Still, if patients are reasonably healthy and active and the fracture is amenable to this type of fixation, we will offer surgery as most patients will have a good outcome." "Older dorsal implants worked well to stabilize the fracture but had a high rate of complications, and although the volar plates are a better implant, we continue to see some complications with surgical treatment. "Mayo Clinic has extensive experience with the volar approach, and we are leaning toward internal fixation more than in the past because we have better locking plates that can stabilize the fracture from the palmar side of the wrist," Dr. Other limitations of volar plating include the inability to visualize the joint surface or interosseous ligament injuries and difficulty in stabilizing distal and ulnar-sided radius fracture fragments. It also can result in complications that require revision surgeries, such as tendon rupture. Volar plate fixation has proved superior to external fixation in terms of recovery and minor complications, but studies have not shown that it improves long-term overall function. If needed, a dorsal arthrotomy or arthroscopy is used to obtain reduction of the joint surface. The process then continues with reduction of the volar lunate facet, the dorsal lunate facet and the radial styloid. In intra-articular fractures, the exposure may include release of the brachioradialis tendon to expose the fracture site and allow access to the subchondral bone and to release the deforming force from the brachioradialis. The volar approach commonly used today involves a longitudinal incision over the flexor carpi radialis tendon and takes advantage of an anatomic recess at the pronator quadratus fossa for plate placement. Although volar plates are not applicable to all fractures, the literature increasingly supports volar plate fixation with distal locking screws or pegs for older patients, including those with osteoporosis. One common method of treating extra-articular fractures is to obtain an open reduction and then apply external fixation using a volar locking plate. Surgical treatment is considered if closed reduction with splinting does not result in acceptable alignment." Volar plate fixation On the other hand, some older and low-demand patients may accept a mild or moderate deformity with acceptable function following fracture healing. Many older adults are now remaining more physically active, and they also may benefit from surgical treatment of a displaced or unstable fracture. With young patients, we tend to be more aggressive in achieving a more anatomic reduction of the fracture and the joint surface. "You have to consider a patient's activity level. In general, less invasive treatments that achieve satisfactory alignment and stable reduction of the bone fragments can lead to good outcomes." Treatment optionsįor older, less active patients and adults with low or moderate demands, closed reduction and casting are almost always preferred, especially for mild shortening of 2 to 3 millimeters (mm) and articular displacement of less than 2 mm, Dr. "All of these factors need to be carefully considered and individualized in order to achieve the best functional outcome while also minimizing risk. "The goal of treatment is to restore the previous level of function, but the appropriate treatment may vary, depending upon the patient's age and activity level, existing medical conditions, bone quality, and amount of displacement," he says. Dennison, M.D., a hand and wrist surgeon at Mayo Clinic's campus in Rochester, Minnesota. Radiographs are compared before and after reduction to assess for acceptable alignment in the cast or splint, and additional imaging, such as CT, may be used to look for other problems, such as carpal bone injury.Īlthough surgery is often considered for displaced and unstable distal radius fractures, optimal treatment depends on several factors, according to David G. The various fracture patterns and displacement of the fragments can provide a sense of fracture stability closed reduction and immobilization are then used to help determine treatment. In older adults, a large majority of distal radius fractures result from lower energy injuries such as ground-level falls, often leading to more typical extra-articular, dorsally angulated or displaced fractures. These injuries may result in fractures with metaphyseal comminution, and can, in some cases, cause extensive damage to the joint surface, fragmentation of the metaphysis, and injury to the ulna and triangular fibrocartilage. In young people, for example, distal radius fractures are often caused by high-energy trauma that involves various combinations of bending, compression, impaction and shearing.
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