Fig. 14.1
(a–d) Fracture types, which are suitable for nailing are the AO/OTA types 23-A2, A3, C1 and C2
Also metaphyseal fractures with a simple articular extension (AO/OTA 23-C1-2) (Fig. 14.1c, d) are suitable for nailing. The articular part of the fracture should be minimally displaced, or should be anatomically reduced in a closed manner. The fracture line should proceed in the sagittal plane in order to be crossed and compressed by the interlocking screws going from lateral to medial. Articular fracture lines in the frontal plane are a contraindication for a nailing procedure with a lateral entry portal. Fractures with articular comminution only qualify for intramedullary nailing in geriatric patients. If the surgeon decides to use external fixation as ligamentotaxis in order to reduce comminuted articular fragments, an intramedullary nail with 3–4 subchondral fixation screws may well maintain the initial reduction when the external fixator is removed 6 weeks after surgery.
14.3 Surgical Technique
The operation technique is outlined in Fig. 14.2a–e [12]. Surgery is performed using the Targon® DR (Distal Radius) intramedullary nail under general or brachial plexus anaesthesia.
Figure 14.2a: skin incision on the radius
The patient is placed in supine position and the supinated arm lays in 90° abduction on a radiolucent side table. A 4-cm skin incision is made from the tip of the radial styloid process towards distal. The superficial branch of the radial nerve is identified and protected for the duration of the procedure.
Figure 14.2b1–3: closed reduction of the fracture by insertion of a Kirschner-wire
The dissection is deepened to the styloid process of the radius between the first and the second extensor compartment. The fracture is reduced by traction and palmar flexion of the wrist as well as by ulnar abduction. If necessary, a Kapandji wire can be inserted from dorsoulnar in order to achieve a better volar tilt [13]. For maintenance of reduction during the preparation of the nail bed, a Kirschner-wire (1.7 mm) is inserted from the tip of the styloid process across the fracture line (Fig. 14.2b1). The fixation of the Kirschner-wire should be bicortical and have 30–40° to the longitudinal axis of the radius. Intraoperative anteroposterior and lateral radiographs confirm fracture reduction and correct placement of the K-wire. The second K-wire is placed for preparation of the nail bed (Fig. 14.2b2–3).
Figure 14.2c1–3: stepwise widening of the intramedullary canal
The intramedullary canal is opened with a canulated drill using the second Kirschner-wire as a guide. Afterwards, the intramedullary canal is stepwise widened with profilers by positioning the forearm in flexion and ulnar deviation. If there is a very small intramedullary canal, all profilers have to be driven forward with care. The flaking of a little bone fragment while widening the intramedullary canal can be tolerated. The avulsed fragment can be fixed in its anatomical position by one or several interlocking screws of the Targon® DR nail.
Figure 14.2d1–6: Insertion of the nail and fixation with Kirschner wires
The Targon® DR is then implanted under image intensifier control and four Kirschner-wires are inserted in the distal fragment using the sleeves of the aiming arm. The ideal position for the first wire is the subchondral bone. The Kirschner-wires should not penetrate the opposite cortex. In case of ulna plus (relative shortening of the radius), further restoration of radial length is now possible by pulling the device towards distal. If the optimal length of the radius is achieved, the Targon® DR nail is interlocked proximally and distally with Kirschner-wires using an aiming device. At this stage, a fixed bone-implant construct is created.
Figure 14.2e1–4: replacement of Kirschner wires by screws
Surgery is completed by replacing the Kirschner wires by screws, removal of the aiming device and wound closure.
Additional volar splinting is provided for not longer than 3 days, allowing early functional aftertreatment. Implant removal is not recommended. In case of a weak bone stock, interlocking screws risk to back out laterally.
14.3.1 Tip
In order to prevent screws from backing out, there is the possibility to dissect a small portion of the second tendon retinaculum and fix it underneath the second tendon at the third tendon retinaculum, thus leading to a full coverage of the implant and locking screws.
14.4 Outcome
14.4.1 Prospective Study on Intramedullary Nailing in Geriatric Patients
Fifty-seven geriatric patients ranging in age from 65 to 91 years (mean: 75.3 ± 0.91 years) with concomitant osteopenic bone loss (89 % reduced bone quality <120 mg HA/cm [3] as measured by pQCT) who were suffering from distal radius fractures (extraarticular: n = 8; intra-articular: n = 49) were treated by intramedullary nailing. No additional cast was applied and patients were encouraged to return to activities of daily living without restriction from the first postoperative day on. The follow-up rate 2 years post-surgery reached 90 % (Fig. 14.3a–f).
Fig. 14.3
Sixty-seven year old female with an AO/OTA 23-A3 fracture of the right distal radius. (a, b) Preoperative anteroposterior and lateral radiographs of the distal radius. (c, d) Anteroposterior and lateral views of the distal radius 1 year after surgery. (e, f) Anteroposterior and lateral views of the distal radius 2 years after surgery
All fractures united. Radiologic analysis revealed a mean palmar inclination of 1.34° ± 0.74°, radial shortening of 2 mm in two cases and failure to restore palmar inclination with residual dorsal displacement of 5° in two cases, 10° in one case. Patients tolerated surgery very well. Eight weeks after surgery, Visual Analogue Score (VAS) dropped to <1.8 and the range of extension/flexion reached 80 % of the uninjured side. Two years after surgery, almost complete restoration of hand function was achieved, the mean Gartland-Werley Score being excellent (2.22 ± 0.57).
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