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Needs of patients with complex distal radius fractures should guide treatment
Douglas P. Hanel, MD, said constructs must withstand very high stresses across the wrist.
Complex distal radius fractures involving soft tissue injuries can be more challenging to manage in multiply injured patients. Extra attention must be given to fragment identification, plate selection and placement, and soft tissue reconstruction, according to a surgeon at Harborview Medical Center in Seattle.
Since multiply injured individuals will need to safely weight-bear on their upper extremities to achieve full rehabilitation, Douglas P. Hanel, MD, recommended distal radius treatments with a strong construct that facilitates short- and intermediate-term rehabilitation and directly promotes long-term rehabilitation.
“I happen to use a lot of small fragment fixation over large fragment fixation. I augment this with bilateral internal fixators,” Hanel said at the American Academy of Orthopaedic Surgeons annual meeting during a presentation on enhanced stability and fixation of complex distal radius fractures.
Stable fixation
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Hanel told audience members the constructs they select for complex distal radius fractures — from various thickness and length plates, to pins, screws, wires and internal and external fixators — must withstand the rigors of patients weight-bearing on a freshly healing distal radius fracture that can reach 360 N.
Implants that hold up under such conditions are hard to find, he added.
Patients may have other major fractures that are healing at the same time.
Select a treatment centered on the demands of the fracture, not the demands of the plate, Hanel said.
Complex issues
Equally critical is making the right diagnosis and identifying all the articular fragments and their significance to ensure good reduction of complex distal radius fractures, he noted.
Some of these are “complex by association,” occurring with elbow, forearm and tibial fractures, head trauma, contusions and damaged tissues, Hanel explained. To keep the situation from becoming more complex, orthopedists may need to perform tendon, nerve and vascular repairs, carpal tunnel releases and address soft tissue coverage.
For an “internal” fixator, Hanel said he prefers 2.4-mm or 3.5-mm stainless steel spanning plates with the larger plate placed in the fourth dorsal compartment and the smaller in the second compartment.
“This is not my answer to all distal radius fractures, but it is to this particular problem and in this particular setting.”
A fracture plate alone may not always be sufficient.
“In the case of multiple trauma, you ought to augment that … By adding an internal or external fixator you can double the fixation and the stiffness of any construct to withstand weight-bearing,” Hanel noted.
He also suggested selecting devices that can be applied quickly in the operating room and avoiding external fixators in patients whose stay in the intensive care unit will be lengthy because that setting is associated with higher rates of pin track infections.
The technique preferred by Hanel and David S. Ruch, MD, of Durham, N.C., uses internal and external fixation and plating. The external fixator can be kept in place 14 to 52 weeks, but they removed it without problem around 14 weeks in their series of about 100 cases.
“It is the promotion of aggressive rehabilitation that gets us what we want,” he said.
For more information:
- Douglas P. Hanel, MD, can be reached at Harborview Medical Center, Department of Orthopedics, Box 359798, 325 9th Ave., Seattle, WA 98104-2499; 206-744-8315; e-mail: dhanel@u.washington.edu. He is on the speaker’s bureau for AO, Biomet, Small Bone Innovations, Trimed and Zimmer and receives research or institutional support from AO, Arthrex, Biomet, DePuy, a Johnson & Johnson Company, Johnson & Johnson, Sawbones/Pacific Research Laboratories, Smith & Nephew, Stryker, Synthes, Trimed and Zimmer.
Reference:
- Hanel DP. Complex fracture management. Symposium L: Distal radius fractures: new concepts in treatment. Presented at the American Academy of Orthopaedic Surgeons 76th Annual Meeting. Feb. 25-28, 2009. Las Vegas.