Mr G Shyamalan Consultant Hand Surgeon HEFT
Understanding the radiograph Classification Imaging and consent Approach Surgical case based discussion Classic volar plate Conclusion
Colles
Smiths and Bartons
Chauffeur’s and Lunate die punch
Frykman’s
Melone’s
AO – Too complex Mayo – Extra/Intra-articular Reducible/Irreducible Fernandez – mechanism classification
Fragment Specific – Robert Medoff (intra- articular fractures). Radial styloid, dorsal wall, impacted articular fragments, dorsal ulna corner (die-punch), volar rim fragment (tear drop)
Daniel Rikli & Pietro Regazzoni Lateral – length and alignment Intermediate – weight bearing and notch Medial - rotation
Low energy Vs High Energy Normal Vs Osteoporotic Dominant Vs Non – Dominant Occupation and Functional Demands Soft tissues (skin, nerves, tendons) Pre-morbid conditions including MTS Patient choice! Fracture patterns and mechanism Ulna fracture or carpal injury Timing of consult
Continued pain Malunion Infection Stiffness Chronic regional pain syndrome (500mg Vitamin C daily for 6 weeks) Nerve/Vessel/Tendon Injury Non-union Instability carpus and ulna Removal of metal work Carpal Tunnel Syndrome
Bring the kitchen sink! Volar plates, dorsal straight plates, k-wires, Ex-fix, hand plating system
Volar Henry’s releasing brachioradialis Dorsal Combined
Volar plate Dorsal plate Fragment specific Percutaneous Wires Bridge plating Ex-fix ? Arthroscopic assisted Bone graft or bone graft substitute Bit of everything Plan for a two stage?!
Have an assistant who knows what they are doing Traction the fracture closed Open and Reduce +/- K wire Put plate on shaft and gliding hole screw and screen Plate can be rotated and pushed up or down depending on xray Fill ulna holes distally, check lateral and then put in radial ones and complete proximally
Don’t go bicortical distally Check screw length on xray Angle screws out of joint
Don’t be afraid to put a K-wire and a plate on the radial styloid If in doubt do a carpal tunnel decompression Always release brachioradialis If problems with dorsal fragment reduction, put in screws distally first and reduce fragment onto shaft Continuous traction or Ex-fix can help with fixation Multi-fragmentary fractures, intra-articular fractures try bridge plating
Look at scapho-lunate interval on both wrists Screen in radial and ulna deviation with sometimes compression Look at ulna position, stress views and examine other side Have no issues about implant removal If in doubt do nothing and send to specialist