Distal Radial fracture

Case presentation

Emil Dionysian, MDKaiser Permanente, Orange County, CA

Case #1

• 63 y/o RHD male active architect• Fell on wet floor in his backyard

Operative Decision point

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review

,-

Table 3

Level of evidence for the most commonly used definitions

Page 8 of 18

Level of

Year Definition evidence .

Secondary NA Displaced fracture following adequate reduction Expert opinion displacement (V)

Lafontaine 1989 At least three of the following criteria: Ill

• Dorsal angulation > 20° • Dorsal comminution • Intra-articular radiocarpal fracture • Associated u In ar fracture • Age > 60 years

Volarly displaced NA • Smith fracture Expert opinion • Reversed Barton fracture (V)

Irreducible NA • frreducible fracture Expert opinion (V)

AO type C2 1990 • Complete articular fractures Expert opinion • Simple articular fracture (V)

• Multifragmentary metaphyseal component

Poigenflirst 1980 • Radioulnar separation Expert opinion • The presence of dorsal comminution (V)

• Associated ulna fracture resulting in ulnar disinsertion

Cooney 1979 One or more of the following: Expert opinion • Radial shortening of IO mm (V) • Dorsal angulation > 20° • Marked comminution combined with intra-articular

fragments

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Abbreviation: NA, not applicable.

'The levels of evidence for definition of unstable distal radius fracture based in original study on the Oxford Centre for Evidence-based Medicine Levels of Evidence (March 2009),i

Only Lafontaine's definition originated from a clinical study, describing a retrospective cohort of 167 cases.s- Lafontaine et al performed a univariate analysis for each risk factor and found a significant influence of each factor on the radiological outcome. They concluded that only patients with three or fewer instability factors had a satisfactory radiological outcome. Accordingly, Lafontaine considered a distal radius fracture unstable if three or more of the following factors were present: dorsal angulation exceeding 20°; dorsal comminution; intra-articular radiocarpal fracture; associated ulnar fracture; and

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626227/ 2/6/2021

Journal of wrist surgery 2015 Nov. 4(4)307-316“The Unstable Distal radius Fracture- How do we define it”systematic review of 479 studiesWalenkamp et al.Amsterdam, The Netherlands

Lafontaine Criteria for “unstable fx “:3 out of 5Dorsal angulation > 20 deg.Dorsal ComminutionIntra-articular radio-carpal fxAssociated ulnar fxAge > 60

• Additional imaging ?

CT scan

ORIF with 10 lbs traction off the hand table with finger traps

• Case #2• 53 y/o female executive• fell off her bicycle 4 days prior• closed injury, no neurovascular injury

Closed reduction with traction

Itraoperative picture under traction

Intraop X-ray

2 wks post

Case #3

• 53 y/o right hand dominant female• fell in campground with left distal intra-

articular distal radius fracture• healthy except for extreme obese• BMI 62 • Lives alone, recently divorced

Attempted reduction in sugar tongue splint with traction

2 weeks postop

6 weeks post op f/uno sig. pain

• What next?

CT at 6 weeks postop

6 wks postop

What next?

• 6 wks• Out of wrist brace• Stiff wrist• OT or OR?

Redo ORIF and span and ulnar hook plate

One year post spanning plate removalwrist extension/ flexion 40/35

occasional minimal pain

Case #4

• 53 y/o homemaker RHD female fell off an electric scooter

• Grade 1 open fx

4 months post op