Speaker: Account for fracture pattern, surgeon skillset for distal radius fractures
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KOLOA, Hawaii — Surgeons should individualize treatment of distal radius fractures based on fracture pattern, patient factors and the surgeon’s skillset, according to a presenter here.
In his presentation at Orthopedics Today Hawaii, Sanjeev Kakar, MD, FAOA, noted surgeons should have adequate exposure when treating a distal radius fracture. Although surgeons may want to use a mini-invasive approach on distal radius fractures, he said the extended flexor carpi radialis approach may provide a better view.
“[The flexor carpi radialis approach is] a little bit different to what you may be used to where we have added that extra inch where we go across the wrist crease,” Kakar said. “It was considered that you should not go across the wrist crease, but it gives you an unparalleled view of the distal radius.”
Surgeons should also pay attention to where they place the plate, making sure it is not too distal to the volar lunate facet, according to Kakar.
“The take-home message here is that the plate should be [at the line along the volar limb of the radius] or dorsal to that line,” he said. “Once you’re volar to that line, you start irritating those flexor tendons.”
Use of imaging
Kakar added surgeons should get adequate reduction of the radiocarpal joint and the distal radial ulnar joint, and to use fluoroscopic imaging to prevent intra-articular hardware. While Kakar noted he does not find the lateral view to be useful, he said a tilt radiographic view can provide a better visual.
“A quick technical pearl of how to get that tilt view, because sometimes you’re sitting there and you’re moving it live and you’re not sure: If you take your hand and put it underneath the wrist, that roughly gives you that tilt view that you need when you’re using fluoroscopy in terms of the angle,” Kakar said.
He also noted that dorsal tangential views have become more popular in the last 5 to 10 years to identify whether a screw is too long, and these views can be obtained by hyperflexing the wrist downward and placing the beam along the parallel aspect of the forearm. The extended distal radial ulnar joint view, which is performed using either a formal X-ray machine or a mini-fluoroscopy machine without flexing the wrist, can also identify if a screw is too long and if the distal radius ulnar joint has been reduced, according to Kakar.
Because X-rays may not show everything, Kakar noted joint reductions could be assessed with fluoroscopy, dorsal capsulotomy or arthroscopy.
“[Dry arthroscopy] is a big deal in hand and wrist surgery. We’re moving away from using fluid and we’re doing it dry,” Kakar said. “The reason why you don’t want to put a ton of fluid in the wrist during arthroscopy is you worry about compartment syndrome and soft tissue extravasation.”
Highly comminuted distal radius fractures
When it comes to plating, patients with highly comminuted distal radius fractures should not receive a volar plate, according to Kakar. Instead, he noted patients with highly comminuted fractures do well with bridge plating.
“The bridge plate is great for getting your height and length back, but doesn’t do anything to the articular reduction,” Kakar said. “So, for me, typically when I’m putting a bridge plate on, I’ll get the articular reduction the best that I can with K-wires and hold it and then the bridge plate goes on second, not the other way around.”
Kakar noted that surgeons treating patients with highly comminuted distal radius fractures should start from the volar ulnar corner, which is the strongest foundation of the distal radial ulnar joint. From there, Kakar said surgeons should move to the dorsal ulnar corner.
“Now you have the sigmoid notch for pronosupination, that’s the stable foundation of the wrist, and then you build off of that,” he said. “Then you’re addressing the intermediate column and the radial column and, if there is an ulnar fracture, fixing the ulnar.”
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Kakar S. Complications of distal radius fractures: How to stay out of trouble. Presented at: Orthopedics Today Hawaii; Jan. 8-12, 2023; Koloa, Hawaii.
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