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Overlooked Wrist Trauma
- 1. NEGLECTED WRIST TRAUMA Dr.Y.Nageswara rao OSSAPCON 2012 Rajahmundry Organisng secretary Prof.Dr.C.Hanumanta Rao
- 2. OSSAPCON 2012, RAJAHMUNDRY NEGLECTED TRAUMA AROUND WRIST Carpal injuries Distal radius# 20% all skeletal injuries Willful negligence Radius# DRUJ disruption
- 3. 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
- 4. OSSAPCON 2012, RAJAHMUNDRY WRIST EVOLUTION
- 5. OSSAPCON 2012, RAJAHMUNDRY DISTAL RADIUS The distal end of the radius is the anatomic foundation of the wrist joint.
- 6. OSSAPCON 2012, RAJAHMUNDRY WGLECTED WRIST TRAUMA Willful negligence
- 7. OSSAPCON 2012, RAJAHMUNDRY “One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain; the deformity, however, will remain undiminished throughout life.‖ 1773--1843
- 8. OSSAPCON 2012, RAJAHMUNDRY ―enjoy perfect freedom in all . . . motions, and exempt from pain,‖ an Exception, rather a rule
- 9. OSSAPCON 2012, RAJAHMUNDRY ‘IT IS WHAT we THINK WE KNOW THAT KEEPS US FROM LEARNING’ ----------CLAUDE BERNARD
- 10. OSSAPCON 2012, RAJAHMUNDRY 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
- 11. 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
- 12. OSSAPCON 2012, RAJAHMUNDRY RADIOLOGICAL PARAMETERS
- 13. OSSAPCON 2012, RAJAHMUNDRY 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.
- 14. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY RADIAL TILT 11 degree Acceptable – dorsal-15 volar-20 <10 degree dorsal angulation- normal FA rotation >30 degree gross restriction of FA >30 degreewrist motor function is significantly affected
- 15. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY RADIAL LENGTH Normal-11mm Acceptable-<4mm >4mm increased load on lunate facet
- 16. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY ULNAR VARIANCE Normal-0-neutral Acceptable—4mm Aro and Koivunen4 classification 3 types radioulnar relationships at the DRUJ after distal radius fractures. Axial shortening of the radius by less 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
- 17. OSSAPCON 2012, RAJAHMUNDRY PATHOANATOMY ROTATATIONA L MOLUNION Dorsal angulation- supination deformity Volar angulation Pronation deformity Minimal role in FA rotations Soft tissue 38 degr rotation is required is to diagnose contracture plays rotational mol union by cortical mismatch major role The Journal of Volar shifting of ulna is an indication of rotational Hand Surgery / Vol. 29A No. 1 Correction per operative assesment- January 2004
- 18. OSSAPCON 2012, RAJAHMUNDRY wrist instability in two distinct patterns: (1) dorsal radiocarpal subluxation, with normal midcarpal alignment, and (2) adaptive midcarpal dorsal intercalated segment instability (DISI) deformity CARPAL MECHANICS poor functional outcome, with a radiolunate angle > 25°
- 19. OSSAPCON 2012, RAJAHMUNDRY 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
- 20. OSSAPCON 2012, RAJAHMUNDRY 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
- 21. 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
- 22. OSSAPCON 2012, RAJAHMUNDRY CORRECTIVE OSTEOTOMIES Closing Wedge osteotomies Opening Wedge osteotomies Variations
- 23. OSSAPCON 2012, RAJAHMUNDRY CORRECTIVE OSTEOTOMIES Closed wedge osteotomy Open wedge osteotomy
- 24. OSSAPCON 2012, RAJAHMUNDRY OSTEOTOMY VARIATIONS Sliding osteotomy for Trapezoidal osteotomy correction Watson HK,Castle TH Jr: J Hand Surg [Am] 1988;13:837-843. 1998, Thivaios GC, McKee MD: J Orthop Trauma 2003;17:326-333.)
- 25. OSSAPCON 2012, RAJAHMUNDRY OSTEOTOMY &BONE GRAFTING structural bone graft Non structural bone from graft is equally good the iliac crest in long term results the olecranon resected portion of the distal ulna, local graft from the radius
- 26. 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)
- 27. OSSAPCON 2012, RAJAHMUNDRY TIMING OF OSTEOTOMY Nascent malunion(8-12wks) Mature malunion long term results are equal
- 28. OSSAPCON 2012, RAJAHMUNDRY 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
- 29. OSSAPCON 2012, RAJAHMUNDRY ARTICULAR MAL UNION- SURG OPTIONS AS PER SAFFAR Description of malunion Surgical options 1.Scaphoid Facet malunion 1.Intra articular osteotomy 2.Radial styloidectomy 3.Proximal Row carpectomy 2. Lunate facet malunion 1.Intra articular osteotomy 2.Radio Lunate Fusion 3. Global wrist arthrosis 1.Early osteotomy 2.Wrist denervation 3.Wrist Arthrodesis 4.Anterior or Posterior Rim 1.Rim excision malunion
- 30. OSSAPCON 2012, RAJAHMUNDRY ARTICULAR MALUNION
- 31. OSSAPCON 2012, RAJAHMUNDRY MALUNITED ARTICULAR FRACTURES LIMITATIONS The limitation of articular access additional articular damage still challenging.
- 32. OSSAPCON 2012, RAJAHMUNDRY 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:
- 33. OSSAPCON 2012, RAJAHMUNDRY ULNAR SIDE PROCEDURES
- 34. OSSAPCON 2012, RAJAHMUNDRY MILCH ULNAR SHORTENING
- 35. OSSAPCON 2012, RAJAHMUNDRY DARRACH’S EXCISION
- 36. OSSAPCON 2012, RAJAHMUNDRY SAUVE –KAPANDJI PROCEDURE
- 37. OSSAPCON 2012, RAJAHMUNDRY 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
- 38. OSSAPCON 2012, RAJAHMUNDRY PROX ROW CARPECTOMY
- 44. 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
- 45. OSSAPCON 2012, RAJAHMUNDRY THANK YOU
Notas del editor
- Not because fracture has changed, but because of better understanding of biomechanics
- Radilogy is imp to quantify the deformity& to qualitate joint status
- contraindications toFAILED osteotomy or in whom attempts atosteotomy have failed or for radiocarpal arthritis