Management of a Complex, Multioperated Intra-Articular Distal Radius Fracture

Abstract

Distal radius fractures predominantly affect two adult population groups: elderly patients with fragility fractures and young adults following high-energy trauma. These injuries represent 20% of all adult fractures, of which up to 50% have an intraarticular component. The development of posttraumatic arthritis following intra-articular fractures is well known, resulting in pain and functional impairment. Malunion causing articular step-offs leading to changes in contact stresses may result in degenerative changes. 1 For this reason the management principles of intra-articular fractures aim to achieve anatomic reduction and fixation to restore joint line congruity.One of the key focuses is the articular support of the carpal bones, with articular alignment and congruity thought to be most important in restoring pain-free wrist function.The main compromised joint in distal radial fractures is the radiocarpal joint, 2 but distal radioulnar joint (DRUJ) involvement is also frequently observed, particularly when the fracture involves the sigmoid notch. This can have damaging effects on upper limb function and increase the morbidity of the fracture. With patients in whom the DRUJ is involved or dysfunctional, restoration of normal anatomy is key, to enable free rotation to position the hand in space appropriately. Keywords► distal radius fracture ► distal radioulnar joint (DRUJ) ► hemiarthroplasty AbstractBackground Intra-articular distal radius fractures can have many complications, including radiocarpal osteoarthritis and distal radioulnar joint (DRUJ) dysfunction leading to pain and restricted wrist function. Case Description We describe the case of a 38-year-old patient who sustained a left distal radius intra-articular fracture, which was treated with volar plating. She developed pain from the radiocarpal joint as a result of intra-articular malunion and was listed for total wrist fusion. On the day of surgery this was converted to a Darrach procedure for minor DRUJ symptoms. This resulted in pain from the DRUJ as a result of instability, in addition to persisting radiocarpal arthritis pain. Due to her subsequent poor wrist function, she presented to the authors and underwent DRUJ arthroplasty with a proximally placed Scheker prosthesis to deal with her DRUJ symptoms and, later, a KinematX radiocarpal hemiarthroplasty for her radiocarpal symptoms. She remains happy with her outcome at 36-month follow-up. Literature Review The complications of the Darrach procedure include painful radioulnar convergence and wrist instability. The Scheker prosthesis allows restoration of stability of the DRUJ with good outcomes and 100% 5-year survival in one series. Sparing the midcarpal joint, the KinematX hemiarthroplasty allows preservation of the dart thrower's motion arc, which is key in many complex wrist movements and functions. Clinical Relevance This case highlights the negative consequences of distal ulna resection and shows both the Scheker and KinematX prostheses as viable, effective means to restore function to young,...

Advances in MRI around metal

“…While small scaphoid screws may be imaged without major limitations, more complex hardware such as the frequent palmar ORIF for distal radius fractures causes more severe artifacts even when using advanced techniques. Concomitant injuries to cartilage, ligaments or triangular disc as well as carpal injuries or posttraumatic osteoarthritis may be depicted on MARS imaging …”

Distal Radioulnar Joint Replacement in the Scarred Wrist

“…These include arthritis either isolated or in conjunction with prior trauma or inflammation, instability, or failed prior reconstructive procedures. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Placement of the radial component of the implant at or near the original sigmoid notch will optimize its overall function and limit/undo stresses on both components of the implant. In the face of prior wrist surgeries, this may prove technically more difficult.…”

Case Report of Customized Distal Radius Prosthesis Replacement: An Alternative Treatment for Post-traumatic Unreconstructable Intraarticular Distal Radius Malunion

“…Unreconstructable intraarticular distal radius malunion can lead to severe pain and functional impairment, which result in significant deterioration of patient quality of life. Aiming to achieve a painless, functional range of motion of the wrist, many treatments have been proposed based on timing, osteoarthritis involvement, malunion configuration, and patients' functional requirements [1,10,11]. Re-cutting the displaced fractures and reducing them anatomically is one of the proposed options.…”

“…We needed to use tendon grafts to reconstruct dorsal radiocarpal ligaments and distal radioulnar ligaments atomically and sew the soft tissue around the joint to the prosthesis's pores to enhance stability. In the 36month follow-up report of a young patient with malunion of the distal radius treated with hemiarthroplasty and DRUJ arthroplasty, flexion/extension arc of 60°, pronation 90°, and supination 80° were documented [1]. A report of hemiarthroplasty in an elderly patient with unreconstructable distal radius fracture showed 25° flexion, 37° extension, 80° supination, and 70° pronation at 28 months postoperative follow-up [11].…”

“…Distal radius fracture represents 20% of adult fractures with the intraarticular component accounting for as much as 50% of cases [1]. Without achieving anatomic reduction, malunion alters contact stresses resulting in posttraumatic arthritis [2].…”