radius fracture 桡骨远端骨折课件

Fracture of Distal Radius Zhi-jie Xi, MD The Department of trauma and Hand Surgery The First Affiliated Hospital of university of Guangxi Traditional Chinese Medicine Outline Epidemiology Anatomy and biomechanics Radiographical and arthroscopic evaluation Classification Criteria for acceptable reduction predictors of instability Complication AAOS-guidelines Debates Epidemiology Frequency Distal radial fractures account for 1/6 of all fractures seen in the ED Race No racial preferences have been reported Age Peaks at ages 5-14 years and at ages 60-69 years. Young patients intra-articular Elderly patients extra-articular Gender Postmenopausal women, female-to- male ratio 4:1 Adolescent boys and girls, the ratio is 3:1 Anatomy volar radial tuberosity lunate facet buttress PQ = Pronator Quadratus Line, or PQ Line WS = Watershed Line, X = Volar Radial Tuberosity VR = Volar Radial Ridge Biomechanics 80% of the load is taken on the distal radius and 20% of the load is taken on the TFCC DIC=dorsal intercarpal ligament DRC=dorsal radiocarpal ligament Radiographic Assessment X-ray CT MRI Arthroscopic evaluation X-ray 0.9mm 10-15 10-15 正面切线位（11） 侧面切线位（21） 标准侧位 关节面切线位 CT CT MRI Arthroscopy Classification Fracture classification systems are, in effect, tools. The purpose of the tool is to help the surgeon to choose an appropriate method of treatment for each and every fracture occurring in a particular anatomical region. The classification tool should not only suggest a method of treatment, it should also provide the surgeon with a reasonably precise estimation of the outcome of that treatment.“ -Albert H. Burstein, PhD, Deputy Editor for Research, Journal of Bone and Joint Surgery Colles fracture is an extraarticular low energy fracture primarily sustained in the elderly, a fracture almost unique to caucasian women. a “classic“ Colles fracture Sir Abraham Colles Fracture (1814) Smiths fracture 1847 Robert William Smith considered this “an injury of exceedingly rare occurrence,“ but its description heralded the age of vehicular trauma in 1847: The patient, in endeavouring to save himself from being run over by a car, fell with great violence upon the back of his hand . . . Robert William Smith (1807-1873) woodcut from Smiths original description The classic Bartons fracture describes the dorsal rim fracture subluxation, a shear- type injury. John Rhea Bartons addresses the difference between a true dislocation and this fracture: a dislocation typically has no crepitus, and once reduced tends to remain that way John Rhea Barton (1794-1871) Bartons Fracture (1838) Die punch “die punch“ fracture, or lunate load impact fracture of the posteromedial corner of the radius, was more recently described by Scheck The absence of ligamentous attachments to the depressed fragment precludes reduction. In high energy trauma, one component of an unstable displaced fracture the axial load through the lunate creates an impact fracture on the lunate facet A case report a1 a2 Chauffeurs fracture The backfire, or Chauffeurs fracture, was “extremely common in these days of voluminous traffic“ according to Harold C. Edwards, who described 42 fractures sustained from the impact of the downward swing of the automotive crank handle. This is a high energy styloid fracture with carpal subluxation. Salter-Harris Classification (1963) Pediatric Fracture Classification The growth plate is the weakest structure in the developing ends of long bones, and therefore a common site for injuries, including the distal radius. Frykman 1967 Fernandez 1996 Type I: bending Type II: Shearing Type III: Compression Type IV: avulsion, including radiocarpal injuries Type V: combined, high energy fractures type A extra articular type B partial articular AO (1987) type C complete intra-articular Medoff Anatomy Classification (1999) Five predictors of instability a patient over 60 an intra-articular fracture dorsal incomminution dorsal angulation of more than 20 an associated ulnar fracture Treatment options Closed reduction and immobilization Closed reduction and Percutaneous pinning External fixation Arthroscopically assisted reduction and Ex. Fixation of intraarticular fracture. ORIF with plate fixation Bone grafting There is no consensus on the management of theses fractures But definitions seem unclear in many papers.This might be the reason of discrepancy Treatment of Type C3 Distal Radius Fracture Guidelines for Reduction of Distal Radial Fractures Radial shortening 15 degrees Sagittal tilt on lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt Intraarticular step-off or gap 3mm, dorsal tilt 10 degrees, or intra-articular displacement or step-off 2mm Rigid immobilization removable splints for displaced fractures treated non-operatively Patients do not need to begin early wrist motion Vitamin C for the prevention of disproportion- ate pain. 14 Inconclusive Results To perform nerve decompression when nerve dysfunction persists after reduction Casting as definitive treatment for unstable fractures that are initially adequately reduced Any one specific operative method for fixation of distal radius fractures Operative treatment for patients over age 55 with distal radius fractures Locking plates in patients over the age of 55 who are treated operatively Immobilization of the elbow in patients treated with cast immobilization Using of bone graft (autograft or allograft) or bone graft substitutes for the filling of a bone void as an adjunct to other operative treatments using of supplemental bone grafts or substitutes when using locking plates Over-distraction of the wrist when using an external fixator Fixation of ulnar styloid fractures associated with distal radius fractures Using external fixation alone for the Management of distal radius fractures where there is depressed lunate fossa or 4-part fracture (sagitt