8: Closed Reduction and Pinning of Distal Radius Fractures

Closed Reduction and Pinning of Distal Radius Fractures

Dennis E. Kramer

Indications

Unstable distal radius fracture unable to be controlled by cast alone

Displaced distal radius fracture that is in unacceptable alignment following a reduction and casting maneuver

• If greater than 2 years of growth remaining, acceptable alignment includes:

20–25° of dorsal or volar angulation

10° of radial-ulnar deviation

50% translational displacement

Redisplacement following a previous reduction and casting maneuver

• Completely displaced fractures have 60–80% rate of redisplacement after incomplete reduction.

• Following redisplacement, outcomes and complications are similar with re-reduction and casting vs. re-reduction and pin fixation.

• Pin fixation reduces the incidence of remanipulation but caries concomitant risks for infection, neurovascular injury, and general anesthesia.

• Consider pin fixation if re-reduction is unstable or incomplete.

Other consideration that may preclude circumferential cast immobilization:

• Significant soft tissue swelling

• Neurovascular compromise

• Open fractures or skin issues

For distal radial physeal fractures, multiple reduction attempts or repeated late reduction attempts should be avoided. If reduction remains unacceptable, consider allowing the fracture to heal and observing the deformity over time, proceeding with late corrective osteotomy if remodeling does not occur.

Distal ulnar fractures often accompany distal radial fractures. Acceptable alignment for distal ulnar fractures includes up to 50% translation and 20° of angulation.

Pitfalls

• Weekly radiographs are necessary to rule out loss of reduction in fractures treated with cast immobilization alone.

Controversies

• Late displacement following initial fracture reduction occurs in approximately one third of cases and is most related to initial fracture displacement, degree of fracture obliquity, and inadequate initial closed reduction.

Examination/Imaging

Posteroanterior and lateral wrist films are obtained.

Dorsal/volar angulation and radial tilt are evaluated. The lateral radiographic wrist view in Figure 1 shows a displaced distal radial fracture with over 30 degrees of dorsal angulation.

FIGURE 1

Treatment Options

• Repeat closed reduction and casting in the clinic or emergency department

• Repeat closed reduction and casting in the operating room

• Closed reduction and pinning in the operating room

Surgical Anatomy

Dorsal sensory branch of the radial nerve (DSBRN)

• The DSBRN pierces the brachioradialis (BR) and emerges between the extensor carpi radialis longus and brevis 8 cm proximal to the radial styloid.

• It then crosses over the extensor retinaculum before dividing into medial and lateral branches.

• It lies dorsal to proper pin position (Fig. 2).

FIGURE 2

• The radial artery runs with the DSBRN between the BR and flexor pollicis longus.

• It runs radial to the flexor carpi radialis at the wrist.

• It lies palmar to proper pin position (see Fig. 2).

Positioning

The patient is placed in the supine position with a nonsterile high-arm tourniquet.

The arm is positioned on a hand table (Fig. 3).

FIGURE 3

Pearls

• Allow plenty of room for the C-arm fluoroscopy machine to enter when fluoroscopic views are necessary (see Fig. 3).

Portals/Exposures

Pins are placed using a “nick-and-spread” technique.

For physeal fractures or fractures near the physis, the pin entry site is through the radial styloid (Fig. 4A).

FIGURE 4

For more proximal metaphyseal fractures, the pin entry site is started just proximal to the distal radial physis to avoid placing pins across the physis.

Fluoroscopy is used to plan the incision site (Fig. 4B).

Pearls

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Tags: Operative Techniques Pediatric Orthopaedic Surgery

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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