u l to identi y th e racture plan e, which is possible u pward o 8 to 12 weeks a ter th e in ju ry. An MRI or wrist arth roscopy m ay play a u se u l role in evalu atin g th e am ou n t o cartilage dam age.

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• Variable an gle (VA) lockin g com pression plate (LCP) distal radiu s set • VA LCP volar colu m n plate 2.4 • Osteotom e • Oscillatin g saw • Poten tial n eed or au togen ou s bon e gra t • Im age in ten si er

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

a

b

To begin , position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm ( a ). Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. Th e orearm is later placed in a pron ated position or th e dorsal approach ( b ). A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.3-6 a – b

402

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

4

Su rgica l a p p ro a ch

Pa lm a r a n d d o rs a l a p p ro a ch e s

Two su rgical approach es were u sed to treat th is patien t’s in ju ry. First, a m odi ed Hen ry palm ar approach was requ ired (see Ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s).

Fig 5.3-7

a

Th e secon d su rgical approach u sed was a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s). With th is dorsal approach , on ly th e th ird exten sor com partm en t was open ed. Th e in term ediate an d radial colu m n s were approach ed separately u sin g a sin gle dorsal skin in cision .

Fig 5.3-8

b

Th rou gh th e m odi ed Hen ry approach , th e palm ar aspect o th e radiu s w as exposed an d th e m alu n ion becam e eviden t ( a ). Th e dorsal approach , ollow ed by a dorsal capsu lotom y o th e join t su r ace, revealed th e exact location o th e articu lar step ( b ).

Fig 5.3-9 a – b

403

Pa rt II Case s

5

Re d u ct io n

Os t e o t o m y

a

c

b

d

Th rou gh th e palm ar approach , th e osteotom y w as in itiated u sin g an osteotom e an d w as gu ided th rou gh th e plan e o th e m alu n ion u sin g th e im age in ten si er.

Fig 5.3-1 0a –d

404

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

5

Re d u ct io n (co n t )

a

c

b

d

Th e h an d is th en tu rn ed dow n in to pron ation an d th e w rist is f exed over a bolster or layer o tow els to h elp determ in e th e exact location o th e step-o . Th e osteotom e is u sed to im plem en t th e osteotom y rom distal to proxim al, an d is gu ided by th e im age in ten si er u n til th e palm ar an d dorsal cu ts m eet an d th e palm ar ragm en t becom es ree to be redu ced. It is im portan t to leave th e radiocarpal ligam en ts attach ed to th e palm ar ragm en t to avoid th e risk o carpal in stability. A palm ar capsu lotom y is proh ibited, oth erw ise carpal in stability can develop.

Fig 5.3-1 1a –d

405

Pa rt II Case s

5

Re d u ct io n (co n t ) Hyp e re xt e n d t h e w ris t

Th e dorsal view allow ed a clearer view o th e articu lar step, an d allow s precise placem en t o th e osteotom e to create th e osteotom y.

Fig 5.3-1 2

To assist in redu ction o th e osteotom y, place a rolled tow el or bolster u n der th e w rist an d h yperexten d it. Per ect an atom ical redu ction can be ach ieved by direct m an ipu lation u sin g a den tal pick or a n e h ook.

Fig 5.3-1 3

Alt e rn a t ive : re d u ct io n u s in g p la t e

a

b

Th e plate can be u sed to pu sh th e palm ar ragm en t to ach ieve redu ction u sin g an appropriate screw th rou gh th e oblon g plate h ole. Th e redu ction m u st be con rm ed w ith th e u se o im age in ten si cation .

Fig 5.3-1 4a –b

406

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

6

Fixa t io n

Pa lm a r p la t e fixa t io n

a

b

c

d

Fixation o th e distal radiu s sh ou ld be per orm ed w ith an appropriate palm ar plate en su rin g it bu ttresses th e articu lar ragm en ts an d avoids later displacem en t. For th is patien t, stable xation o th e osteotom ized palm ar ragm en t w as ach ieved u sin g an LCP volar colu m n plate 2.4, w h ich allow ed or early reh abilitation o th e radiocarpal an d radiou ln ar join ts.

Fig 5.3-1 5a –d

Th e xation procedu re ollow s th e u su al steps o selectin g an d applyin g th e plate, in sertin g distal an d proxim al screw s, an d in traoperative im agin g. For u rth er in orm ation on th ese steps see ch apter 4.6 Distal radiu s—m u lti ragm en tary in traarticu lar ractu re treated w ith a palm ar plate.

407

Pa rt II Case s

6

Fixa t io n (co n t )

Co m p le t e t h e fixa t io n

a

Fin al screw s w ere in serted an d th e distal radiu s xation com pleted. In traoperative im ages sh ow ed correct placem en t o th e plate.

Fig 5 .3 -16

7

b

Th e n al in traoperative im ages sh ow ed th e an atom ical redu ction .

Fig 5.3-1 7a –b

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.3-18

408

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

8

Ou t co m e

a

b

At th e 4-m on th ollow -u p, th e AP an d lateral x-rays sh ow ed com plete h ealin g.

Fig 5.3-1 9a –b

a

b

c

d

Fig 5.3-2 0a –d

Th e clin ical ou tcom e resu lted in n o pain an d a good u n ction al resu lt.

409

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n

In t ra a r t icu la r m a lu n io n t re a t e d w it h o s t e o t o m y a n d a ra d ia l co lu m n p la t e a n d s cre w s

a

b

a

A 22-year-old em ale m edical stu den t su ered a ractu re o th e distal radiu s, a pelvis ractu re, an d oth er in ju ries in a m otor veh icle acciden t. A ter in itial treatm en t, sh e w as seen by m edical specialists 2 m on th s a ter th e in ju ry, an d w h ile h ealin g h ad progressed w ith h er oth er in ju ries, sh e con tin u ed to h ave w rist pain an d lim itation in ran ge o m otion . Th e PA an d lateral x-rays sh ow ed a displaced partially h ealed ractu re o th e radial styloid h avin g an eviden t displacem en t w ith radiocarpal in con gru ity.

Fig 5.3-2 1a –b

b

Th e radial CT scan s dem on strated a 2 m m articu lar step-o an d displacem en t on su pin ation o th e radial styloid, both o w h ich w ere cau sin g radiocarpal in con gru ity.

Fig 5.3-2 2a –b

In d ica t io n s

2 mm

In con gru en cy on th e join t su r ace o th e radiu s u ltim ately leads to cartilage degen eration an d th is is especially so wh en th ere is a m alu n ited radial styloid with a step-o o 2 m m or m ore an d ran k radiocarpal in con gru ity. For th is reason , a corrective osteotom y an d radial colu m n plate xation with addition al h eadless com pression screws was con sidered or th is patien t.

Fig 5.3-23

410

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

9

Alt e rn a t ive t e ch n iq u e : ca s e d e s crip t io n (co n t )

Su rgica l a p p ro a ch

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s). With th is dorsal approach , on ly th e th ird exten sor com partm en t was open ed. Th e in term ediate an d radial colu m n s were approach ed separately u sin g a sin gle dorsal skin in cision .

Fig 5.3-24

a

b

Th rou gh a dorsal approach , th e th ird com partm en t was open ed in lin e with th e exten sor pollicis lon gu s (EPL) ten don in th e exten sor retin acu lu m . Th e EPL ten don is reed, protected, an d retracted to th e radial side o th e wrist. Th e ou rth an d secon d com partm en ts were elevated su bperiosteally, leavin g both com partm en ts in tact. Th e ou rth com partm en t was retracted u ln arly an d th e secon d com partm en t radially. Th e lateral colu m n an d part o th e in term ediate colu m n were exposed. Th e dorsal capsu le was in cised to expose th e join t, m akin g th e step-o o th e join t su r ace clearly visible. Th e lin e o th e ractu re was iden ti ed u sin g th e m agn i yin g lou pes.

Fig 5.3-25a –b

411

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n Re d u ct io n

a

b

With th e de orm ity n ow in clear view ( a ), u sin g a n arrow osteotom e an d a sm all cu rette, an osteotom y is per orm ed th rou gh th e im m atu re callu s ( b ).

Fig 5.3-2 6a –b

a

b

Redu ce th e osteotom ized ragm en t u sin g poin ted redu ction orceps ( a ). Th en in sert a gu ide w ire rom th e radiu s m etaph ysis in to th e styloid ragm en t as perpen dicu lar as possible to th e ractu re site ( b ).

Fig 5.3-2 7a –b

412

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t )

Pass an addition al gu ide w ire across th e ractu re site, gain in g pu rch ase in to th e cortex o th e radial styloid.

Fig 5.3-2 8

Followin g th e osteotom y an d tem porary redu ction , provision al xation was per orm ed u sin g th e gu ide wires. Redu ction was ch ecked u sin g th e im age in ten si er an d by direct vision o th e join t su r ace.

Fig 5.3-29

Fixa t io n w it h ra d ia l co lu m n p la t e

An LCP radial colu m n plate 2.4 was placed over th e radial colu m n . Th e appropriate plate is selected accordin g to th e ractu re con gu ration an d con tou red i n ecessary. Slide th e plate u n dern eath th e rst com partm en t an d apply it on to th e radial colu m n . In sert a stan dard cortex screw in to th e oblon g plate h ole proxim al to th e m alu n ion . Tigh ten in g th is screw will redu ce th e radial styloid.

Fig 5.3-30

413

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) In s e r t t h e a d d it io n a l la g s cre w s

a

b

Usin g gu ide w ires, tw o 3 m m h eadless com pression screw s are in serted exertin g in ter ragm en tary com pression on th e osteotom y lin e.

Fig 5.3-3 1a –b

In s e r t p ro xim a l a n d d is t a l s cre w s

a

b

Com plete th e radial colu m n plate xation by in sertin g proxim al an d distal screw s in to th e plate h oles. Th e plate in creases stability an d allow s u n restricted early m obility.

Fig 5.3-3 2a –b

414

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .3 Distal radius—intraarticular malunion tre ate d with oste otomy and palmar plate

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t )

In traoperative im ages sh ow ed th e an atom ical redu ction an d th e correct placem en t o th e plates an d screw s.

Fig 5.3-3 3

Co m p le t e t h e fixa t io n

Tw o bon e an ch ors w ere placed on th e dorsal rim o th e radiu s.

Fig 5.3-3 4

Th e dorsal capsu le w as su tu red back on to th e dorsal rim o th e radiu s u sin g th e an ch or’s su tu res.

Fig 5.3-3 5

415

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e : re d u ct io n a n d fixa t io n (co n t ) Ou t co m e

a

b

At th e 3-m on th ollow -u p, th e radiological im ages in dicated good h ealin g.

Fig 5.3-3 6a –b

a

b

c

d

Fig 5.3-3 7a –d

Th ere w as also an excellen t clin ical ou tcom e or th is aspirin g m edical

pro ession al.

416

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.4

1

Distal radius—extraarticular and intraarticular malunion treated with osteotomy and dorsal double plating

Ca s e d e s crip t io n

A 27-year-old h ou se clean er h ad a all w h ile w orkin g yet did n ot presen t or m edical advice u n til 6 m on th s later. Sh e h ad su ered a com plex ractu re o h er righ t distal radiu s an d h ad lim ited w rist an d orearm m otion . Sh e com plain ed o persisten t pain w ith both w ork-speci c an d n orm al activities o daily livin g. Th e PA an d lateral x-rays revealed a com bin ed in traarticu lar an d extraarticu lar distal radial ractu re m alu n ion .

Fig 5 .4 -1a –b

a

b

6 mm

a

b

Th e axial CT scan sh owed an im paction o th e lu n ate acet with a 6 m m step-o an d gap, an d in traarticu lar in con gru en cy o th e distal radiou ln ar join t (DRUJ).

Fig 5.4-2a –b

417

Pa rt II Case s

1

Ca s e d e s crip t io n (co n t )

35°

a

b

c

Th e sagittal CT scan sh ow ed 35 degrees dorsal an gu lation du e to th e extraarticu lar m etaph yseal de orm ity. Radial sh orten in g an d su pin ation o th e distal ragm en t w ere also eviden t.

Fig 5.4-3 a – c

418

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating

2

In d ica t io n s

Co m b in e d in t ra a r t icu la r a n d e xt ra a r t icu la r m a lu n io n

In som e in stan ces ollow in g a distal radial ractu re, a com bin ed in traarticu lar an d extraarticu lar m alu n ion can occu r, w h ich can adversely a ect both th e radiocarpal an d radiou ln ar join t u n ction s. As discu ssed in th e previou s ch apters in th is section , de orm ity in volvin g greater th an 1 m m step-o at th e articu lar su r ace, or greater th an 10 degrees o dorsal an gu lation as a resu lt o extraarticu lar m alu n ion , are in dication s or treatm en t by osteotom y. Both th ese levels o de orm ity w ere greatly exceeded in th is patien t. Care u l u n derstan din g o th e com pon en t parts o th e m alu n ion is cru cial to plan n in g th e type an d location o th e osteotom ies.

Im a gin g

1

1

3 2 3 2

a

b

Axial 2-D CT an d 3-D CT scan s provide a clearer u n derstan din g o th e articu lar in con gru ity an d th e act th at th e articu lar m alu n ion in th is case con sisted o th ree m ajor com pon en ts. Th ese in clu de both th e dorsal an d lu n ate acets an d th e radial styloid.

Fig 5.4-4a –c

1

2 c

3

419

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Eq u ip m e n t

• Variable an gle (VA) lockin g com pression plate (LCP) distal radiu s set • VA LCP dorsal plates 2.4 • 2.0 m m cortex screw • 1.1 m m or 1.2 m m K-w ires • Oscillatin g saw • Osteotom e • Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.4-5

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed was a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s).

Fig 5.4-6

420

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating

4

Su rgica l a p p ro a ch (co n t )

a

b

Th e dorsal exposu re isolated th e exten sor pollicis lon gu s. Th e posterior in terosseou s n erve was iden ti ed an d section ed.

Fig 5.4-7a –b

5

Re d u ct io n

Pla n t h e o s t e o t o m y

Osteotom y lin es are plan n ed on to th e bon e ollow in g th e variou s ractu re pattern s. On ce per orm ed, th e osteotom ies separate th e dorsou ln ar com pon en t an d th e m etaph ysis.

Fig 5.4-8

421

Pa rt II Case s

5

Re d u ct io n (co n t )

Pe r fo rm t h e a r t icu la r co m p o n e n t o s t e o t o m y

a

b

An osteotom y is rst per orm ed at th e articu lar site. Th e dorsal lu n ate acet is osteotom ized an d retracted distally. Th is w ill n ow expose th e back o th e palm ar lu n ate acet an d displaced radial styloid ( a ). K-w ires are in trodu ced in to th e palm ar lu n ate acet an d radial styloid com pon en ts to be later u sed as joysticks ( b ).

Fig 5.4-9 a – b

Pe r fo rm t h e m e t a p h ys e a l co m p o n e n t o s t e o t o m y

a

b

An osteotom y is th en per orm ed at th e site o th e m etaph yseal m alu n ion ( a ). Note th at it is im portan t to release th e attach m en t o th e brach ioradialis to gain realign m en t or adequ ate len gth o th e articu lar com pon en t. Th e osteotom y is open ed u sin g a lam in ar spreader an d th e dorsal m etaph yseal de orm ity redu ced leavin g a gap in th e m etaph yseal area o th e bon e ( b ).

Fig 5.4-1 0a –b

422

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating

5

Re d u ct io n (co n t ) Bo n e gra ft

Iliac crest

Th e K-wire is rem oved rom th e palm ar lu n ate acet an d th e dorsal lu n ate acet is reposition ed an d h eld with a K-wire th rou gh both lu n ate acet ragm en ts. Th e redu ction o both th e articu lar an d m etaph yseal de orm ities are tem porarily h eld with K-wires.

Fig 5.4-11

Harvest th e corticocan cellou s gra t m aterial rom th e iliac crest.

Fig 5.4-1 2

Ha r ve s t in g b o n e w e d ge

2–4 cm

a

b

Expose th e crest over a 2–4 cm segm en t an d m ark ou t th e preplan n ed gra t size to be h arvested ( a ). Con sider th e sh ape an d size o th e de ect in th e distal radiu s an d h ow th e gra t w ill ll th e de ect created by th e osteotom y ( b ). Harvest th e selected gra t u sin g a sh arp osteotom e. Con trol bleedin g w ith a w ou n d pack an d u se a sm all su ction drain i n ecessary. Close th e skin an d apply a pressu re dressin g.

Fig 5.4-1 3a –b

423

Pa rt II Case s

5

Re d u ct io n (co n t )

In s e r t t h e b o n e gra ft

a

On ce th e optim al an atom ical position is ach ieved, th e parts are tem porarily xated an d th e iliac crest bon e w edge is in trodu ced in to th e m etaph yseal osteotom y site.

Fig 5.4-1 4

6

b

In traoperative im ages sh ow th e correction o both th e in traarticu lar an d extraarticu lar m alu n ion s an d th eir tem porarily stabilization w ith K-w ires.

Fig 5.4-1 5a –b

Fixa t io n

Fixa t io n o f a r t icu la r co m p o n e n t s

It m ay be n ecessary to x th e articu lar com pon en ts w ith a radially in serted 2.0 m m lag screw .

Fig 5.4-1 6

424

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating

6

Fixa t io n (co n t )

Fixa t io n o f in t e rm e d ia t e co lu m n

Fixa t io n o f ra d ia l co lu m n

To xate th e m etaph ysis, tw o plates are placed on th e dorsal side. First, th e in term ediate colu m n m u st be su pported by a su itable in term ediate colu m n dorsal plate. For th is patien t, a straigh t plate w as u sed.

Fig 5.4-1 8

Fig 5.4-1 7

Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g th e plate, an d in sertin g proxim al an d distal screw s. For u rth er in orm ation on th ese steps see th e xation o in term ediate colu m n topic in ch apter 4.5 Distal radiu s—dorsally displaced in traarticu lar ractu re treated with dou ble platin g.

7

To com plete th e xation , a straigh t plate w as u sed or th e radial colu m n . Th e xation procedu re ollow s th e u su al steps o selectin g, con tou rin g, an d applyin g th e plate, an d in sertin g proxim al an d distal screw s; h ow ever on th is occasion , th e plate w as placed m ore adjacen t to th e in term ediate colu m n plate on th e dorsal side.

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.4-19

425

Pa rt II Case s

8

Ou t co m e

a

b

At th e 1-year ollow -u p th e osteotom ies w ere sh ow n to be h ealed.

Fig 5.4-2 0a –b

a Fig 5.4-2 1a –d

426

b

c

d

At an 11-year ollow -u p th e im plan ts w ere electively rem oved.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .4 Distal radius—e xtraarticular and intraarticular malunion tre ate d with oste otomy and dorsal double plating

8

Ou t co m e (co n t )

a

b

c

e Fig 5.4-2 2a –f

d

f

Th e patien t h ad excellen t u n ction an d ran ge o m otion , w ith n o w rist arth ritis.

427

Pa rt II Case s

428

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.5

1

Rheumatoid arthritis treated with radiolunate arthrodesis

Ca s e d e s crip t io n

a

b

A 60-year-old em ale beau ty th erapist presen ted com plain in g o progressive pain an d u n ction al lim itation in h er le t wrist a ter su erin g rh eu m atoid arth ritis or 15 years. Th e PA an d lateral x-rays revealed join t space n arrowin g at th e radiolu n ate join t an d th e distal radiou ln ar join t (DRUJ).

Fig 5.5-1a –b

a

b

c

Th e CT scan s dem on strated on goin g arth ritis with radiolu n ate join t space n arrowin g, u ln ar tran slation (displacem en t in an u ln ar direction ) o th e carpu s, an d cystic ch an ges at th e radiolu n ate articu lation .

Fig 5.5-2a –c

Th e 3-D CT scan s u rth er in dicated th e u ln ar tran slation o th e carpu s.

Fig 5.5-3

429

Pa rt II Case s

2

In d ica t io n s

Wris t d ys fu n ct io n fro m rh e u m a t o id a r t h rit is

a

b Norm al joints

Arthritic joints

Rh eu m atoid arth ritis is a w ell-recogn ized problem w h ere th e body’s ow n im m u n e system starts to attack th e join ts. O ten a ectin g th e h an d an d w rist, it resu lts in in f am m ation , pain , an d sti n ess an d th icken in g in th e a ected join ts, an d m ay even even tu ally a ect th e m ajor organ s. In itial treatm en t can in clu de m edication s, steroids, an d su pport braces or im m obilization , bu t severe cases can be treated w ith su rgical treatm en t to repair or u se th e join ts.

Fig 5.5-4a –b

Sym ptom atic w rist dys u n ction o an y etiology can requ ire recon stru ction , an d salvage procedu res are requ en tly th e on ly w ay to o er th e patien t a stable pain - ree w rist. A n u m ber o su rgical option s th at ideally preserve m otion an d avoid com plication s in th e lon g term can be con sidered: • Lim ited w rist arth rodesis • Proxim al row carpectom y (w h ich is con train dicated in th is case becau se th e rh eu m atoid arth ritis a ects th e lu n ate acet o th e distal radiu s) • Arth roplasty (in volvin g replacem en t o th e w rist join t) • Total w rist arth rodesis.

Lim it e d w ris t a r t h ro d e s is

A lim ited w rist arth rodesis in volves th e su rgical u sion o a selection o bon es in th e w rist depen din g on th e exten t o th e a ected area. Th e u ltim ate goals o a lim ited w rist arth rodesis in clu de elim in atin g pain th at is related to th e join ts th at h ave ocal arth ritis w h ile sim u ltan eou sly preservin g as m u ch m otion as possible th rou gh th e rem ain in g articu lar su r aces. Frequ en tly, th e radiolu n ate or radioscaph oid join ts are in volved an d sign i can t pain an d de orm ity are n oted. In som e cases (as w ill be seen in th e altern ative tech n iqu es later in th is ch apter) th e partial or u ll rem oval o an a ected carpal is n ecessary in an attem pt to preserve u n ction al m otion .

430

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .5 Rheumatoid arthritis tre ate d with radiolunate arthrode sis

2

In d ica t io n s (co n t )

Ra d io lu n a t e a r t h ro d e s is

Im a gin g

X-rays an d CT scan s an d laboratory testin g m ay su pport an in itial diagn osis o rh eu m atoid arth ritis. Th ey m ay also h elp to exclu de oth er diseases w ith sim ilar sym ptom s.

a

b

c

A radiolu n ate arth rodesis is a lim ited wrist arth rodesis procedu re in dicated wh en th ere is palm ar or u ln ar tran slation o th e carpu s or localized radiolu n ate arth ritis ( a ), com m on ly seen in patien ts with rh eu m atoid arth ritis bu t also n oted in th ose with die pu n ch ractu res with in th e lu n ate ossa. For th is patien t, a lockin g com pression plate (LCP) distal u ln a (h ook) plate was placed in to th e dorsal rim o th e lu n ate at on e en d an d to th e radiu s at th e oth er, u sin g th e segm en ts togeth er ( b –c ).

Fig 5.5-5a –c

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

LCP distal u ln a plate 2.0 1.4 m m to 1.6 m m K-w ires Bon e n ibbler/ ron geu r Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.5-6

431

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s). Th e in cision w as th rou gh th e th ird exten sor com partm en t.

Th e dorsal capsu le o th e le t w rist w as open ed in a T- ash ion , exposin g th e radiolu n ate join t. Note th e absen ce o h yalin e cartilage on th e lu n ate.

Fig 5.5-7

5

Fig 5.5-8

Re d u ct io n

Bo n e gra ft

Lister tubercle

a

Harvest gra t m aterial rom th e distal radiu s or later in sertion in to th e a ected w rist join ts. A good an d sa e place is proxim al an d sligh tly radial to Lister tu bercle. Wh en h arvestin g, retract th e ten don s o th e secon d com partm en t radially an d th e exten sor pollicis lon gu s in an u ln ar direction .

Fig 5.5-9

432

b

Th rou gh th e existin g dorsal approach , an d with th e exten sor ten don s retracted radially an d u ln arly, th e Lister tu bercle was u sed as a sou rce o au togen ou s bon e gra t.

Fig 5.5-10a –b

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .5 Rheumatoid arthritis tre ate d with radiolunate arthrode sis

5

Re d u ct io n (co n t )

Re d u ce t h e lu n a t e a n d in s e r t t h e gra ft

A ter decortication o th e articu lar su r aces o both th e lu n ate an d lu n ate ossa, an d placin g th e au togen ou s bon e gra t betw een th e join t su r aces, th e lu n ate is redu ced an d provision ally h eld with a K-w ire.

Fig 5.5-11

6

a

b

Th e PA an d lateral in traoperative im ages sh ow th e placem en t o th e K-w ire. Th e lu n ate is redu ced in n eu tral position .

Fig 5.5-1 2a –b

Fixa t io n

Se le ct a n d a p p ly t h e p la t e

a

b

c

In sert th e h ook plate. Th e plate adapts w ell to th e radiolu n ate articu lation . Th e h ooks are placed in to th e dorsal rim o th e lu n ate. On ce applied, th e h ook plate w ill be w ell seated an d avoids th e lu n ocapitate join t. Take great care th at th e h ooks o th e h ook plate do n ot orce th e lu n ate in to exten sion . A tem porary radiolu n ate K-w ire can preven t th is.

Fig 5.5-1 3a –c

433

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t s cre w s

a

b

c

An gu lar stable screw s are u sed to x th e plate to both th e lu n ate an d radiu s m etaph ysis. Th e m ost distal screw is directed proxim ally in to th e distal radiu s an d placed u n der com pression .

Fig 5.5-1 4a –c

a

b

On e lockin g screw w as in serted in to th e lu n ate an d a lag screw w as also placed th rou gh th e lu n ate an d w as th readed on th e palm ar cortex o th e radiu s.

Fig 5.5-1 5a –b

434

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .5 Rheumatoid arthritis tre ate d with radiolunate arthrode sis

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.5-16

8

Ou t co m e

a

b

At a ollow-u p approxim ately 6 m on th s a ter su rgery, th e AP an d lateral x-rays sh owed excellen t u sion .

Fig 5.5-17a –b

a

b

c

d

Fu ll orearm rotation w as ach ieved bu t w ith som e lim itation o w rist f exion an d exten sion . How ever, th e patien t w as com pletely pain ree.

Fig 5.5-1 8a –d

435

Pa rt II Case s

9

Alt e rn a t ive t e ch n iq u e 1

Ra d io s ca p h o lu n a t e a r t h ro d e s is

a

b

c

A radioscaph olu n ate arth rodesis is a lim ited w rist arth rodesis procedu re in dicated or patien ts w ith degen erative join t disease th rou gh ou t th e radiocarpal join t ( a ). It in volves th e en tire join t su r ace. Th e x-ray an d CT scan s sh ow radiocarpal osteoarth ritis on a righ t h an d ollow in g a m alu n ited in traarticu lar distal radial ractu re ( b – c ). Note th at th e cartilage o th e m idcarpal join t w as n ot dam aged, w h ich is a prerequ isite to in dicate th is tech n iqu e.

Fig 5.5-1 9a –c

Fixa t io n a n d o u t co m e

a

b

c

Th e radioscaph olu n ate arth rodesis in volved th e placem en t o tw o 3.0 m m h eadless com pression screw s com in g rom th e radiu s, on e in to th e scaph oid an d on e in to th e lu n ate. At th e 5-year ollow -u p, PA an d lateral x-rays sh ow ed excellen t u sion , an d th e patien t sh ow ed pain less u n ction al w rist m otion . Clin ical m otion (f exion an d exten sion ) can be seen in th e lateral x-rays.

Fig 5.5-2 0a –c

436

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .5 Rheumatoid arthritis tre ate d with radiolunate arthrode sis

10 Alt e rn a t ive t e ch n iq u e 2 Ra d io s ca p h o lu n a t e a r t h ro d e s is w it h re s e ct io n o f t h e d is t a l h a lf o f t h e s ca p h o id

a

b

Th e CT scan s o th is patien t dem on strate arth ritic in volvem en t o both th e radiolu n ate an d radioscaph oid join t as sequ elae o a m alu n ited distal radial ractu re in itially treated by closed redu ction an d percu tan eou s xation . Th e cartilage o th e m idcarpal join t was n ot dam aged. Note th e palm ar su blu xation o th e carpu s in th e lateral view an d a gap o 4–5 m m in th e distal radial articu lar su r ace. Fu rth er treatm en t with a radioscaph olu n ate arth rodesis was requ ired.

Fig 5.5-21a –b

a

b

c

Wh en th e radiocarpal join t u n dergoes a u sion procedu re, th e wrist’s ran ge o m otion is con siderably redu ced, o ten as m u ch as 50% . For th is reason , rem oval o th e distal h al o th e scaph oid is som etim es recom m en ded to im prove m otion th rou gh th e m idcarpal join t ( a ). Fixation can in volve screws in serted in a cross orm ation ( b ) or com in g parallel rom th e radial styloid ( c ).

Fig 5.5-22a –c

437

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e 2 Fixa t io n a n d o u t co m e

a

b

A good ran ge o m otion w as ach ieved by th e 7-year ollow -u p.

Fig 5.5-2 4a –b

a

b

Treatm en t in volved rem oval o th e distal h al o th e scaph oid alon g w ith in sertion o tw o 3.5 m m screw s w ith w ash ers an d a K-w ire. Th e PA view x-ray sh ow s total h ealin g o th e u sion 4 m on th s a ter su rgery ( a ). Note th at th e n orm al relation sh ip betw een th e scaph oid an d lu n ate w as preserved in order to m ain tain th e con gru en cy o th e m idcarpal join t. Solid u sion is sh ow n at 6 m on th s ollow in g su rgery ( b ). Th e screw rom th e radiu s in to th e scaph oid w as rem oved at th at tim e becau se o ten don irritation .

Fig 5.5-2 3a –b

438

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.6

1

Kienbock’s disease treated with total wrist arthrodesis

Ca s e d e s crip t io n

a

b

c

d

A 47-year-old righ t-h an d dom in an t taxi driver experien ced a m ildly pain u l wrist or 3 years u n til h e su ered a torsion al in ju ry li tin g a h eavy object (car wh eel). His wrist pain becam e extrem e. Th e PA an d lateral x-rays sh owed Kien bock´s disease stage IIIB with severe lu n ate collapse an d osteoporosis ( a –b ). Th e MRIs con rm ed th e diagn osis, with loss o vascu larization an d collapse o th e lu n ate bein g eviden t ( c–d ).

Fig 5.6-1a –d

Th e clin ical exam in ation revealed n oticeable swellin g o th e wrist an d lim ited m otion . He h ad on ly 10 degrees o wrist exten sion an d 5 degrees o f exion , with on ly 10 degrees o u ln ar deviation an d absen ce o radial deviation . Grip stren gth in th e a ected h an d h ad allen m arkedly to ju st 15.5 kg (average grip stren gth or th e n orm al popu lation at th e sam e age was 52 kg).

439

Pa rt II Case s

2

In d ica t io n s

Kie n b o ck ’s d is e a s e (a va s cu la r n e cro s is o f t h e lu n a t e )

a

b Stage I

d

c Stage II

Stage IIIA

e Stage IIIB

Stage IV

Kien bock’s disease is a disorder th at in volves n ecrosis o th e lu n ate an d its poten tial even tu al collapse. It resu lts rom an in terru ption o blood su pply to th e lu n ate cau sed by an y n u m ber o actors, bu t typically in volvin g an in itial trau m a to th e w rist. Th e exten t o collapse an d ragm en tation o th e lu n ate can be u sed to h elp classi y th e disorder, as ollow s: • Stage I: Norm al lu n ate ractu re • Stage II: Sclerosis o th e lu n ate w ith ou t collapse • Stage IIIA: Lu n ate collapse an d ragm en tation in addition to proxim al m igration o th e capitate • Stage IIIB: Lu n ate collapse an d ragm en tation in addition to proxim al m igration o th e capitate plu s xed f exion de orm ity o th e scaph oid • Stage IV: Degen eration arou n d th e lu n ate w ith radiocarpal an d m idcarpal arth ritic ch an ges.

Fig 5.6-2 a – e

Sym ptom atic w rist dys u n ction o an y etiology can requ ire recon stru ction , an d salvage procedu res are requ en tly th e on ly w ay to o er th e patien t a stable pain - ree w rist. A n u m ber o su rgical option s th at ideally preserve m otion an d avoid com plication s in th e lon g term can be con sidered: • Lim ited w rist arth rodesis • Proxim al row carpectom y • Arth roplasty • Total w rist arth rodesis. 440

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .6 Kie nbock’s dise ase tre ate d with total wrist arthrode sis

2

In d ica t io n s (co n t )

To t a l w ris t a r t h ro d e s is

Ch o ice o f im p la n t Short curvature a

Standard curvature b

Straight c Optional Mandatory

A total w rist arth rodesis in volves th e total u sion o th e radiocarpal an d m idcarpal join ts. Th is is a salvage procedu re w h ere th e patien t h as lost u n ction al w rist m otion or su ers persisten t an d u n relen tin g pain an d exten sive in tercarpal arth ritis. Th e u ltim ate goal is a pain - ree an d stable w rist w ith restoration o u n ction al grip stren gth .

Fig 5.6-3

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

A wrist u sion plate with sh ort or stan dard cu rvatu re (or in som e in dication s n o ben d at all) is th e im plan t o ch oice. Th e precon tou red cu rved plates redu ce th e n eed or in traoperative ben din g to ollow th e n atu ral con tou rs o th e wrist. Th e plate also places th e h an d in an optim al position . Th e design o th e cu rved wrist u sion plates places th e radiu s in 10 degrees exten sion , wh ich is ideal as th e goal is to ach ieve th e arth rodesis with th e wrist in 10 degrees o exten sion an d 15 degrees o u ln ar deviation . For th is patien t, th e sh ort cu rved plate was selected.

Fig 5.6-4a –c

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Lockin g com pression plate (LCP) w rist u sion set Wrist u sion plate 2.7/ 3.5 Bon e n ibbler/ ron geu r Osteotom e Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.6-5

441

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as a dorsal approach (see ch apter 1.8 Dorsal approach to th e distal radiu s). With th is dorsal approach , th ere w as a straigh t lon gitu din al in cision betw een th e th ird an d ou rth exten sor com partm en ts.

Fig 5.6-6

A straigh t dorsal lon gitu din al in cision was m ade ( a ). Th e dorsal side o th e wrist a ter lon gitu din al capsu lar open in g ( b ).

Fig 5.6-7a –b

a

b

Ch on dral debridem en t o th e radiocarpal an d m idcarpal join ts w as u n dertaken u n til reach in g bleedin g su r aces.

Fig 5.6 -8

442

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .6 Kie nbock’s dise ase tre ate d with total wrist arthrode sis

5

Re d u ct io n

Bo n e gra ft

Lister tubercle

a

b

Harvest gra t m aterial rom th e distal radiu s or later in sertion in to th e a ected w rist join ts. On th is occasion , Lister tu bercle an d th e dorsal h al o th e distal radiu s w ere rem oved or u se as bon e gra t m aterial.

Fig 5.6-9 a – b

In s e r t t h e b o n e gra ft

H L

M C

R S Optional a

Mandatory

b

Join ts to u se (below ): R: Radiu s L: Lu n ate S: Scaph oid C: Capitate H: Ham ate M: Th ird m etacarpal Expose an d prepare th e join t su r aces to be in clu ded in th e u sion . Th en distribu te th e can cellou s bon e gra t th rou gh ou t th e radiocarpal an d m idcarpal join ts to en h an ce th e u sion procedu re.

Fig 5.6-1 0a –b

443

Pa rt II Case s

6

Fixa t io n

Se le ct a n d a p p ly t h e p la t e

In sert th e w rist u sion plate th rou gh th e approach an d position th e plate directly over th e th ird m etacarpal distally an d th e radiu s proxim ally.

Fig 5.6-1 1

Me a s u re s cre w d e p t h

a

b

Place th e drill gu ide in th e rst (m ost distal) h ole an d drill with a 2.0 m m drill bit to th e desired len gth . Rem ove th e drill an d drill gu ide an d m easu re or screw len gth .

Fig 5.6-12a –c

c

444

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .6 Kie nbock’s dise ase tre ate d with total wrist arthrode sis

6

Fixa t io n (co n t )

In s e r t d is t a l s cre w s 1

3

2

In th is procedu re, 2.7 m m com pression or lockin g screw s are u sed or th e distal en d o th e plate, goin g in to th e capitate or m etacarpals. Larger 3.5 m m com pression or lockin g screw s are u sed or th e radiu s. In sert th e 2.7 m m distal screw s rst (w ith recom m en ded sequ en ce o screw in sertion sh ow n ).

Fig 5.6-1 3

a

b

In traoperative im ages sh ow th e 2.7 m m lockin g screw s bein g placed in to th e th ird m etacarpal.

Fig 5.6-1 4a –b

Me a s u re a n d in s e r t s cre w in t o t h e ca p it a t e

a Fig 5.6-15a –b

b

Determ in e screw len gth an d in sert a 2.7 m m lockin g screw th rou gh th e cen tral plate h ole in to th e capitate.

445

Pa rt II Case s

6

Fixa t io n Align p la t e a n d m e a s u re p ro xim a l s cre w d e p t h

Th e distal xation in to th e th ird m etacarpal an d capitate is sh ow n .

Align th e plate over th e radiu s. Place th e drill gu ide in th e th ird m ost proxim al h ole an d drill with a 2.5 m m drill bit to th e desired len gth . Th is will becom e screw n u m ber 5. Rem ove th e drill an d drill gu ide an d m easu re or screw len gth . Veri y with im age in ten si cation .

Fig 5.6-1 6

Fig 5.6-17

In s e r t p ro xim a l s cre w s

6

5

7

8

Th e 3.5 m m com pression or lockin g screws are n ow u sed or in sertion in to th e radiu s (with recom m en ded sequ en ce o screw in sertion sh own ). Th e th screw can be applied as a com pression screw in order to apply th e plate toward th e dorsal cortex o th e radiu s.

Fig 5.6-18

446

Th e in traoperative im age sh ow s a 3.5 m m lockin g screw bein g placed in to th e radiu s.

Fig 5.6-1 9

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .6 Kie nbock’s dise ase tre ate d with total wrist arthrode sis

6

Fixa t io n (co n t )

Co m p le t e t h e fixa t io n

a

b

Fig 5.6-2 0a –b

7

Local bon e gra t rom th e earlier debridem en t w as in serted in to th e area to com plete th e xation .

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.6-21

447

Pa rt II Case s

8

Ou t co m e

a

a

b

At th e 13-week ollow-u p, th e x-rays sh owed th e total wrist arth rodesis was com plete with u ll in tegration o th e bon e gra t.

Fig 5.6-22a –b

b

A ter a period o 6 m on th s ollowin g wrist u sion su rgery, th e patien t retu rn ed to h is job as a taxi driver. At th e 5-year ollow-u p, h e n oted occasion al discom ort with stren u ou s activity, bu t gen erally good ran ge o m otion ( a –b ), an d grip stren gth th at h ad im proved to 46.5 kg. He h ad a patien t satis action ratin g o 9 (VAS: 0-10).

Fig 5.6-23a –b

Vid e o

Th is video dem on strates a wrist arth rodesis with a wrist u sion plate.

Vid e o 5.6-1

448

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.7

1

Malunited fracture with associated ulnar abutment syndrome treated with an ulnar shortening osteotomy

Ca s e d e s crip t io n

a

b

c

A 64-year-old m an su stain ed a closed ractu re o h is n on dom in an t le t distal radiu s a ter a all. Th e ractu re w as m an aged n on operatively in a sh ort arm cast or 6 w eeks an d h ealed w ith a m in or loss o radial len gth .

Fig 5.7-1a – c

Follow in g n on operative treatm en t, n ew PA x-rays sh ow ed positive u ln ar varian ce o 2 m m an d an avu lsion o th e tip o th e u ln ar styloid ( a ). Forearm rotation becam e in creasin gly pain u l an d lim ited h is ability to u lly pron ate. New MRI scan s revealed edem atou s ch an ges in th e u ln ar corn er o th e lu n ate an d th e opposin g part o th e u ln ar h ead ( b – c ), w h ich w ere th e resu lt o on goin g im pact betw een th e u ln a an d th e lu n ate.

449

Pa rt II Case s

2

In d ica t io n s

Ra d io u ln a r le n g t h d is cre p a n c y a n d u ln a r a b u t m e n t s yn d ro m e

A m in or degree o radiou ln ar len gth discrepan cy is n ot u n com m on a ter a h ealed distal radial ractu re, h owever, en du rin g sym ptom s are u n u su al. In th is case, relative len gth en in g o th e u ln a (as a con sequ en ce o radial sh orten in g) h as resu lted in redu ced orearm rotation (du e to distal radiou ln ar join t [DRUJ] su blu xation ), an d u ln ar sided wrist pain . Patien ts com plain th at u ln ar sided wrist pain is worse in u ll pron ation an d f exion . Th ere is o ten a redu ced ran ge o total orearm rotation com pared with th e n orm al side. For th is patien t, in itial m an agem en t with rest, splin t im m obilization , an d steroid in jection s h ad ailed to resolve th e sym ptom s, so an u ln ar sh orten in g osteotom y was recom m en ded. Uln ar abu tm en t (or u ln ar im paction ) syn drom e is cau sed by excessive im pact betw een th e u ln a an d its closest carpals, typically th e lu n ate, an d o ten as a resu lt o positive u ln ar varian ce. Th e con dition can ran ge rom sim ple w ear pattern s, to trian gu lar brocartilage com plex per oration , to advan ced cases w ith u ln ocarpal osteoarth ritis.

Uln a r va ria n ce

2 mm

Im a gin g

- 2 mm

a

b Positive variance

Ne gative variance

Variation in relative len gth o th e distal articu lar su r aces o th e u ln a an d radiu s is described as u ln ar varian ce. Wh en th e articu lar su r ace o th e u ln a is m ore distal com pared with th e articu lar su r ace o th e radiu s th ere is positive u ln ar varian ce ( a ), an d a m ore proxim al u ln ar len gth resu lts in n egative u ln ar varian ce ( b ). Varian ce o 2 m m or greater typically requ ires operative treatm en t. Th e varian ce can be assessed in a variety o ways radiologically bu t it is m an datory to obtain a com parison x-ray o th e u n in ju red side to ju dge th e relevan ce o th e radiological m easu rem en ts.

Fig 5.7-2a –b

450

Plain x-rays in a stan dardized position sh ou ld be taken . For best resu lts, seat th e patien t an d place th e a ected arm w ith 90 degrees o abdu ction at th e sh ou lder, f exed 90 degrees at th e elbow , w ith th e arm lyin g in n eu tral orearm rotation .

Fig 5.7-3

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

2

In d ica t io n s (co n t )

Ach ie vin g s h o r t e n in g

a

b

c

Wh en treatin g radiou ln ar len gth discrepan cies th rou gh u ln ar sh orten in g, th e procedu re can be ach ieved by: • Rem ovin g a portion o bon e rom th e u ln ar h ead (w a er resection ) via open or arth roscopic su rgery • Or by sh orten in g th e bon e th rou gh a distal diaph yseal osteotom y (u ln ar sh orten in g osteotom y).

Fig 5.7-4a –c

A w a er resection does n ot address su blu xation o th e DRUJ an d is in dicated in prim ary u ln ocarpal abu tm en t rath er th an secon dary abu tm en t created by radial sh orten in g. A w a er resection rem oves th e term in al portion o th e u ln ar h ead bu t accu rate resection o a preplan n ed am ou n t is di cu lt to ach ieve. How ever, th e DRUJ is n ot distu rbed ( a ). An u ln ar sh orten in g osteotom y can be per orm ed precisely an d allow s an exact resection , produ cin g an accu rate am ou n t o sh orten in g ( b ). In appropriate cases, th e DRUJ can be realign ed. A straigh t plate is u sed to stabilize th e osteotom y. Altern atively, an obliqu e osteotom y creates a larger su r ace area or bon e u n ion an d also stabilizes rotation o th e ragm en ts, preven tin g a rotation al m alu n ion ( c ). An obliqu e osteotom y also h as advan tages in applyin g in tern al xation . A straigh t plate is again u sed to stabilize th e osteotom y bu t w ith a lag screw bein g passed perpen dicu larly across th e osteotom y site. An obliqu e osteotom y w as ch osen or th is patien t.

Ch o ice o f im p la n t

A lockin g com pression plate (LCP) u ln a osteotom y system 2.7 an d a straigh t plate can be u sed to create an exact preplan n ed am ou n t o sh orten in g an d to produ ce stable xation .

451

Pa rt II Case s

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

LCP u ln a osteotom y set LCP u ln a osteotom y plate 2.7 1.4 m m to 1.6 m m K-w ires Oscillatin g saw Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal u ln a an d radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.7-5

452

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

4

Su rgica l a p p ro a ch

Ap p ro a ch

Th e su rgical approach u sed w as an u ln ar approach (see ch apter 1.10 Uln ar approach to th e distal u ln a).

Fig 5.7-6

Th e approach w as m ade via a lon gitu din al in cision over th e distal su bcu tan eou s border o th e u ln a.

Fig 5.7-7

Th e f exor carpi u ln aris (FCU) is retracted toward th e radial side. Th is protects th e u ln ar n eu rovascu lar bu n dle an d reveals th e f at su r ace o th e distal u ln ar diaph ysis.

Fig 5.7-8

453

Pa rt II Case s

5

Re d u ct io n

In s e r t t h e s h o r t e n in g gu id e

a

b

c

d

Th e correct sh orten in g gu ide is selected based on th e plan n ed am ou n t o sh orten in g (2 m m in th is case). Th e sh orten in g block is placed on th e f attest part o th e distal u ln a ( a –b ). Th e gu ide is attach ed to th e distal u ln a u sin g K-wires th at m u st pen etrate both cortices ( c–d ). In traoperative x-rays are taken to en su re correct align m en t.

Fig 5.7-9a –d

454

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

5

Re d u ct io n (co n t )

Se le ct t h e cu t t in g b lo ck a n d a n gle a n d p e r fo rm t h e o s t e o t o m y

a

b

c

d

Th e appropriate cu ttin g block is selected (in th is case, an obliqu e osteotom y h ad been plan n ed) an d applied to th e sh orten in g gu ide ( a – b ). Th e preplan n ed osteotom y is m ade u sin g parallel saw blades o th e preselected size (2 m m ) ( c– d ). Th e saw blades m u st cu t th e ar cortex u lly to en able a n eat apposition o th e osteotom y su r aces.

Fig 5.7-1 0a –d

Th e slice o resected bon e w as excised an d th e gu ide block w as th en rem oved.

Fig 5.7-1 1

455

Pa rt II Case s

6

Fixa t io n

Se le ct a n d in s e r t t h e p la t e

a

b

c

Th e plate is selected an d in trodu ced over th e K-w ires an d pu sh ed dow n on to th e su r ace o th e bon e ( a –b ). Rotation al align m en t is m ain tain ed by virtu e o th e K-w ires ( c ).

Fig 5.7-1 2a –c

In s e r t s cre w s

a Fig 5.7-13a –b

456

b

Th e im plan t m u st be stabilized by sequ en tially rem ovin g each K-wire an d replacin g it with a cortex screw.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

6

Fixa t io n (co n t )

a

b

Tw o distal screw s w ere in serted rst, w h ich secu red th e align m en t o th e plate on to th e bon e su r ace ( a ). Be ore rem ovin g th e proxim al K-w ire, a plate redu ction clam p w as applied to tem porarily stabilize th e position o th e im plan t on th e proxim al part o th e osteotom y ( b ).

Fig 5.7-1 4a –b

Th e proxim al screw w as in serted an d tigh ten ed an d th e osteotom y gap closes in to com pression . It is critical to com press in to th e axilla o th e obliqu e osteotom y or stability.

Fig 5.7-1 5

457

Pa rt II Case s

6

Fixa t io n (co n t )

In s e r t la g s cre w

a

b

c

A cortex screw is in serted th rou gh th e plate as a lag screw to u rth er com press th e osteotom y an d im prove its stability.

Fig 5.7-16a –c

In s e r t lo ck in g s cre w s

a Fig 5.7-1 7a –b

458

b

Lockin g screw s are in serted at each en d o th e im plan t on ce u ll com pression h as been ach ieved.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

6

Fixa t io n (co n t )

a

b

c

Intraoperative images con rmed th e correct placemen t o th e implan t and correct len gth o th e lag screw. Veri cation o the amou n t o u ln ar sh orten ing ach ieved sh ould be per ormed.

Fig 5.7-18a –c

Dis t a l ra d io u ln a r jo in t a s s e s s m e n t

a

b

A ter xation , th e DRUJ sh ou ld be assessed or both orearm rotation an d stability. Th e m eth ods or determ in in g i DRUJ in stability exists are sh ow n in th e xation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.7-1 9a –b

459

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.7-20

8

Ou t co m e

a

b

At th e 6-m on th ollow-u p, th e x-ray an d CT scan im ages con rm ed radiological u n ion .

Fig 5.7-21a –b

460

a

b

c

d

Th e patien t h ad obtain ed excellen t ran ge o m otion , an d with th e u ln a/ lu n ate abu tm en t resolved, was pain ree.

Fig 5.7-22a –d

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

8

Ou t co m e (co n t )

Th is video dem on strates an u ln ar sh a t treated w ith an obliqu e sh orten in g osteotom y u sin g th e LCP u ln a osteotom y system 2.7.

Vid e o 5 .7 -1

9

Alt e rn a t ive t e ch n iq u e 1

Uln a r s h o r t e n in g u s in g a s t a n d a rd d yn a m ic co m p re s s io n p la t e

a

b

A stan dard dyn am ic com pression plate (DCP) or lim ited con tact LC-DCP 3.5 can be u sed in stead o th e u ln ar sh orten in g system . Th e osteotom y is created reeh an d, eith er tran sverse or (as sh ow n h ere) obliqu ely. Th e im plan t m u st be preben t to produ ce com pression on th e ar cortex an d an obliqu e osteotom y m u st be plan n ed so th at com pression can occu r in to th e axilla.

Fig 5.7-2 3a –b

461

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e 2 Me t a p h ys e a l u ln a r s h o r t e n in g u s in g a d is t a l u ln a p la t e

a

b

c

d

Th e prin ciple an d altern ative tech n iqu es described in th is ch apter so ar h ave in volved osteotom ies in th e diaph ysis, wh ere cortical bon e is th ick an d can cellou s su r ace area is lim ited. Con sequ en tly, h ealin g can be slow. Yet, th e distal u ln ar m etaph ysis h as a large can cellou s su r ace area with th in cortical bon e, an d so a m ore distally placed osteotom y sh ou ld h eal m ore qu ickly as a resu lt.

Fig 5.7-24a –d

A 39-year-old m ach in e operator with lon g stan din g pain at th e u ln ar side o th e le t wrist h ad u n dergon e u n su ccess u l n on operative treatm en t. Th e 2-D an d 3-D CT scan s sh owed th e in con gru ity o th e distal u ln ar join t ( a –b ). Bon e scan s sh owed in creased u ptake o tech n etiu m n u cleotide (an d th ere ore abn orm alities) arou n d th e DRUJ ( c–d ).

462

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

10 Alt e rn a t ive t e ch n iq u e 2 (co n t ) Se le ct t h e p la t e

De t e rm in e t h e le ve l o f va ria n ce

2 mm

a

b

Fig 5.7-25a –b

As selected or th is patien t, th e distal u ln a (h ook) plate, with its lockin g screws on both sides o th e osteotom y (wh ich is created reeh an d in eith er a tran sverse or obliqu e ash ion ), provides excellen t stability or th is m ore distally placed procedu re.

Fig 5.7-2 6

Th e rst step is to assess an d determ in e th e level o varian ce. For th is patien t th ere w as 2 m m o positive u ln ar varian ce.

Ap p ly t h e p la t e

Pe r fo rm t h e o s t e o t o m y

2 mm

Th e plate is applied w ith th e h ook over th e u ln ar styloid, an d tem porary xation is m ade w ith tw o screw s in to th e u ln ar h ead.

Fig 5.7-2 7

Th e plate an d screws are rem oved an d a 2 m m wa er o bon e is resected rom th e distal u ln ar m etaph ysis.

Fig 5.7-28

463

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e 2 (co n t ) Re a p p ly t h e p la t e

a

b

In traoperative im ages sh ow th e 2 m m w a er bein g created an d rem oved, revealin g th e site o th e osteotom y.

Fig 5.7-2 9a –b

a

Fig 5.7-3 0

Th e plate an d distal screw s are reapplied.

b

Usin g a drill gu ide as a h an dle, th e plate can be m oved proxim ally an d th e osteotom y site an d u ln a, redu ced.

Fig 5.7-3 1a –b

464

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .7 Malunite d fracture with associate d ulnar abutme nt syndrome tre ate d with an ulnar shortening oste otomy

10 Alt e rn a t ive t e ch n iq u e 2 (co n t ) In s e r t p ro xim a l s cre w s

a Fig 5.7-3 2

Th e proxim al screw s are placed, w ith axial com pression applied th rou gh th e plate.

Fig 5.7-33a –b

Op t io n : o b liq u e o s t e o t o m y

Ou t co m e

a

b

As a u rth er option , th e procedu re can be per orm ed with an obliqu e osteotom y ( a ), allowin g or th e placem en t o a lag screw to provide addition al su pport ( b ).

Fig 5.7-34a –b

b

Th e u ln a plate an d screws are n ow secu red with th e osteotom y site placed u n der com pression .

a

b

By th e 3-m on th ollow-u p a ter su rgery, com plete u n ion h ad been ach ieved.

Fig 5.7-35a –b

465

Pa rt II Case s

10 Alt e rn a t ive t e ch n iq u e 2 (co n t )

a

b

c

d

Fig 5.7-36a –d

466

Th e patien t h ad ach ieved a u lly u n ction al recovery with ou t pain .

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.8

1

Long-standing nonunion treated with resection of the distal ulna and double plating of the radius

Ca s e d e s crip t io n

a

b

c

A 67-year-old retired m an h ad a lon g-stan din g extraarticu lar n on u n ion o h is righ t distal radiu s, w ith obviou s de orm ity. Clin ical im ages an d x-rays dem on strated sh orten in g, an gu lation , an d th e su ggestion o syn ovial pseu darth rosis. Th e patien t w as previou sly told n oth in g cou ld be don e, yet on goin g in stability, de orm ity, an d pain orced h im to con tin u e to seek m edical advice.

Fig 5 .8 -1a –c

467

Pa rt II Case s

2

In d ica t io n s

No n u n io n o f t h e d is t a l ra d iu s

a

b PA vie w

AP vie w

Failu re to ach ieve u n ion ollow in g a distal radial ractu re is exceedin gly u n com m on . Failed in tern al xation , in ection , or Ch arcot arth ropath y are am on g th e m ost likely cau ses. I u n treated, du e to its proxim ity to th e radiocarpal join t, th ere is a poten tial or th e n on u n ion to develop in to a m obile pseu darth rosis addin g to th e com plexity o an y recon stru ction . Fu rth erm ore, th e lim ited size o th e distal m etaph yseal an d articu lar com pon en t as w ell as th e likelih ood o associated disu se osteoporosis presen ts a de n ite ch allen ge to ach ievin g stable in tern al xation an d u ltim ate u n ion .

Fig 5.8-2a –b

Dis t a l u ln a re s e ctio n

Wh ile preservation o th e distal radiou ln ar join t (DRUJ) is h elp u l or both m otion an d stability, w ith lon g-stan din g n on u n ion s su ch as w ith th is low -dem an d patien t, len gth discrepan cy an d posttrau m atic DRUJ arth rosis m ay requ ire resection o th e distal u ln a, w h ich can provide local bon e gra t m aterial.

468

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .8 Long-standing nonunion tre ate d with re se ction of the distal ulna and double plating of the radius

2

In d ica t io n s (co n t )

Ch o ice o f im p la n t

a

b

Palmar plate

2-column plate

c Volar column plate

d Radial column plate

Given a n on u n ion to su ch an exten t alon g a patien t’s distal radial sh a t, lon ger an gu lar stable plates an d plates with larger m u ltiple-h ole h eads an d variable an gle (VA) lockin g screw option s sh ou ld be con sidered to h elp with stability. For added stability, in sertion o a radial colu m n plate is also recom m en ded.

Fig 5.8-3a –d

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t

• • • • • • •

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

A palm ar lockin g plate w ith lon ger sh a t Radial colu m n plate 2.4 1.4 m m to 1.6 m m K-w ires Sm all extern al distractor Au togen ou s bon e gra t or bon e su bstitu te Oscillatin g saw Im age in ten si er

Position th e patien t su pin e an d place th e orearm on a h an d table. Su pin ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.8-4

469

Pa rt II Case s

4

Su rgica l a p p ro a ch

Ap p ro a ch e s

a

b

Th e in itial su rgical approach u sed w as a m odi ed Hen ry palm ar approach (see Ch apter 1.6 Modi ed Hen ry palm ar approach to th e distal radiu s). Th is w as ollow ed by an u ln ar approach to th e u ln a (see ch apter 1.10 Uln ar approach to th e distal u ln a).

Fig 5 .8 -5 a –b

a

b

Th e distal radiu s w as approach ed th rou gh th e m odi ed Hen ry palm ar in cision . Th e f exor carpi radialis (FCR) ten don w as iden ti ed ( a ). Th e con tracted FCR ten don w as section ed ollow ed by th e ten don o th e brach ioradialis ( b ).

Fig 5.8-6 a – b

Th e secon d in cision w as th en per orm ed based alon g th e u ln a. Th is allow ed th e u ln a to be osteotom ized.

Fig 5.8-7

470

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .8 Long-standing nonunion tre ate d with re se ction of the distal ulna and double plating of the radius

4

Su rgica l a p p ro a ch (co n t )

Uln a r o s t e o t o m y

a

b

Measu re an d rem ove a section o u ln a to create equ al len gth alon g th e radiu s an d u ln a. Th e resected bon e m aterial is th en able to be u sed or bon e gra t m aterial later on .

Fig 5.8-8 a – b

5

Re d u ct io n

In s e r t e xt e rn a l fixa t io n p in s

a

b

Tw o sm all th readed extern al distractor pin s/ K-w ires are in serted to be u sed as joysticks, w ith on e pin in th e distal radial m etaph ysis an d on e in th e proxim al sh a t.

Fig 5.8-9 a – b

471

Pa rt II Case s

5

Re d u ct io n (co n t )

a

b

Th e n on u n ion is th en realign ed an d th e position secu red w ith th e sm all distractor ( a ). Debridem en t o th e n on u n ion requ ired rem oval o th e syn ovial m em bran e ( b ).

Fig 5.8-1 0a –b

In s e r t t h e b o n e gra ft

On ce realign ed, prepare an d in sert th e bon e gra t obtain ed rom th e u ln ar osteotom y.

Fig 5.8-1 1

472

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .8 Long-standing nonunion tre ate d with re se ction of the distal ulna and double plating of the radius

6

Fixa t io n

Pa lm a r p la t e fixa t io n

a

b

Fixation o th e distal radiu s sh ou ld be per orm ed with an appropriate palm ar plate. Th e u su al steps in volve selectin g an appropriate plate based on th e con gu ration o th e n on u n ion , in sertin g distal screws, in sertin g proxim al screws, an d in traoperative im agin g.

Fig 5.8-12a –b

Ra d ia l co lu m n p la t e fixa t io n

Th is is ollow ed by in sertion o a radial colu m n plate or u rth er stability. Th e steps in volve selectin g, con tou rin g, an d applyin g th e plate, stabilizin g th e radial colu m n , an d in sertin g proxim al an d distal screw s.

Fig 5.8-1 3

473

Pa rt II Case s

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.8-14

8

Ou t co m e

a

b

At th e 6-m on th ollow-u p, x-rays sh owed u n ion o th e distal radiu s with restoration o a m ore n orm al align m en t.

Th e x-ray at 3 years postoperatively sh ow ed com plete h ealin g.

Fig 5.8-15a –b

a

Fig 5.8-1 6

b

Th e resu lt was th at th e patien t h ad a stable an d well-align ed orearm an d wrist. Despite m an y previou s years o dys u n ction , h is h an d u n ction h ad n ow retu rn ed with good stren gth an d n orm al sen sation .

Fig 5.8-17a –b

474

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5.9

1

Chronic intercarpal arthritis treated with scaphoid resection and 4 -corner fusion

Ca s e d e s crip t io n

a

b

a

A 42-year-old m ale jew elry sh op ow n er an d design er ell on h is ou tstretch ed w rist bu t did n ot seek treatm en t u n til 1 year later, w h en h e h ad persisten t pain an d lim itation o w rist m obility. Th e x-rays sh ow ed eviden ce o osteoarth ritic ch an ges in th e radioscaph oid join t an d a scaph oid ractu re n on u n ion .

Fig 5.9-1a – b

a

b

Coron al view CT scan s revealed lon g-stan din g scaph oid n on u n ion with in tercarpal an d radiocarpal arth ritis, or “SNAC” wrist.

Fig 5.9-3a –b

b

Th e sagittal CT scan s sh ow ed carpal collapse, de orm ity, an d sh orten in g o th e scaph oid, w h ile osteoarth ritic ch an ges w ere also eviden t.

Fig 5.9-2 a – b

a

b

Th e MRI sh ow ed cartilage loss at th e radioscaph oid join t. Treatm en t in volvin g ou r-corn er u sion w as o ered as a salvage procedu re.

Fig 5.9-4 a – b

475

Pa rt II Case s

2

In d ica t io n s

In t e rca rp a l o s t e o a r t h rit is a n d t h e SLAC/ SNAC w ris t

SNAC SLAC

a

b Norm al

c SLAC

SNAC

It h as already been sh ow n in th is pu blication th at scaph oid ractu res an d su rrou n din g ligam en t dam age are com m on , an d du e to a w ide variety o actors, can ail to h eal. Th e resu lt can be especially problem atic w h en th e scaph oid in ju ry is n ot in itially diagn osed or w h en th e patien t ails to seek im m ediate m edical treatm en t. Poten tial resu lts rom su ch situ ation s in clu de n ecrosis an d n on u n ion , bu t it can also lead to con dition s su ch as scaph olu n ate advan ced collapse (SLAC) an d scaph oid n on u n ion advan ced collapse (SNAC), w h ich are orm s o osteoarth ritis greatly a ectin g w rist u n ction . Typically, both con dition s resu lt in loss o w rist m obility, sw ellin g in th e in tercarpal join ts, distortion o th e sh ape o th e scaph oid, ch an ge to join t kin em atics, an d pain . For m an y patien ts, su rgical salvage procedu res provide an e ective treatm en t option .

Fig 5.9-5 a – c

476

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

2

In d ica t io n s (co n t )

Cla s s ifica t io n o f s ca p h o id n o n u n io n a d va n ce d co lla p s e

a

b

c

d

Th e ou r stages o scaph oid n on u n ion advan ced collapse are as ollows: I: Arth ritis at th e radial styloid II: Arth ritis o th e scaph oid ossa III: Arth ritis o th e capitolu n ate/ m idcarpal join t IV: Di u se arth ritis o th e carpu s.

Fig 5.9-6a –d a b c d

Stage Stage Stage Stage

Sym ptom atic wrist dys u n ction o an y etiology can requ ire recon stru ction an d salvage procedu res are requ en tly th e on ly way to o er th e patien t a stable pain - ree wrist. A n u m ber o su rgical option s th at ideally preserve m otion an d avoid com plication s in th e lon g term can be con sidered: • Lim ited wrist arth rodesis • Proxim al row carpectom y • Arth roplasty • Total wrist arth rodesis.

477

Pa rt II Case s

2

In d ica t io n s (co n t )

Lim it e d w ris t a r t h ro d e s is w it h fo u r-co rn e r fu s io n

Ch o ice o f im p la n t

Fou r-corn er u sion is per orm ed w ith an in tercarpal u sion plate (dorsal circu lar plate or spider plate). It allow s variable an gle (VA) screw in sertion an d can be adapted to th e speci c an atom y o th e patien t.

Fig 5.9-8

Fou r-corn er u sion is a lim ited w rist arth rodesis treatm en t provided to th ose w ith advan ced degen erative ch an ges in th e w rist w h ere th e carpals are u sed (eg, th e lu n ate, capitate, triqu etru m , an d h am ate bon es). As it in volves on ly partial u sion , it preserves lim ited m otion w h ile allow in g pain redu ction rom th e a ected join ts. Th e “ ou r corn ers” o th e carpal bon es are attach ed by an in tercarpal u sion plate, w h ile th e scaph oid is partially or u lly resected.

Fig 5.9-7

478

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

3

Pre o p e ra t ive p la n n in g

Eq u ip m e n t lis t

• • • • • • •

Pa t ie n t p o s it io n in g

VA lockin g in tercarpal u sion system In tercarpal u sion plate 1.1 m m or 1.2 m m K-w ires 1.4 m m to 1.6 m m K-w ires Bon e n ibbler/ ron geu r Osteotom e Im age in ten si er

Position th e patien t su pin e an d place th e orearm on th e h an d table. Pron ate th e orearm . Th e position o th e lim b sh ou ld allow com plete im agin g in th e ron tal an d sagittal plan e o th e distal radiu s. A n on sterile pn eu m atic tou rn iqu et is u sed. Proph ylactic an tibiotics are option al.

Fig 5.9-9

4

Su rgica l a p p ro a ch

Ap p ro a ch

a

b

Du e to th e speci c n atu re o th e in ju ry, th e su rgical approach u sed w as a dorsal approach to th e carpu s (see ch apter 1.3 Com bin ed approach to th e lu n ate an d perilu n ate in ju ries, h ow ever in th is case, on ly th e dorsal approach w as requ ired). Th is approach in volves a radially based capsu lar ligam en tou s f ap to be elevated an d a capsu lotom y in cision .

Fig 5 .9 -1 0 a – b

479

Pa rt II Case s

4

Su rgica l a p p ro a ch (co n t )

a

b

Th e approach was m ade over th e th ird com partm en t by in cisin g th e exten sor retin acu lu m over th e exten sor pollicis lon gu s (EPL) ten don . Th e EPL ten don was released an d retracted radially, togeth er with th e exten sor ten don s o th e secon d com partm en t.

Th e posterior in terosseou s n erve was iden ti ed an d resected to partially den ervate th is area o th e wrist to h elp lim it postoperative pain .

Fig 5.9-11a –b

a

Fig 5.9-12

b

In traoperative ph otos sh ow th e radially based capsu lar ligam en tou s f ap preservin g th e radiolu n otriqu etal ligam en t ( a ). Th e capsu lar f ap was elevated by sh arp dissection in an u ln ar to radial direction ( b ).

Fig 5.9-13a –b

480

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

4

Su rgica l a p p ro a ch (co n t )

S

R C

L

T

H

Th e carpal bon es were th en exposed an d iden ti ed (S=scaph oid, C=capitate, H=h am ate, T=triqu etru m , L=lu n ate; with R=radiu s).

Fig 5.9-14

Excis e t h e s ca p h o id

a

b

Becau se o th e ch ron ic n on u n ion an d su rrou n din g arth ritic ch an ges th e rst part o th is procedu re w as to com pletely rem ove th e scaph oid. Particu lar care m u st be taken to preserve th e palm ar radioscaph ocapitate ligam en t. In som e in stan ces, th e excised scaph oid can provide som e au togen ou s bon e gra t m aterial.

Fig 5.9-1 5a – b

481

Pa rt II Case s

5

Re d u ct io n

Re d u ce ro t a t io n a l d e fo rm it y a n d p ro vis io n a lly fix t h e ca rp a l b o n e s

a

b

Usin g a th icker joystick K-w ire, th e dorsif exion o th e lu n ate is corrected an d stabilized by bein g in trodu ced th rou gh th e capitate to align th e radiu s, th e lu n ate, an d th e capitate in n eu tral position .

Fig 5.9-16a –c

c

a Fig 5.9-17a –b

482

b

In traoperative im ages sh ow th e K-wire in place.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

5

Re d u ct io n (co n t )

De b rid e t h e m id ca rp a l jo in t

a

b

Usin g a sm all ron geu r an d osteotom e, th e cartilage o th e m idcarpal join t is rem oved to expose th e su bch on dral bon e (debride th e m idcarpal join t) ( a ). Make su re th at sclerotic an d den se su bch on dral bon e is rem oved dow n to can cellou s bon e ( b ). Preparation o th e join t su r aces betw een th e capitate/ h am ate an d lu n ate/ triqu etru m is option al or m ay be carried ou t a ter provision al xation . Excessive rem oval o bon e sh ou ld be avoided oth erw ise th e sh ape o th e carpu s w ill be m odi ed.

Fig 5.9-1 8a –b

6

Fixa t io n

Se le ct fixa t io n m e t h o d a n d p la t e

To ach ieve u sion o th e m idcarpal join t, th e VA lockin g in tercarpal u sion system was u sed (sh own with th e plate in serted), wh ich is a variable an gle lockin g tech n ology or m idcarpal lim ited arth rodesis. Appropriate plate size is ch osen u sin g th e im age in ten si er an d it can also be u sed to veri y correct align m en t o th e carpal bon es.

Fig 5.9-19

483

Pa rt II Case s

6

Fixa t io n (co n t )

Po s it io n re a m in g gu id e

a

b

To begin , ch oose th e ream in g gu ide accordin g to th e selected plate an d x it tem porarily w ith at least on e 1.1 m m / 1.2 m m K-w ire per carpal bon e over th e cen ter o th e ou r-bon e ju n ction ( a ). I n ecessary, rem ove th e palm ar lu n ocapitate K-w ire to avoid later in ter eren ce w ith th e ream er ( b ).

Fig 5.9-2 0a –b

a

b

Th e h an dle o th e ream in g gu ide sh ou ld be in lin e w ith th e radial sh a t ( a ). Th e ream in g gu ide w as tem porarily xed w ith K-w ires over th e cen ter o th e ou r-bon e ju n ction ( b ).

Fig 5.9-2 1a –b

484

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

6

Fixa t io n (co n t )

Op t io n a l in s t ru m e n t : re d u ct io n re a m in g gu id e

Re a m p la t e re ce s s

Use th e redu ction ream in g gu ide i redu ction o th e carpal bon es is requ ired. Th is particu lar ream in g gu ide h as o set eet to allow it to sit com ortably on th e carpu s. I th is gu ide is u sed, its h an dle m u st be located on th e radial side o th e carpu s w h en , as in th is case, a righ t w rist is bein g treated an d on th e u ln ar side o th e carpu s w h en a le t w rist is bein g treated.

Fig 5.9-2 3

Fig 5.9-2 2

Ch oose th e ream er correspon din g to th e (redu ction ) ream in g gu ide. Ream th rou gh th e ream in g gu ide to th e rst laser m arkin g lin e.

Ap p ly t h e p la t e

Use th e plate h older to pick u p th e appropriately sized plate. Position th e plate th rou gh th e redu ction ream in g gu ide.

Fig 5.9-24

485

Pa rt II Case s

6

Fixa t io n (co n t ) Fix p la t e w it h lo ck in g s cre w s

Th e plate w as in serted as sh ow n . Ch eck or su cien t ream in g depth by trial placem en t o th e plate, en su rin g th at th e plate edge does n ot project beyon d th e bon e at an y poin t. It is critically im portan t to en su re th e plate edge does n ot project beyon d th e proxim al m argin o th e ream ed de ect oth erw ise w rist exten sion w ill be blocked by im plan t im pin gem en t.

Fig 5.9-2 5

Start plate xation w ith th e placem en t o VA lockin g screw s in th e lu n ate. Use th e variable an gle part o th e drill gu ide 1.8 (see m arkin g “VARIABLE ANGLE”) an d u lly in sert it in to th e lockin g h ole. Drill th e h ole w ith th e 1.8 m m drill bit at th e desired an gle.

Fig 5.9-2 6

Me a s u re s cre w le n g t h u s in g t h e d e p t h ga u ge

a

b

In sert lockin g screw s u sin g th e T8 screw driver sh a t w ith stardrive attach ed to th e h an dle w ith qu ick cou plin g. At least tw o screw s sh ou ld be placed in th e lu n ate.

Fig 5.9-2 7a –b

486

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

6

Fixa t io n (co n t )

Bo n e gra ft

Fill th e space between th e ou r bon es with au togen ou s bon e gra t taken rom th e excised scaph oid, or rom th e iliac crest or Lister tu bercle. As an altern ative, bon e gra t can be placed be ore th e plate is in serted.

Fig 5.9-28

7

Re h a b ilit a t io n

Aft e rca re , fo llo w -u p , a n d fu n ct io n a l e xe rcis e s

Th e patien t sh ou ld receive th e stan dard postoperative rest, in ju ry elevation , ollow -u p, rem oval o stitch es, an d im m obilization as requ ired. Follow in g su rgery, begin active con trolled ran ge o m otion exercises. For u rth er in orm ation , see th e reh abilitation topic in ch apter 4.1 Radial styloid— ractu re treated w ith a radial colu m n plate.

Fig 5.9-29

487

Pa rt II Case s

8

Ou t co m e

a

b

Th e 3-m on th ollow -u p x-rays sh ow ed th at u sion w as ach ieved.

Fig 5.9-3 0a –b

a

b

c

d

At th e 1-year ollow -u p th ere w as com plete resolu tion o pain an d a u n ction al ran ge o m otion bu t w ith som e lim itation o f exion an d exten sion .

Fig 5.9-3 1a –d

488

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

5 Re constructions and tre atment of complications 5 .9  Chronic inte rcarpal arthritis tre ate d with scaphoid re se ction and 4 -corne r fusion

8

Ou t co m e

Vid e o

Th is video dem on strates a m idcarpal w rist u sion u sin g th e VA lockin g in tercarpal u sion system .

Vid e o 5 .9 -1

489

Pa rt II Case s

490

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Appendix

492

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Furthe r re ading

Further reading Ca rp a l in ju rie s Ad k is o n JW, Ch a p m a n MW. Treatm en t o

acu te lu n ate an d perilu n ate d islocation s. Clin Orthop Relat Res. 1982;199 –207. Ba in GI, McLe a n JM, Tu rn e r PC, e t a l . Tran slu n ate ractu re w ith associated perilu n ate in ju ry: 3 case reports w ith in trodu ction o th e tran slu n ate arc con cept. J Hand Surg Am. 2008;33:1770 –1776. Bla za r PE, Mu rra y P. Treatm en t o perilu n ate d islocation s by com bin ed dorsal an d palm ar approach es. Tech Hand Up Extrem Surg. 2001;5:2–7. Ca p o JT, Co rt i SJ, Sh a m ia n B, e t a l . Treatm en t o dorsal perilu n ate d islocation s an d ractu re-d islocation s u sin g a stan dardized protocol. Hand N Y. 2012;7:380 –387. Fe n t o n RL. Th e n avicu lo-capitate ractu re syn drom e. J Bone Joint Surg Am. 1956;38A:681–68 4. Fo rli A, Co u r vo is ie r A, Wim s e y S, e t a l . Perilu n ate d islocation s an d tran sscaph oid perilu n ate ractu re-d islocation s: a retrospective stu dy w ith m in im u m ten -year ollow-u p. J Hand Surg Am. 2010;35:62 –68. Gilu la LA, De s t o u e t JM, We e k s PM, e t a l . Roen tgen ograph ic d iagn osis o th e pain u l w rist. Clin Orthop Relat Res. 198 4;52 –64. Gra h a m TJ. Th e in erior arc in ju ry: an add ition to th e am ily o com plex car pal ractu re-d islocation pattern s. Am J Orthop (Belle Mead NJ). 20 03;32:10 –19. Gre e n DP. Th e e ect o avascu lar n ecrosis on Ru sse bon e gra tin g or scaph oid n onu n ion . J Hand Surg Am. 1985;10:597–605. Ha d d a d FS, Go d d a rd NJ. Acu te percu tan eou s scaph oid xation : a pilot stu dy. J Bone Joint Surg. 1998;80:95 –99. He rb e rt TJ, Fis h e r WE. Man agem en t o th e ractu red scaph oid u sin g a n ew bon e screw. J Bone Joint Surg. 1984;66(1):114 –123. He rzb e rg G . Acu te dorsal tran s-scaph oid perilu n ate dislocation s: Open redu ction an d in tern al xation . Tech Hand Up Extrem Surg. 2000;4:2–13. He rzb e rg G, Co m t e t JJ, Lin s ch e id RL, e t a l . Perilu n ate d islocation s an d ractu redislocation s: a mu lticen ter stu dy. J Hand Surg Am. 1993;18:768 –779. He rzb e rg G, Fo ris s ie r D. Acu te dorsal tran s-scaph oid perilu n ate ractu redislocation s: m ed iu m -term resu lts. J Hand Surg. 2002;27:498 –502. Hild e b ra n d KA, Ro s s DC, Pa t t e rs o n SD, e t a l . Dorsal perilu n ate d islocation s an d

ractu re-d islocation s: qu estion n aire, clin ical, an d rad iograph ic evalu ation . J Hand Surg Am. 2000;25:1069 –1079.

In o u e G, Ku w a h a t a Y. Man agem en t o

Min a m i A, Ka n e d a K. Repair an d/or

acu te perilu n ate d islocation s w ith ou t ractu re o th e scaph oid. J Hand Surg. 1997;22:6 47–652. In o u e G, Sh io n o ya K. Herbert screw xation by lim ited access or acu te ractu res o th e scaph oid. J Bone Joint Surg. 1997;79:418 –421. In o u e G, Sh io n o ya K, Ku w a h a t a Y. Herbert screw xation or scaph oid n on u n ion s. An an alysis o actors in f u en cin g ou tcom e. Clin Orthop Relat Res. 1997 Oct;343:99 –106. Jira n e k WA, Ru b y LK, Mille n d e r LB, e t a l . Lon g-term resu lts a ter Ru sse bon egra tin g: th e e ect o m alu n ion o th e scaph oid. J Bone Joint Surg Am. 1992;74:1217–1228. Jo h n s o n RP. Th e acu tely in ju red w rist an d its residu als. Clin Orthop Relat Res. 1980;33 –4 4. Jo n e s DB Jr, Bü rge r H, Bis h o p AT, e t a l . Treatm en t o scaph oid waist n on u n ion s w ith an avascu lar prox im al pole an d car pal collapse. A com parison o two vascu larized bon e gra ts. J Bone Joint Surg Am. 2008;90:2616 –2625. Ju p it e r JB, Nu n e z FA Jr, Nu n e z F, e t a l . Cu rren t perspective on com plex w rist ractu re-d islocation . Instr Course Lect. 2018;67:155 –174. Ka rd a s h ia n G, Ch ris t o fo ro u DC, Le e SK. Perilu n ate dislocation s. Bull N Y U Hosp Jt Dis. 2011;69:87–96. Kn o ll VD, Alla n C, Tru m b le TE. Tran sscaph oid perilu n ate ractu re d islocation s: resu lts o screw xation o th e scaph oid an d lu n otr iqu etral repair w ith a dorsal approach . J Hand Surg Am. 2005; 30:1145 –1152. Ko m u rcu M, Ku rk lu M, Ozt u ra n KE, e t a l . Early an d delayed treatm en t o dorsal tran sscaph oid perilu n ate ractu red islocation s. J Orthop Trauma. 2008;22:535 –54 0. Kre m e r T, We n d t M, Rie d e l K, e t a l . Open redu ction or perilu n ate in ju ries—clin ical ou tcom e an d patien t satis action . J Hand Surg Am. 2010;35:1599 –1606. Krie f E, Ap p y-Fe d id a B, Ro t a ri V, e t a l . Resu lts o perilu n ate d islocation s an d perilu n ate ractu re d islocation s w ith a m in im u m 15-year ollow-u p. J Hand Surg Am. 2015;40:2191–2197. Ma ck GR, Bo s s e MJ, Ge lb e rm a n RH, e t a l . Th e n atu ral h istory o scaph oid n on -u n ion . J Bone Joint Surg Am. 198 4;66:50 4 –509. Ma y e ld JK, Jo h n s o n RP, Kilco yn e RK. Car pal d islocation s: path om ech an ics an d progressive perilu n ar in stability. J Hand Surg Am. 1980;5:226 –241. Me rre ll GA, Wo lfe SW, Sla d e JF III. Treatm en t o scaph oid n on u n ion s: qu an titative m eta-an alysis o th e literatu re. J Hand Surg Am. 2002;27:685 –691.

recon stru ction o scaph olu n ate in terosseou s ligam en t in lu n ate an d perilu n ate dislocation s. J Hand Surg Am. 1993;18:1099 –1106. Na ka m u ra R, Ho rii E, Wa t a n a b e K, e t a l . Prox im al row car pectom y versu s lim ited w rist arth rodesis or advan ced Kien bock’s d isease. J Hand Surg. 1998;23:741–745. Nu n e z FA Jr, Lu o TD, Ju p it e r JB, e t a l . Scaph ocapitate syn d rom e w ith associated tran s-scaph oid, tran s-h am ate perilu n ate d islocation . Hand. 2016;12(2):27-31. Ro b b in s RR, Ca r t e r PR. Iliac crest bon e gra tin g an d Herbert screw xation o n onu n ion s o th e scaph oid w ith avascu lar prox im al poles. J Hand Surg Am. 1995;20:818 –831. Ru s s e O . Fractu res o th e car pal n avicu lar. J Bone Joint Surg Am. 1960;42:759 –768. Sca lcio n e LR, Gim b e r LH, Ho AM, e t a l . Spectru m o car pal dislocation s an d ractu re-dislocation s: im agin g an d m an agem en t. Am J Roentgenol. 2014;203:541–550. Sch u in d F, Ha e n t je n s P, Va n In n is F, e t a l . Progn ostic actors in th e treatm en t o car pal scaph oid n on u n ion s. J Hand Surg Am. 1999;24:761–776. Sh e e t z KK, Bis h o p AT, Be rge r RA. Th e arterial blood su pply o th e distal rad iu s an d u ln a an d its poten tial u se in vascu larized ped icled bon e gra ts. J Hand Surg Am. 1995;20:902 –914. So t e re a n o s DG, Mit s io n is GJ, Gia n n a ko p o u lo s PN, e t a l . Perilu n ate

d islocation an d ractu re dislocation : a critical an alysis o th e volar-dorsal approach . J Hand Surg Am. 1997;22:49 –56. So u e r JS, Ru t ge rs M, An d e rm a h r J, e t a l . Perilu n ate ractu re-d islocation s o th e w rist: com parison o tem porar y screw versu s K-w ire xation . J Hand Surg Am. 2007;32:318 –325. St ra w RG, Da vis TR, Dia s JJ. Scaph oid n on u n ion : treatm en t w ith a pedicled vascu larized bon e gra t based on th e 1,2 in tercom partm en tal su praretin acu lar bran ch o th e rad ial arter y. J Hand Surg. 2002;27:413 –416. Te is e n H, Hja rb a e k J. Classi cation o resh ractu res o th e lu n ate. J Hand Surg. 1988;13:458 –462. Tru m b le T. Fractu res an d d islocation s o th e car pu s. In : Tru m ble T, ed. Principles of Hand Surgery and Therapy. Ph iladelph ia: Sau n ders;2000:90 –125. Tru m b le T, Ve rh e yd e n J. Treatm en t o isolated perilu n ate an d lu n ate d islocation s w ith com bin ed dorsal an d volar approach an d in traosseou s cerclage w ire. J Hand Surg Am. 200 4;29:412 –417.

493

Appendix

Wo za s e k GE, Mo s e r KD. Percu tan eou s

Lin s ch e id RL, Do b yn s JH, Be a b o u t JW, e t a l .

screw xation or ractu res o th e scaph oid. J Bone Joint Surg. 1991;73;138 –142. Za id e m b e rg C, Sie b e rt JW, An grigia n i C. A n ew vascu larized bon e gra t or scaph oid n onu n ion . J Hand Surg Am. 1991;16:474 –478.

Trau m atic in stability o th e w rist: d iagn osis, classi cation , an d path om ech an ics. J Bone Joint Surg Am. 1972;54:1612 –1632. Ma y e ld JK, Jo h n s o n RP, Kilco yn e RK. Car pal d islocation s: path om ech an ics an d progressive perilu n ar in stability. J Hand Surg Am. 1980;5:226 –241. Min a m i A, Ka n e d a K. Repair an d/or recon stru ction o scaph olu n ate in terosseou s ligam en t in lu n ate an d perilu n ate d islocation s. J Hand Surg Am. 1993 Nov;18(6):1099 –1106.

Ca rp a l in sta b ilit y Allie u Y, Bra h in B, As ce n cio G . Car pal

in stabilities: radiological an d clin icopath ological classi cation . Ann Radiol. 1982;25:275 –287. Be rge r RA. Th e ligam en ts o th e w rist: a cu rren t overview o an atom y w ith con sideration s o th eir poten tial u n ction s. Hand Clin. 1997;13:63 –82. Bru n e lli GA, Bru n e lli GA. Car pal in stability w ith scaph o-lu n ate d issociation treated u sin g th e f exor car pi rad ialis an d scaph o-trapezoid ligam en t repair: ou n dation s, tech n iqu e an d resu lts o prelim in ary series. Rev Chir Orthop Reparatrice Appar Mot. 2003;89:152 –157. Co o n e y WP, Bu s s e y R, Do b yn s JH, e t a l . Di cu lt w rist ractu res: perilu n ate ractu re-d islocation s o th e w rist. Clin Orthop Rel Res. 1987;214:136 –147. Fe n t o n RL. Th e n avicu lo-capitate ractu re syn drom e. J Bone Joint Surg Am. 1956;38:681–68 4. Ga rcia -Elia s M, Llu ch AL, St a n le y JK. Th ree-ligam en t ten odesis or th e treatm en t o scaph olu n ate d issociation : in d ication s an d su rgical tech n iqu e. J Hand Surg Am. 20 06;31:125 –134. Ge is s le r WB, Fre e la n d AE, Sa vo ie FH, e t a l . In tracar pal so t-tissu e lesion s associated w ith an in tra-articu lar ractu re o th e distal en d o th e rad iu s. J Bone Joint Surg Am. 1996;78:357–365. Go ld fa rb CA, St e rn PJ, Kie fh a b e r TR. Palm ar m idcar pal in stability: th e resu lts o treatm en t w ith 4 -corn er arth rodesis. J Hand Surg Am. 2004;29:258 –263. Jo h n s o n RP. Th e evolu tion o car pal n om en clatu re: a sh ort review. J Hand Surg Am. 1990;15:834 –838. La rs e n CF, Am a d io PC, Gilu la LA, e t a l . An alysis o car pal in stability, I: description o th e sch em e. J Hand Surg Am. 1995;20:757–764. Lich t m a n DM, Bru ck n e r JD, Cu lp RW, e t a l . Palm ar m idcar pal in stability: resu lts o su rgical recon stru ction . J Hand Surg Am. 1993;18:307–315. Lich t m a n DM, Wro t e n ES . Un derstan din g m idcar pal in stability. J Hand Surg Am. 20 06;31:491–498. Lin s ch e id RL, Do b yn s JH . Treatm en t o scaph olu n ate d issociation . Hand Clin. 1992;8:6 45 –652.

494

Mit s u ya s u H, Pa t t e rs o n RM, Sh a h MA, e t a l . Th e role o th e dorsal in tercar pal

ligam en t in dyn am ic an d static scaph olu n ate in stability. J Hand Surg Am. 200 4;29:279 –288. Re t t ig ME, Ra s k in KB. Lon g-term assessm en t o proxim al row car pectom y or ch ron ic perilu n ate d islocation s. J Hand Surg Am. 1999;24:1231–1236. Rikli DA, Ho n igm a n n P, Ba b s t R, e t a l . In tra-articu lar pressu re m easu rem en t in th e rad iou ln ocar pal join t u sin g a n ovel sen sor: in vitro an d in vivo resu lts. J Hand Surg Am. 2007;32:67–75. Rit t MJPF, Lin s ch e id RL, Co o n e y WP, e t a l . Th e lu n otriqu etral join t: k in em atic e ects o sequ en tial ligam en t section in g, ligam en t repair, an d arth rodesis. J Hand Surg Am. 1998;23:432 –4 45. Sa ffa r P. Classi cation o car pal in stabilities. In : Bü ch ler U, ed. Wrist Instability. Lon don : Martin Du n itz;1996:29 –34. Sh in AY, We in s t e in LP, Be rge r RA, e t a l . Treatm en t o isolated in ju ries o th e lu n otriqu etral ligam en t: a com parison o arth rodesis, ligam en t recon stru ction an d ligam en t repair. J Bone Joint Surg. 2001;83:1023 –1028. Sie ge l JM, Ru b y LK. A critical look at in tercar pal arth rodesis: review o th e literatu re. J Hand Surg Am. 1996; 21:717–723. Ta le is n ik J. The Wrist. New York: Chu rch ill Livin gston e;1985. Vie ga s SF. Ligam en tou s repair ollow in g acu te scaph olu n ate d issociation . In : Gelberm an RH, ed. Master Techniques in Orthopedic Surgery: The Wrist. New York: Raven Press;1994:135 –146. Wa ls h JJ, Be rge r RA, Co o n e y WP. Cu rren t statu s o scaph olu n ate in terosseou s ligam en t in ju ries. J Am Acad Orthop Surg. 2002;10:32 –42. Wa t s o n HK, As h m e a d D IV, Ma k h lo u f MV. Exam in ation o th e scaph oid. J Hand Surg Am. 1988;13:657–660. Wa t s o n HK, We in zw e ig J, Ze p p ie ri J. Th e n atu ral progression o scaph oid in stability. Hand Clin. 1997;13:39 –49. Zd ra vko vic V, Se n n w a ld GR. A n ew rad iograph ic m eth od o m easu r in g car pal collapse. J Bone Joint Surg. 1997; 79:167–169.

Dista l ra d ia l inju rie s Co h e n MD, Ju p it e r JB. Fractu res o th e

d istal rad iu s. In : Brow n er BD, ed. Skeletal Trauma: Basic Science, Management, and Reconstruction. 4th ed. Ph iladelph ia: W B Sau n ders, 2009:1405 –1458. Du m o n t ie r C, Me ye r zu Re xke n d o rf G, Sa u t e t A, e t a l . Radiocar pal dislocation s:

classi cation an d proposal or treatm en t. A review o twen ty-seven cases. J Bone Joint Surg Am. 2001;83:212 –218. Fe rn a n d e z DL. Correction o post-trau m atic w rist de orm ity in adu lts by osteotom y, bon e-gra tin g, an d in tern al xation . J Bone Joint Surg Am. 1982;64:1164 –1178. Fe rn a n d e z DL. Fractu res o th e d istal rad iu s: operative treatm en t. Instr Course Lect. 1993;42:73 –88. Fe rn a n d e z DL, Rin g D, Ju p it e r JB. Su rgical m an agem en t o delayed u n ion an d n onu n ion o distal radiu s ractu res. J Hand Surg Am. 2001;26A:201–209. Go n g HS, Ch o HE, Kim J, e t a l . Su rgical treatm en t o acu te d istal radiou ln ar join t in stability associated w ith distal rad iu s ractu res. J Hand Surg Eur. 2015; 4 0:783 –789. Ha n e l DP, Lu TS, We il WM . Bridge platin g o d istal radiu s ractu res: th e Harbor view m eth od. Clin Orthop Relat Res. 2006;4 45:91– 99. Ja ko b M, Rik li DA, Re ga zzo n i P. Fractu res o th e d istal rad iu s treated by in tern al xation an d early u n ction . A prospective stu dy o 73 con secu tive patien ts. J Bone Joint Surg. 2000;82:340 –34 4. Ju p it e r JB, Rin g D. A com parison o early an d late recon stru ction o m alu n ited ractu res o th e distal en d o th e rad iu s. J Bone Joint Surg Am. 1996;78:739 –74 8. Ka rn e zis IA, Pa n a gio t o p o u lo s E, Tyllia n a k is , e t a l . Correlation between

radiological param eters an d patien t-rated w rist dys u n ction ollow in g ractu res o th e d istal radiu s. Injury. 2005;36:1435 –1439. Krä m e r S, Me ye r H, O’Lo u gh lin PF, e t a l . Th e in ciden ce o u ln ocar pal com plain ts a ter d istal rad ial ractu re in relation to th e ractu re o th e u ln ar styloid. J Hand Surg Eur. 2013;38:710 –717. La fo n t a in e M, Ha rd y D, De lin ce PH . Stability assessm en t o d istal rad iu s ractu res. Injury. 1989;20:208 –210. Le s lie BM, Me d o ff RJ. Fractu re speci c xation o distal rad iu s ractu res. Tech Orthop. 2000;15:336 –352. Lo za n o -Ca ld e ró n SA, Do o rn b e rg J, Rin g D. Fractu res o th e dorsal articu lar m argin o th e d istal part o th e rad iu s w ith dorsal radiocar pal su blu xation . J Bone Joint Surg Am. 2006;88:14 86 –1493. Ma cKe n n e y PJ, McQu e e n MM, Elt o n R. Pred iction o in stability in d istal rad iu s ractu res. J Bone Joint Surg Am. 20 06;88:194 4 –1951.

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Furthe r re ading

Me lo n e CP Jr. Articu lar ractu res o th e

distal rad iu s. Orthop Clin North Am. 198 4;15:217–236. Nu n e z FA Jr, Zh o n g yu L, Ca m p b e ll D, e t a l .

Distal u ln a h ook plate: an gu lar stable im plan t or xation o d istal u ln a. J Wrist Surg. 2013 Feb;2(1):87–92. Orb a y JL, Fe rn a n d e z DL. Volar xed-an gle plate xation or u n stable d istal rad iu s ractu res in th e elderly patien t. J Hand Surg Am. 2004;29:96 –102. Rik li DA, Re ga zzo n i P. Fractu res o th e distal en d o th e rad iu s treated by in tern al xation an d early u n ction . A prelim in ary report o 20 cases. J Bone Joint Surg. 1996;78(4):588 –592. Rin g D, Pro m m e rs b e rge r KJ, Go n zá le z d e l Pin o J, e t a l . Corrective osteotom y or

in tra-articu lar m alu n ion o th e distal part o th e rad iu s. J Bone Joint Surg Am. 20 05;87:1503 –1509. So u e r JS, Rin g D, Ma t s ch ke S, e t a l . E ect o an u n repaired ractu re o th e u ln ar styloid base on ou tcom e a ter platean dscrew xation o a d istal radial ractu re. J Bone Joint Surg Am. 2009; 91:830 –838. Ta le is n ik J, Wa t s o n HK. M idcar pal in stability cau sed by m alu n ited ractu res o th e distal radiu s. J Hand Surg Am. 198 4;9:350 –357. Ze n ke Y, Sa ka i A, Os h ige T, e t a l . Th e e ect o an associated u ln ar styloid ractu re on th e ou tcom e a ter xation o a ractu re o th e distal radiu s. J Bone Joint Surg. 2009; 91:102–107.

Co n s t a n t in e KJ, To m a in o MM, He rn d o n JH, e t a l . Com parison o u ln ar sh orten in g

osteotom y an d th e wa er resection procedu re as treatm en t or u ln ar im paction syn drom e. J Hand Surg Am. 2000;25:55 –60. Da rro w JC Jr, Lin s ch e id RL, Do b yn s JH, e t a l . Distal u ln ar recession or disorders o

th e distal rad iou ln ar join t. J Hand Surg Am. 1985;10:4 82-491. Eke n s t a m F, Ha ge rt CG . An atom ical stu d ies on th e geom etr y an d stability o th e d istal rad iou ln ar join t. Scand J Plast Reconstr Surg. 1985;19:17–25. Frie d m a n SL, Pa lm e r AK. Th e u ln ar im paction syn drom e. Hand Clin. 1991;7:295 –310. Ge is s le r WB, Fe rn a n d e z DL, La m e y DM . Distal rad iou ln ar join t in ju ries associated w ith ractu res o th e d istal radiu s. Clin Orthop Relat Res. 1996 Ju n ;327:135 –146. Hu ls ize r D, We is s AP, Ake lm a n E. Uln arsh orten in g osteotom y a ter ailed arth roscopic débridem en t o th e trian gu lar brocartilage com plex. J Hand Surg Am. 1997;22:694 –698. Ka p a n d ji IA. Th e Kapan dji-Sau ve procedu re. J Hand Surg. 1992;17:125 –126. Nu n e z FA Jr, Ba rn w e ll J, Li Z, e t a l . Metaph yseal u ln ar sh orten in g osteotom y or th e treatm en t o u ln ocar pal abu tm en t syn drom e u sin g distal u ln a h ook plate: Case series. J Hand Surg Am. 2012;37A:1574 –1579. Pa lm e r AK, We rn e r FW. Biom ech an ics o th e d istal rad iou ln ar join t. Clin Orthop Relat Res. 198 4;187:26 –35.

Dista l ra dio uln a r jo int inju rie s

Ma lun ion of d ista l ra d ia l fra ctu re s

Ad a m s BD, Be rge r RA. An an atom ic

Am a d io PC, Bo t t e MJ. Treatm en t o

recon stru ction o th e d istal rad iou ln ar ligam en ts or posttrau m atic distal radiou ln ar join t in stability. J Hand Surg Am. 2002;27:243 –251. Alla n CH, Jo s h i A, Lich t m a n DM . Kien böck’s disease: diagn osis an d treatm en t. J Am Acad Orthop Surg. 2001;9:128 –136. Be d n a r MS, Arn o czk y SP, e t a l . Th e m icrovascu latu re o th e trian gu lar brocartilage com plex: its clin ical sign i can ce. J Hand Surg Am. 1991;16:1101– 1105. Bilo s ZJ, Ch a m b e rla n d D. Distal u ln ar h ead sh orten in g or treatm en t o trian gu lar brocartilage com plex tears w ith u ln a positive varian ce. J Hand Surg Am. 1991;16:1115 –1119. Bre e n TF, Ju p it e r JB. Exten sor car pi u ln aris an d f exor car pi u ln aris ten odesis o th e u n stable d istal u ln a. J Hand Surg Am. 1989;14:612 –617. Ch e n NC, Wo lfe SW. Uln a sh orten in g osteotom y u sin g a com pression device. J Hand Surg Am. 2003;28:88 –93. Ch u n S, Pa lm e r AK. Th e u ln ar im paction syn drom e: ollow-u p o u ln ar sh orten in g osteotom y. J Hand Surg Am. 1993;18:4 6 –53.

m alu n ion o th e distal rad iu s. Hand Clin. 1987;3:541–561. Fe rn a n d e z DL. Correction o post-trau m atic w rist de orm ity in adu lts by osteotom y, bon e-gra tin g, an d in tern al xation . J Bone Joint Surg. 1982;6 4 A:116 4 –1178 an d 200 0;120:23 –26. Fe rn a n d e z DL. Malu n ion o th e distal rad iu s: cu rren t approach to m an agem en t. Instr Course Lect. 1993;42:99 –113. Fe rn a n d e z DL, Ju p it e r B. Fractures of the Distal Radius: A Practical Approach to Management. New York: Sprin ger;1996. Go n zá le z d e l Pin o J, Na g y L, Go n zá le z E, e t a l . Com plex in tra-articu lar osteotom y

or m alu n ion o th e distal rad iu s. In d ication s an d su rgical tech n iqu e. Rev Orthop Traumatol. 2000;4 4:406 –417. Je n k in s NH, Min t o w t-Czyz WJ. Mal-u n ion an d dys u n ction in Colles’ ractu re. J Hand Surg. 1988;13B:291–293. Ju p it e r JB, Fe rn a n d e z DL. Com plication s ollow in g distal radial ractu res. Instr Course Lect. 2002;51:203 –219.

Ju p it e r JB, Rin g D. A com parison o early

an d late recon stru ction o m alu n ited ractu res o th e distal en d o th e rad iu s. J Bone Joint Surg Am. 1996;78A:739 –74 8. Kn irk JL, Ju p it e r JB. In tra-articu lar ractu res o th e distal en d o th e rad iu s in you n g adu lts. J Bone Joint Surg Am. 1986;68A:647–659. Lo za n o -Ca ld e ro n SA, Bro u w e r KM, Do o rn b e rg JN, e t a l . Lon g-term ou tcom es

o corrective osteotom y or th e treatm en t o d istal rad iu s m alu n ion . J Hand Surg Am. 2010;35E:370 –380. Pro m m e rs b e rge r KJ, Va n Sch o o n h o ve n J, La n z UB. Ou tcom e a ter corrective

osteotomy or m alu n ited ractu res o th e d istal end o th e rad iu s. J Hand Surg. 2002;27B:55 –60. Rikli DA, Re ga zzo n i P. Fractu res o th e d istal en d o th e rad iu s treated by in tern al xation an d early u n ction . A prelim in ary report o 20 cases. J Bone Joint Surg. 1996;78(4):588 –592. Rin g D, Ro b e rge C, Mo rga n T, e t a l . Osteotom y or m alu n ited ractu res o th e d istal radiu s: a com par ison o stru ctu ral an d n on stru ctu ral au togen ou s bon e gra ts. J Hand Surg Am. 2002;27A:216 –222. Rin g D, Pro m m e rs b e rge r KJ, Go n za le z d e l Pin o J, e t a l . Corrective osteotom y or

in tra-articu lar m alu n ion o th e d istal part o th e rad iu s. J Bone Joint Surg Am. 2005;87A:1503 –1509.

Arth ro de sis o f th e wrist Ba in GI, Wa t t s AC. Th e ou tcom e o scaph oid

excision an d ou rcorn er arth rodesis or advan ced car pal collapse at a m in imu m o ten years. J Hand Surg Am. 2010; 35(5):719 –725. Bo la n o LE, Gre e n DP. Wrist arth rodesis in post-trau m atic arth ritis: A com parison o two m eth ods. J Hand Surg Am. 1993;18:786 –791. Bo ris ch BN, Ha u s s m a n n P. Rad io-lu n ate arth rodesis in th e rh eu m atoid w rist: a retrospective clin ical an d rad iological lon g-term ollow-u p. J Hand Surg. 2002;27:61–72. Ch a m a y A, De lla Sa n t a D, Vila s e ca A. Rad iolu n ate arth rodesis actor o stability or th e rh eu m atoid w rist. Ann Chir Main. 1983;2:5 –17. Co h e n MS, Ko zin SH . Degen erative arth ritis o th e w rist: prox im al row car pectom y versu s scaph oid excision an d ou r-corn er arth rodesis. J Hand Surg Am. 2001;26:94 – 104. Co o n e y WP, Lin s ch e id RL, Do b yn s JH . Scaph oid ractu res: problem s associated w ith n onu n ion an d avascu lar n ecrosis. Orthop Clin North Am. 198 4;15:381–391. Frie d m a n S, Pa lm e r A. Th e u ln ar im paction syn drom e. Hand Clin. 1991;7:295-310.

495

Appendix

Ga rcia -Elia s M, Co o n e y WP, An KN, e t a l .

Krim m e r H, Wie m e r P, Ka lb K. Com parative

Sh in EK, Ju p it e r JB. Rad ioscaph olu n ate

Wrist k in em atics a ter lim ited in tercar pal arth rodesis. J Hand Surg Am. 1989;14:791– 799.

ou tcom e assessm en t o th e w rist join t— m ed iocar pal partial arth rodesis an d total arth rodesis. Handchir Mikrochir Plast Chir. 200 0;32:369 –374. Mu lfo rd JS, Ce u le m a n s LJ, Na m D, e t a l . Prox im al row car pectom y vs ou r corn er u sion or scaph olu n ate (SLAC) or scaph oid n onu n ion advan ced collapse (SNAC) w rists: a system atic review o ou tcom es. J Hand Surg Eur. 2009;34(2):256 –263. Na g y L, Bü ch le r U. Lon g-term resu lts o rad ioscaph olu n ate u sion ollow in g ractu res o th e d istal rad iu s. J Hand Surg. 1997;22:705 –710. Ozyu re ko glu T, Tu rke r T. Resu lts o a m eth od o 4 -corn er arth rodesis u sin g h ead less com pression screw s. J Hand Surg Am. 2012;37(3):486 –492. Pa lm e r AK, Do b yn s JH, Lin s ch e id RL. Man agem en t o post-trau m atic in stability o th e w rist secon dar y to ligam en t ru ptu re. J Hand Surg Am. 1978;3:507–532. Sh in AY. Fou r-corn er arth rodesis. J Am Soc Surg Hand. 2001;1:93 –111.

arth rodesis or advan ced degen erative radiocar pal osteoarth ritis. Tech Hand Up Extrem Surg. 2007;11:180 –183. St ra u ch RJ. Scaph olu n ate advan ced collapse an d scaph oid n onu n ion advan ced collapse arth ritis—u pdate on evalu ation an d treatm en t. J Hand Surg Am. 2011; 36(4):729 –735. Wa t s o n HK, Ba lle t FL. Th e SLAC w rist: scaph olu n ate advan ced collapse pattern o degen erative arth ritis. J Hand Surg Am. 1984;9:358 –365. We is s APC, Ha s t in gs H . Wrist arth rodesis or trau m atic con d ition s: a stu dy o plate an d local bon e gra t application . J Hand Surg Am. 1995;20:50 –56. Wyrick JD, St e rn PJ, Kie fh a b e r TR. Motion -preser vin g procedu res in th e treatm en t o scaph olu n ate advan ced collapse w rist: prox im al row car pectom y versu s ou r-corn er arth rodesis. J Hand Surg Am. 1995;20:965 –970.

Go n zá le z d e l Pin o J, Ca m p b e ll D, Fis ch e r T, e t a l . Variable an gle lock in g in tercar pal

u sion system or ou r-corn er arth rodesis: In d ication s an d su rgical tech n iqu e. J Wrist Surg. 2012 Au g;1(1):73 –78. Ha s t in gs H . Arth rodesis o th e osteoarth ritic w rist. In : Gelberm an RH, ed. Master Techniques in Orthopaedic Surgery. The Wrist. New York: Raven Press;1994:345 –350. Ha s t in gs H, We is s APC, Qu e n ze r D, e t a l . Arth rodesis o th e w rist or post-trau m atic disorders. J Bone Joint Surg Am. 1996;78:897–902. Kra ka u e r JD, Bis h o p AT, Co o n e y WP. Su rgical treatm en t o scaph olu n ate advan ced collapse. J Hand Surg Am. 1994;19:751–759.

496

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Distal radius and ulna

AO/ OTA Fracture and Dislocation Classi cation Distal radius and ulna Hand and carpus

For u rth er edu cation al m aterial abou t th e classi cation an d access to th e com plete Fractu re an d Dislocation Classi cation Com pen diu m , please u se th e QR code.

Appendix

498

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Distal radius and ulna

Distal radius and ulna 2R3/ 2U3 Lo ca tio n: Radius/ Ulna, dista l e n d se gm e n t 2R3/ 2U3

U

R

Type s: Radius, distal end segment, e xtra a rticu la r fra cture 2R3A

Radius, distal end segment, p a rtia l a rticu la r fra cture 2R3B

Radius, distal end segment, co m p le te a rticu la r fra ctu re 2R3C

Ulna, distal end segment, e xtra a rticu la r fra cture 2U3A

Ulna, distal end segment, pa rtia l a rticu la r fra cture 2U3B

Ulna, distal end segment, co m p le te a rticu la r fra ctu re 2U3C

499

Appendix

2R3A Typ e : Radius, distal end segment, e xtra a rticu la r fra cture 2R3A Gro up : Radius, distal end segment, extraarticular, ra d ia l stylo id a vu lsion fra cture 2R3A1

Grou p : Radius, distal end segment, extraarticular, sim p le fra ctu re 2R3A2 Su b grou p s: Tra nsve rse , n o disp la ce m e n t / tilt (m a y b e sh o rte n e d ) 2R3A2.1

Do rsa l disp la ce m e n t / tilt (Co lle s) 2R3A2.2

Vola r d ispla ce m e n t / tilt (Sm ith’s) 2R3A2.3

Grou p : Radius, distal end segment, extraarticular, we d ge o r m u ltifra gm e n ta ry fra ctu re 2R3A3 Su b grou p s: Inta ct we d ge fra ctu re 2R3A3.1

500

Fra gm e n ta ry we d ge fra ctu re 2R3A3.2

Mu ltifra gm e n ta ry fra ctu re 2R3A3.3

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Distal radius and ulna

2U3A Typ e : Ulna, distal end segment, e xtra a rticula r fra ctu re 2U3A Gro u p: Ulna, distal end segment, extraarticular, stylo id p ro ce ss fra ctu re 2U3A1 Su bgro u ps: Tip of st yloid fra ctu re 2U3A1.1

Ba se o f st yloid fra ctu re 2U3A1.2

Gro u p: Ulna, distal end segment, extraarticular, sim p le fra ctu re 2U3A2 Su bgro up s: Sp ira l fra ctu re 2U3A2.1

Ob liqu e fra ctu re (>_30°) 2U3A2.2

Tra n sve rse fra ctu re (< 30°) 2U3A2.3

> − 30°

< 30°

Gro u p: Ulna, distal end segment, extraarticular, m ultifra gm e n ta ry fra cture 2U3A3

501

Appendix

2R3B Typ e : Radius, distal end segment, p a rtia l a rticu la r fra ctu re 2R3B Grou p : Radius, distal end segment, partial articular, sa gitta l fra ctu re 2R3B1 Su b grou p s: In volvin g sca p h oid fossa 2R3B1.1

In volvin g lun a te fo ssa 2R3B1.3

Grou p : Radius, distal end segment, partial articular, d orsa l rim (Ba rto n’s) fra cture 2R3B2 Su b grou p s: Sim ple fra cture 2R3B2.1

Fra gm e n ta ry fra cture 2R3B2.2

With d o rsa l d islo ca tio n 2R3B2.3

Grou p : Radius, distal end segment, partial articular, vo la r rim (re ve rse Ba rto n ’s , Go yra n d -Sm ith ’s II) fra ctu re 2R3B3 Su b grou p s: Sim p le fra cture 2R3B3.1

502

Fra gm e n ta ry fra ctu re 2R3B3.3

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Distal radius and ulna

2R3C Type : Radius, distal end segment, co m p le te a rticu la r fra ctu re 2R3C Gro u p: Radius, distal end segment, complete, sim p le a rticu la r a n d m e ta p h yse a l fra ctu re 2R3C1 Su bgro u ps: Dorsom e d ia l a rticu la r fra cture 2R3C1.1*

Sa gitta l a rticu la r fra ctu re 2R3C1.2*

Fro n ta l/ coro na l a rticu la r fra cture 2R3C1.3*

*Qualif cations: t DRUJ stable u DRUJ unstable

Grou p : Radius, distal end segment, complete, simple articular, m e ta ph yse a l m u ltifra gm e n ta ry fra ctu re 2R3C2 Su b grou p s: Sa gitta l a rticu la r fra ctu re 2R3C2.1*

Fro n ta l/ co ro na l fra ctu re 2R3C2.2*

Exte n din g in to th e d ia p hysis 2R3C2.3*

*Qualif cations: t DRUJ stable u DRUJ unstable

Gro u p : Radius, distal end segment, complete, a rticu la r m ultifra gm e n ta ry fra ctu re , sim ple o r m u ltifra gm e n ta ry m e ta p h yse a l fra cture 2R3C3 Su b grou p s: Simple metaphyseal racture 2R3C3.1*

Metaphyseal multi ragmentary racture 2R3C3.2*

Extending into the diaphysis 2R3C3.3*

*Qualif cations: t DRUJ stable u DRUJ unstable Qu a lif ca tio n s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one qualif cation can be applied or a given racture classif cation, separated by a comma. For a more detailed explanation, see the compendium introduction.

503

Appendix

Ha n d a n d ca rp u s

78

An a to m ica l re gio n : Ha n d a n d ca rpu s 7

78

78

78 78

78

78

78 78

78

78

78 78 78

*

77

77

77

77 77 76 74 76

76

Bo n e s: Hand and Hand and Hand and Hand and Hand and Hand and Hand and Hand and Hand and

75

73 72 71

carpus, Lu n a te 71 carpus, Sca p h o id 72 carpus, Ca p ita te 73 carpus, Ha m a te 74 carpus, Tra p e ziu m 75 carpus, Oth e r ca rp a l b o n e s 76 carpus, Me ta ca rp a l 77 carpus, Ph a la n x 78 carpus, Cru sh e d , m u ltip le fra ctu re s 79

Qu a lif ca tio n s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one qualif cation can be applied or a given racture classif cation, separated by a comma. For a more detailed explanation, see the compendium introduction.

504

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Hand and carpus

Lu n a te 71 Bo n e : Hand and carpus, lu n a te 71 Typ e s: Hand and carpus, lunate, a vu lsio n fra ctu re 71A

Hand and carpus, lunate, sim p le fra ctu re 71B

Hand and carpus, lunate, m u ltifra gm e n ta ry fra ctu re 71C

Hand and carpus, scaphoid, sim p le fra ctu re 72B*

Hand and carpus, scaphoid, m u ltifra gm e n ta ry fra ctu re 72C*

Sca p h o id 72 Bo n e : Hand and carpus, sca p h o id 72 Typ e s: Hand and carpus, scaphoid, a vu lsio n fra ctu re 72A

*Qualif cations: a Proximal pole b Waist c Distal pole

Ca p ita te 73 Bo n e : Hand and carpus, ca p ita te 73 Typ e s: Hand and carpus, capitate, a vu lsio n fra ctu re 73A

Hand and carpus, capitate, sim p le fra ctu re 73B

Hand and carpus, capitate, m u ltifra gm e n ta ry fra ctu re 73C

Hand and carpus, hamate, sim p le fra ctu re 74B

Hand and carpus, hamate, m u ltifra gm e n ta ry fra ctu re 74C

Hand and carpus, trapezium, sim p le fra ctu re 75B

Hand and carpus, trapezium, m u ltifra gm e n ta ry fra ctu re 75C

Ha m a te 74 Bo n e : Hand and carpus, h a m a te 74 Typ e s: Hand and carpus, hamate, h o ok fra ctu re 74A

Tra p e ziu m 75 Bo n e : Hand and carpus, tra p e zium 75 Typ e s: Hand and carpus, trapezium, a vu lsio n fra ctu re 75A

505

Appendix

Oth e r 76 ._. Bo n e : Hand and carpus, o the r 76.__. Pisifo rm 76.1.

Triq u e trum 76.2.

Tra p e zo id 76.3.

→ The bone identi er (between two dots .__.) is added to the code after the anatomical region.

76 .1 Hand and carpus, p isiform 76.1. Typ e : Hand and carpus, other, pisiform, a vu lsio n fra ctu re 76.1.A

Hand and carpus, other, pisiform, sim p le fra ctu re 76.1.B

Hand and carpus, other, pisiform, m u ltifra gm e n ta ry fra ctu re 76.1.C

Hand and carpus, other, triquetrum, sim p le fra ctu re 76.2.B

Hand and carpus, other, triquetrum, m u ltifra gm e n ta ry fra ctu re 76.2.C

Hand and carpus, other, trapezoid, sim p le fra ctu re 76.3.B

Hand and carpus, other, trapezoid, m u ltifra gm e n ta ry fra ctu re 76.3.C

76 .2 Hand and carpus, triq u e tru m 76.2. Typ e : Hand and carpus, other, triquetrum, a vu lsio n fra ctu re 76.2.A

76 .3 Hand and carpus, tra p e zo id 76.3. Typ e : Hand and carpus, other, trapezoid, a vu lsio n fra ctu re 76.3.A

506

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Hand and carpus

Me ta ca rp a ls 77.__. Bo n e : Hand and carpus, m e ta ca rp a l 77.__.

Metacarpal identifiers 3 Distal Bone segment location

2 Diaphyseal

5

4

3

2

1

1 Proximal

→ → → →

The metacarpal bones are identi ed as follows: Thumb = 1, index = 2, long or middle = 3, ring = 4, and little = 5. The metacarpal identi er is added (between two dots .__.) after the bone code. The bone segment location is then added. Example: Hand, 3rd metacarpal, proximal end segment = 77.3.1

Lo ca tio n: Hand and carpus, metacarpal, p roxim a l e n d se gm e n t 77.__.1 → Example code for the 3rd metacarpal is indicated with an underline 77.3.1 Typ e s: Hand and carpus, metacarpal, proximal end segment, e xtra a rticu la r fra cture 77.3.1A

Hand and carpus, metacarpal, proximal end segment, p a rtia l a rticu la r fra ctu re 77.3.1B

Hand and carpus, metacarpal, proximal end segment, co m p le te a rticu la r 77.3.1C

Lo ca tio n: Hand and carpus, metacarpal, d ia ph yse a l fra ctu re 77.__.2 → Example code for the 3rd metacarpal is indicated with an underline 77.3.2 Typ e s: Hand and carpus, metacarpal, diaphyseal, sim p le fra ctu re 77. 3.2A

Hand and carpus, metacarpal, diaphyseal, we d ge fra ctu re 77. 3.2B

Hand and carpus, metacarpal, diaphyseal, m u ltifra gm e n ta ry fra ctu re 77. 3.2C

Lo ca tio n: Hand and carpus, metacarpal, d ista l e n d se gm e n t 77.__.3 → Example code for the 3rd metacarpal is indicated with an underline 77.3.3 Typ e s: Hand and carpus, metacarpal, distal end segment, e xtra a rticu la r fra cture 77. 3.3A

Hand and carpus, metacarpal, distal end segment, p a rtia l a rticu la r fra ctu re 77. 3.3B

Hand and carpus, metacarpal, distal end segment, co m p le te a rticu la r fra ctu re 77. 3.3C

507

Appendix

Ph a la n x 78.__.__. Bo n e : Hand and carpus, p h a la n x 78.__.__. Finger 3 4

2

5

3 1 2 Phalanges

1

3 Distal 2 Diaphyseal

Bone segment location

1 Proximal

→ The ngers and phalanges are identi ed as follows: Fingers: Thumb = 1, index = 2, long or middle = 3, ring = 4, and little = 5. Phalanges: Proximal phalanx = 1, middle phalanx = 2, and distal phalanx = 3. The nger identi er plus phalanx identi er are added (between dots .__.__.) after the bone code. → Example: Proximal thumb phalanx is 78.1.1. → The location is then added. → An a to m ica l re gio n + b o ne .Finge r.Pha la n x.Bo ne se gm e nt loca tio n → Example: Proximal thumb phalanx proximal end segment is 78.1.1.1 Loca tio n : Hand and carpus, phalanx, p roxim a l e n d se gm e n t 78.1.1.1 → Example code for proximal thumb phalanx is indicated with an underline 78.1.1.1 Typ e s: Hand and carpus, phalanx, proximal end segment, e xtra a rticu la r fra ctu re 78.1.1.1A

Hand and carpus, phalanx, proximal end segment, p a rtia l a rticula r fra ctu re 78.1.1.1B

Hand and carpus, phalanx, proximal end segment, co m p le te a rticu la r fra ctu re 78.1.1.1C

Loca tio n : Hand and carpus, phalanx d ia ph yse a l fra ctu re 78.1.1.2 → Example code for proximal thumb phalanx is indicated with an underline 78.1.1.2 Typ e s: Hand and carpus, phalanx, diaphyseal, sim p le fra ctu re 78.1.1.2A

Hand and carpus, phalanx, diaphyseal, we dge fra cture 78.1.1.2B

Hand and carpus, phalanx, diaphyseal, m u ltifra gm e n ta ry fra ctu re 78.1.1.2C

Loca tio n : Hand and carpus, phalanx, d ista l e n d se gm e n t 78.1.1.3 → Example code for proximal thumb phalanx is indicated with an underline 78.1.1.3 Typ e s: Hand and carpus, phalanx, distal end segment, Hand and carpus, phalanx, distal end segment, Hand and carpus, phalanx, distal end segment, e xtra a rticu la r fra ctu re p a rtia l a rticu la r fra ctu re co m p le te a rticu la r fra ctu re 78.1.1.3A 78.1.1.3B 78.1.1.3C

508

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z

Hand and carpus

Cru sh e d , m u ltip le fra ctu re s 79 Hand and carpus, cru sh , m u ltip le fra ctu re s h a n d 79

Qua lif ca tion s are optional and applied to the racture code where the asterisk is located as a lower-case letter within rounded brackets. More than one qualif cation can be applied or a given racture classif cation, separated by a comma. For a more detailed explanation, see the compendium introduction.

509

510

Ma n u a l o f Fra ct u re Ma n a ge m e n t—Wris t Je sse  B  Jupite r,  Douglas  A  Cam pbe ll,  Fie sky  Nuñe z