Distal radial fracture: corrective osteotomy for malunion, Synthes Distal Radius Sterile Kit (DRSK)
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Distal radius malunion is a common complication of the conservative / non-operative treatment of distal radius fractures. The incidence is approximately 24% however, the majority of malunions are asymptomatic and do not require corrective osteotomy. The incidence of malunion for surgically treated distal radius fractures is also surprisingly high at around 10%. The real key to managing distal radius fractures is to determine which fractures are unstable and require operative treatment initially and therefore avoid the sequalae of late malunion. Also, when operating you must ensure that an anatomical reduction has been achieved and it is adequately stabilised.
To help determine which fractures are unstable, a simple “rule of thumb” is if the fracture is displaced by the original injury and requires a manipulation, then it is very likely to be unstable. This doesn’t mean that all manipulated fractures require operative treatment, as some patient’s functional demands may be low and may therefore tolerate some deformity. The British Orthopaedic Association Standard for Trauma (BOAST) states that, “In patients 65 years of age or older, non-operative treatment can be considered as a primary treatment for dorsally displaced distal radius fractures unless there is significant deformity or neurological compromise”. Unfortunately, there is no clear consensus on what constitutes significant deformity.
The American Academy of Orthopedic Surgeons (AAOS) has published a Clinical Practice Guideline (2020) for the Management of Distal Radius Fractures. Under the heading “Indications for fixation (non-geriatric patients*)”, it recommends fixation for the following radiographic parameters:
- Radial shortening > 3mm
- Dorsal tilt > 10 degrees
- Intra-articular displacement or step-off > 2mm
*The term non-geriatric is intended to indicate patients with a high functional demand or age < 65 years.
While these parameters are helpful to aid decision making, they haven’t addressed the scenario of the young patient with an initially displaced distal radius fracture that has had an anatomic reduction following a closed manipulation. This patient would therefore not fulfil the above radiographic parameters but is potentially at risk of re-displacement.
Lafontaine et al (1989) published a nice paper looking at 112 cases of non-operatively treated distal radius fractures that underwent closed reduction and cast immobilisation. They classified the fractures according to these criteria:
- Dorsal angulation > 20 degrees
- Dorsal comminution
- Intra-articular fracture
- Associated ulnar fracture
- Age > 60
They found that despite all radiographic parameters improving following reduction, there was a consistent re-displacement, and this correlated with the number of criteria. They concluded that fractures with 3 or more criteria were at an increased risk of re-displacement and therefore needed closer surveillance and/or operative treatment.
In this technique I present the case of a gentleman in his 40s that had a closed anatomic reduction of a distal radius fracture; however, it subsequently underwent late displacement and became symptomatic. I will be using the Synthes Distal Radius Sterile Kit (DRSK) which contains the 2.4/2.7 mm Variable Angle LCP Two-Column Volar Distal Radius Plate. The Variable Angle Distal Radius Plates are indicated for complex intra- and extra-articular fractures and osteotomies. The plates / sets are available in both stainless steel and titanium. The plates feature variable angle locking screw technology which allow up to 15 degrees angulation in any direction (total arc 30 degrees). The plate also has multiple 1.25 mm K-wire holes which allows it to be accurately positioned and temporarily held prior to definitive screw placement. The DRSK set contains both surgical instruments, and a single plate and screw caddy with sufficient options to complete the procedure. If additional screws are required, then separately packed sterile screws can be used. I particularly like the DRSK sets as they decrease the amount of time waiting for sterile screws to be opened and the instrumentation is really simple and easy to use.
Lafontaine M, Hardy D, Delince Ph. Stability assessment of distal radius fractures. Injury 1989; 20: 208-210
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Author: Ross Fawdington FRCS(Tr and Orth)
Institution: The Queen Elisabeth Hospital, Birmingham, UK.
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.