Distal Radius Fractures
Collin J. May, MD, MPH
Closed Reduction Percutaneous Pinning (CRPP)
Indications
Displaced radial physeal fracture with median neuropathy
Unstable distal radius fracture that will not remodel sufficiently
Floating elbow
Equipment
0.45, 0.62 C-wires
Fluoroscopy
Small instrument kit
Power drill
Position
Supine with the affected arm on a radiolucent hand table
Surgeon and assistant opposite each other for reduction
Surgeon on the radial side of the hand during pinning
Fluoroscopy from foot of bed for pinning
Technique
Fracture Reduction
Displaced distal radial metaphyseal fracture
Accentuate deformity in hyperextension
Push radius distally
Reduce distal radius over the top onto the proximal fragment
Toggle/walk fragment from dorsal to volar for anatomic reduction
If required, make a small dorsal incision and insert freer elevator to lever fracture reduction
Displaced Salter-Harris type II physeal distal radius fracture
Gently reduce fracture under anesthesia with dorsal to volar reduction, also correcting radial to ulnar deviation
Do NOT over-traumatize physis (minimize reduction attempts)
Do this within 5 days of injury to lessen risk of physeal arrest
Pin Placement Technique
Incision
Palpate, mark volar and dorsal distal radius on lateral; radial styloid on AP
Overlay wire on wrist and mark desired path with fluoroscopy (Figure 13-1)
Make small ˜2 cm incision over radial styloid for pin entry
Figure 13-1 ▪ Outline fracture site and desired pin placement with skin markings based on fluoroscopic images.
For physeal fracture, enter radial styloid epiphysis
For metaphyseal, one may be able to enter metaphysis or epiphysis
Bluntly dissect down to bone with a hemostat
Protect radial sensory nerve and adjacent extensor tendons with Ragnell retractors or drill sleeve
Pinning
Push pin up against styloid (most common) or if feasible, metaphysis
Use oscillate mode with pin driver to advance into bone to protect soft tissues
Check fluoroscopy imaging to be certain of path in center of distal radius on both AP and lateral views. Adjust if necessary
Pass pin across the fracture site with an assistant maintaining anatomic reduction
Pierce far cortex of radius with oblique pin for bicortical purchase
Recheck X-rays in AP and lateral views
Test stability
If sufficient for single pin, then stop
If unstable
Add second pin either from styloid in parallel (Figure 13-2) and/or from fourth-fifth compartment interval for the cross-pin technique
Fourth-fifth compartment will be from dorsal ulnar edge to volar radial cortex (Figure 13-3).
Some fractures are markedly unstable and require multiple pins (Figure 13-4)
Figure 13-2 ▪ Two slightly divergent percutaneous pins from radial styloid for fracture fixation.
Figure 13-3 ▪ Outlining crossing distal ulnar to proximal radial pin for cross-pin stabilization.
Irreducible fractures
Some fractures benefit from mini-open reduction at the fracture site
Fracture site is localized with fluoroscopy (Figure 13-5)
In between extensor compartments, a small longitudinal incision is made, a blunt freer elevator is inserted into the fracture site (Figure 13-6) and the freer is used to lever the fracture into reduction
While holding the fracture reduced, a percutaneous wire is placed while protecting the radial sensory and extensor tendons (Figure 13-7)
Reduction and pin placement are checked on fluoroscopy and a second pin in the crossed technique is placed for additional stability (Figure 13-8)
Some irreducible fractures require a volar approach to extract periosteum and/or pronator quadratus by the same approach as the open reduction internal fixation (ORIF)Related posts:
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