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NEGLECTED WRIST TRAUMA
Dr.Y.Nageswara rao
OSSAPCON 2012 RajahmundryOrganisng secretaryProf.Dr.C.Hanumanta Rao
OSSAPCON 2012, RAJAHMUNDRY
NEGLECTED TRAUMA AROUND WRIST
Distal radius#
Radius# DRUJ disruption
Carpal injuries
20% all skeletal injuriesWillful negligence
OSSAPCON 2012, RAJAHMUNDRY
WRIST&HAND
Highly evolved part of musculoskeletal system
It Occupies major part of motor cortex But most common neglected
anatomical region in trauma The natural fascination for hip in
academics and in practice has kept many sub specialities in low esteem
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WRIST EVOLUTION
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DISTAL RADIUS
The distal end of the radius is the anatomic foundation of the wrist joint.
OSSAPCON 2012, RAJAHMUNDRY
WGLECTED WRIST TRAUMA
Willful negligence
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1773--1843
“One consolation only remains, that the limb will at some remote period again enjoyperfect freedom in all its motions, andbe completely exempt from pain; thedeformity, however, will remain undiminishedthroughout life.”
OSSAPCON 2012, RAJAHMUNDRY
“enjoy perfectfreedom in all . . . motions, and exemptfrom pain,”
an Exception, rather a rule
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‘IT IS WHAT we THINK WE KNOW THAT KEEPS US FROM LEARNING’ ----------CLAUDE BERNARD
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OVERLOOKED WRIST TRAUMA
Distal radius malunions 1.Extra articular A. Dorsal malunion B. Volar malunion C. ulnar angulated molunion 2.Intraarticular malunions
3.Rotational malunion
Distal radius nonunoin
.
OSSAPCON 2012, RAJAHMUNDRY
WORK OUT
Radiological examination PA view &lateral view Comparative– x-rays in neutral position CT scan--------rotation of distal fragment MRI------------carpal abnormalities, TFCC
injuries, DRUJ evaluation
OSSAPCON 2012, RAJAHMUNDRY
RADIOLOGICAL PARAMETERS
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PATHOANATOMY & PATHOMECHANICS
RADIAL INCLINATION Normal 22degr Acceptable range >15deg
Decreasing the radial inclination shifted the load distribution so that there was more load in the lunate fossa and less load in the scaphoid fossa.
OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMYRADIAL TILT
11 degreeAcceptable – dorsal-15 volar-20
<10 degree dorsal angulation-normal FA rotation>30 degree gross restriction of FA>30 degreewrist motor function is significantly affected
OSSAPCON 2012, RAJAHMUNDRY
PATHOANATOMY
RADIAL LENGTH Normal-11mm Acceptable-<4mm
>4mm increased load on lunate facet
PATHOANATOMYULNAR
VARIANCENormal-0-neutralAcceptable—4mm
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Aro and Koivunen4 classification 3 types radioulnar relationships at theDRUJ after distal radius fractures.Axial shortening of the radius byless than 3 mm, designated grade 0,. Grade1- 3 to 5 mm of shortening. Grade 2- >5mm poor prognosis >2.5mm ↑40% ulnar load
Ulnar impaction syndrome
PATHOANATOMYROTATATIONAL
MOLUNIONDorsal angulation-supination deformity
Volar angulationPronation deformityMinimal role in FA rotationsSoft tissue contracture plays major role The Journal of Hand Surgery / Vol. 29A No. 1 January 2004
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38 degr rotation is required is to diagnose rotational mol union by cortical mismatchVolar shifting of ulna is an indication of rotational Correction per operative assesment-
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CARPAL MECHANICS
wrist instability in two distinct patterns:
(1) dorsal radiocarpal subluxation,with normal midcarpalalignment, and (2) adaptivemidcarpal dorsal intercalated segmentinstability (DISI) deformity
poor functional outcome, with a radiolunate angle > 25°
DRUJ BIOMECHANICS
Axial load at wrist 80% radius 20% ulna Ulnar variance of >2.5mm increases ulnar load by 42% Radial shortening& Dorsal angulation shifts center of rotation proximaxlly stretches dorsal radio ulnar ligaments
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DR ARTICULAR#S&RADIOCARPAL ARTHRITIS
step-off of >2 mm 100% incidence of
radiological arthritis 93% were said to be
symptomatic. AP distance of the injured
wrist when healed by >4mm
Tear drop angle(normal 70o ) decreased angle in lunate fossa depression
OSSAPCON 2012, RAJAHMUNDRY
MANAGEMENT STRATAGIES
Surgical management consists four major independent components:
1.Osteotomy, closed or open 2.Bone grafting, structural or
nonstructural 3.Fixation, dorsal-more stable volar-better soft tissue coverage volar fixed angle locking plate 4.Ulnar-side procedures
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CORRECTIVE OSTEOTOMIES
Closing Wedge osteotomies Opening Wedge osteotomies Variations
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CORRECTIVE OSTEOTOMIES
Closed wedge osteotomy
Open wedge osteotomy
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OSTEOTOMY VARIATIONS
Sliding osteotomy for correction
Thivaios GC, McKee MD: J Orthop Trauma 2003;17:326-333.)
Trapezoidal osteotomy
Watson HK,Castle TH Jr: J Hand Surg [Am] 1988;13:837-843. 1998,
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OSTEOTOMY &BONE GRAFTING
structural bone graft from the iliac crest the olecranon resected
portion of the distal ulna,
local graft from the radius
Non structural bone graft is equally good in long term results
OSSAPCON 2012, RAJAHMUNDRY
ROTATIONAL OSTEOTOMY
Sagittal rotational malunion after distal radius
osteotomy through the “hinge” point, and correcting the dorsal tilt A pure derotational osteotomy corrected
the apparent shortening of the radius and restored the volar tilt (Hand Surg Eur Vol April 2009 vol. 34 no. 2 160-165)
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TIMING OF OSTEOTOMY
Nascent malunion(8-12wks) Mature malunion long term results are equal
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MALUNITED ARTICULAR FRACTURES
The indication for the osteotomy
Dorsal or Volar subluxation of radiocarpal joint
Articular incongruity of >2 mm as on a PA radiograph
surgery is not based on symptoms because,by the time that symptoms develop,there may already be irreversible articular damage
ARTICULAR MAL UNION- SURG OPTIONS AS PER SAFFAR
Description of malunion Surgical options
1.Scaphoid Facet malunion
1.Intra articular osteotomy2.Radial styloidectomy3.Proximal Row carpectomy
2. Lunate facet malunion
1.Intra articular osteotomy2.Radio Lunate Fusion
3. Global wrist arthrosis
1.Early osteotomy2.Wrist denervation3.Wrist Arthrodesis
4.Anterior or Posterior Rim malunion
1.Rim excision
OSSAPCON 2012, RAJAHMUNDRY
OSSAPCON 2012, RAJAHMUNDRY
ARTICULAR MALUNION
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MALUNITED ARTICULAR FRACTURES
The limitation of articular access
additional
articular damage still
challenging.
LIMITATIONS
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MALUNITED ARTICULAR FRACTURES
CONTRAINDICATIONS for osteotomy Established, advanced arthrosis Low-demand and infirm patients Patients with an age > 70 years have few symptoms and adequate wrist function:
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ULNAR SIDE PROCEDURES
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MILCH ULNAR SHORTENING
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DARRACH’S EXCISION
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SAUVE –KAPANDJI PROCEDURE
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MANAGEMENT OPTIONS IN LATE STAGES
Other Surgical Options(Salvage options )
Proximal row carpectomy, Radio scaphoid fusion, RadioScaphoLunate fusion Total wrist arthroplasty Total wrist fusion is the ultimate salvage procedure as a last resort.1
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PROX ROW CARPECTOMY
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OSSAPCON 2012, RAJAHMUNDRY
TAKE HOME MESSAGE
Clinically asses the functional deficit “Willful negligence” concept to be applied
very cautiously Restore radial height, Restore radio ulnar relation Most cases require ulnar side procedure Be aggressive in treating young patients You cannot plead innocence because you
are ignorant------it could be legal negligence
OSSAPCON 2012, RAJAHMUNDRY
THANK YOU