All right, we're going to get started here. So thank you all for coming out this early. I imagine some people will trickle in as we get rolling here. So this is Instructional Course 37, What Every Hand Surgeon Should Know About Distal Radius Fractures, a couple of disclosures to run through. We have a great faculty this morning, Dr. Pedro Baragiclian from Thomas Jefferson University and a Chief of Hand Surgery at the Rothman Institute, Dr. Douglas Hannel from out here, University of Washington, Harborview, and Jeffrey Greenberg from the Indiana Hand to Shoulder Center. I'm also part of the Division of Hand Surgery from the Rothman Institute. We'll get started. You guys going to be able to see that okay? All right, so this first case, she's a 22-year-old right-hand dominant female. She fell while snowboarding. It's a closed injury. She's nervously intact. She presents to the office with no numbness or tingling. She has some mild visible deformity. These are her x-rays. So Dr. Hannel, when you see a patient with a wrist injury and you're looking at the x-rays of the wrist, what are some of the things that you look at? How do you start evaluating this problem? Well, the first part that I do it and you've given it away is I want to know everything else about you. I want to know about your head injuries, what happened, give me the circumstances, make sure that I'm not overlooking that and just focusing on the one injury that's not going to kill you. And so having done that as my first series of things, then my next maneuver with these patients is if I looked at that and I said, if I did nothing at all, and I'm thinking about this, if I did nothing at all, would you do okay? And if that stayed exactly where it was, would that be okay? And then having said that, the other thing, the other qualifier is, is how difficult would it be to improve this fracture and the location of this fracture? Because there's a couple things about it that when I look and break down a fracture that I may or may not like. I break my fractures up into what's stable and what's unstable. And the stability is metametaphyseal stability. And do I get a pointer? Do we have a pointer here? We don't, but I can serve as a little bit of a surrogate. If we go to the, just go to the lateral and the far right. I look at that amount of comminution. If that comminution is greater than one-third of the AP diameter, that's an unstable construct. You can, you may reduce that, but it's not going to stay there. That's number one. Number two is that, is that if I leave it just the way that it is, it's probably going to heal it. Even if I reduce it and reduce it perfectly, if I treat it closed and closed alone, that's where it's going to end up. We know that. That's the natural history of closed reductions. The next point that I have is, and looking again at the lateral radiograph, is I see a nice buried head. It's a true radiograph. The pisiform is sitting halfway between the tuberosity, the scaphoid, and the capitalin, and the scaphoid. So that is a true lateral. We do not have instability on that lateral reduction. And then as far as the articular surface goes and the transverse surface, I don't see any articular step-offs or breaks. So do you want me to go on how I would treat this, or do you want me to leave it at that? Let's leave it at that for now. Okay. Dr. Greenberg, anything else that you? The one other point that I make, and I do this all the time in the office, is comparison views. So, you know, you could look at this and you could say, well, the radial inclination is probably a little flat here. You know, if you just look at standard norms, but what's the inclination on the other side? You know, she probably has, she does have a little bit of reversal of her tilt on the lateral x-ray, but what is it on the other side? So, yeah. Dr. Hannel mentioned that he looks at the amount of comminution on the metaphysis to determine whether or not this is something that's likely to remain reduced or that's an indicator of stability of the fracture. Is that what you use as well? Yes, and, but it's qualified a little bit because I think that metaphyseal comminutia in a healthy 22-year-old person is probably a little different than metaphyseal comminutia in a 70-year-old person with osteopenia. So, I think that, you know, your potential for instability probably varies a little bit biologically and physiologically. Dr. Jekim? The other thing I like to look at is if you just point with a pointer to the volar cortex, there's a little bit of a step off, and in a more severe displacement, that's called a shell sign, and to me, as Dr. Hannel pointed out, it's really dorsal comminution, but also, in my experience, when there is any shifting of that contour of the volar cortex, they lose a lot of that buttress effect of a strong volar side of the radius, and when there's any significant displacement there, that to me is another potential predictor of instability. Yeah. Dr. Greenberg mentioned that he gets x-rays of the contralateral side. I have here a PA oblique and a lateral, or a little bit of an elevated tilt lateral, which I'll show you guys later. Are there any other x-ray views that you get routinely in evaluating wrist injuries, or is this adequate? It's adequate also. I, myself, would encourage everybody else to be very observant of a scapholuminate relationship. It's difficult to get good views when you have a patient that has a fracture, although you need to be very vigilant, and in my experience, that's one reason to look at the lateral side, just to compare. Dr. Agee, you've pointed to your elbow there. Do you routinely get elbow or forearm films in patients with wrist fractures? Yeah. So, routinely. I think that's a routine. I mean, to mention that, it still is, it's a basic fracture principle, the joint above and below, so we do that. So, just a couple quick things about x-rays. Just remember, these standard PA views don't compensate for the normal volar tilt of the distal radius. You can elevate the wrist a little bit and get a much more tangential view of the articular surface, and again, on the lateral view, where I think it's even more pronounced, you can see the standard lateral views really obscure some of the articular surface, and an elevated tilt view can be real helpful in evaluating the articular surface, both in the injured state and intraoperatively for looking at the quality of the reduction, as well as the extra-articular nature of your screws. Can you go back one more? Yeah. Just looking at that, if it's not a reminder for everybody, is I do, when I take somebody to the OR, I'm always, I always have a bump underneath the wrist, so that I'm always looking at these views at 10 to 15 degrees because of that. It just becomes routine. Your x-ray, you don't have to tilt your x-ray or your image intensifier. You just make your wrist come up by placing a bump under that. Do you think that there's any change, or maybe I should say any clinically relevant change, particularly on the lateral view, between your assessment of volar tilt with a standard lateral versus an elevated tilt lateral? And the reason I ask is, at first glance, it doesn't really seem like there should be, but I have noticed that when I try and measure volar tilt on a standard lateral versus an elevated tilt view, I'll sometimes get more dorsal tilt on the elevated tilt view. Yeah. Well, I think that's because you're really profiling the lunate fossil on the lateral tilt view, and that gets overshadowed by the scaphoid fossa on a routine. Yeah. I think another point, and this really, it really speaks more to your x-ray techs, but you know, you'll sometimes order trauma x-rays, and you'll just get a series of these obliques because your x-ray tech either doesn't know or is too lazy to do something to the arm. You know, in acute trauma, it's frequently hard to have the patient really assist you, but you know, just as these views show, you know, tilting the arm or tilting the beam can frequently give you the view you want, you know, instead of just taking it with the beam perpendicular to the plate all the time. Indeed. Dr. Barajiklian, you've written about the importance of changes in ulnar variance with forearm rotation. The magnitude is not that great, but it is there. Is this something that you pay close attention to when evaluating these fractures? I do. I'll give you a guide to determine whether or not there's any DRU-J instability. As Dr. Greenberg said, that's one added bonus of getting a contralateral view. In terms of getting, you know, the true neutral rotation PA, I'm not that uptight anymore about it, just because the magnitude is really very small, depending on, regardless of the rotation of the forearm. To that end, where do you measure your ulnar variance from? Do you use the dorsal? Do you use the trauma dorsal? Do you use the, what landmark do you use? I just use the very distal end of the ulna and the sigmoid notch of the radius in whatever PA or AP view I can get. How about you, Jeff, what do you do? You know, there's, if you look up measurement of ulnar variance, there's all different ways of measuring ulnar variance from, you know, using the volar lip of the radius, using the dorsal lip of the radius, using a ratio. Andy Palmer actually popularized, and I remember when I was a resident, he actually had these circular templates made, and we used to put these circles on, and you'd try to match the arc of the radial inclination and use that. And I think it really doesn't matter how you do it, but if you just do it the same way all the time, and for whatever system you do. So I personally use the volar lip of that corner right there, and I just draw a perpendicular, and then look at the most prominent portion of the pole of the ulna and use that. That's how I do it all the time. Yeah. I think the point is, whatever you choose, just do it consistently. Okay. So you had touched on this, Dr. Hanell. The question that you ask yourself is, is this alignment acceptable? Will she do okay if we leave the fracture like this? And the corollary question, what degree of malalignment do you accept? And I measured this at about 13.2 degrees, you know, from neutral. So is that an acceptable alignment? Is that okay in a dominant hand of a 22-year-old? Well, so in this particular case, I'm going to say just categorically, no, I don't think it's acceptable. Now, I'm going to throw this out. She comes to you because she's been bouncing around the system or whatever, and she shows up in your office, and we're now four weeks out. Is this acceptable? I'm not going to touch this at four weeks, okay? This is going to be acceptable for me at four weeks. Even though in this lateral, the thing that is the most bothersome is if you draw your straight line through the mid-portion of the radius, just that longitudinal line, just extend it, and notice that it cuts the capitate in a volar one-quarter, one-third, and dorsal two-thirds. That's just the opposite of normal anatomy. The center of the capitate ought to be well volar to the longitudinal axis of the radius. And so I use that as my determinant. Once I get past this neutral minus 5, if the carpus has translated or translocated dorsally, then I view that as not acceptable. And in this case, it's not acceptable. To be fair, I think this is a little bit of an oversupinated. I don't think it's a perfectly true lateral, but yes, for sure. I see what you're saying there. Dr. Greenberg? This, I'm just getting back to what I mentioned about a contralateral view. So I think that, you know, looking at what you're seeing here on the, that's a pretty good PA neutral. You see the ulnar styloid in almost full profile, which is an indicator that you have almost a zero rotation view. So I would call this, you know, based on the way I measure ulnar variance, I would call this, you know, slightly ulnar positive. And I think what you're seeing here is the secondary ulnar positivity from the malalignment. So this is one where, for sure, I would get a contralateral comparison view. And I would suspect that on her contralateral view that she's probably ulnar minus because this is, she has basically acquired ulnar positivity from the shortening. So, and the point that Doug made is, I think, critical is looking for the secondary carpal changes relative to what's going on, and not necessarily scapulonic association, but I think that's a key point. Now, getting back to, you know, this particular case, this is a 23-year-old person where, you know, my trigger point for doing something about this would be really different if this was a 75-year-old lady. Where is your transition point? You've got to be very careful about where you're going. So I just turned 57, and my point keeps changing every year of practice. No, I don't know. I think, you know, I really don't know. I think, I don't think you could put a chronologic age on it. You know, when people say, oh, anybody over 65 or over, you know, the old population over 55, you know, so I think when you're going to make a decision based on more physiologic age. So, you know, if people, you know, I have, I'm sure all of us have, you know, 80, 85, 90-year-old patients that are still driving, living independently, doing all their shopping, playing golf or other sports. You know, that's, you know, that, you have 50-year-old people that are, you know, diabetic with CHF that sit at home and have trouble pushing the TV remote. So I think, I think you have to just look at the whole, the whole patient. We talked about the stability of this fracture pattern. Dr. Berejiklian mentioned the shelf sign, which is the significant translation of the volar cortices. We frequently talk about the LaFontaine criteria, age greater than 60, dorsal comminution greater than 50%, dorsal angulation of 20 degrees, distal ulna fracture, or a displaced intraarticular fracture. This was a nice study. Dr. Greenberg had mentioned age of the patient. This was from Journal of the Hand about 10 years ago, looking at the risk of displacement based on the LaFontaine criteria, and they found that age was the most significant factor. And the risk of losing reduction was, took until age 58 before that was 50%. But you can see if you've maintained the reduction for a week after the initial reduction, the likelihood of subsequent displacement went down almost by half from the initial, from the initial risk. So here's the, here's the key question. The patient's sitting in your office. She's 22 years old. She's, you know, has a dominant handed injury, which we've all agreed is not acceptably aligned in her age and functional group. She has young age, which is in her favor. She has some dorsal metaphyseal comminution. How are we going to counsel this patient, Dr. Berejiklian? How would you treat this patient in your hands? Obviously, there's many different ways you could approach this. And I think, you know, we've really shifted towards plating pretty much everything that we see. But I think there's still a lot of value in a patient like this with good bone stock, young age, where you can get by with lesser invasive methods. And I think in a patient like this that is young, good bone stock, I think percutaneous pinning, if you can get an adequate close reduction, would be a perfectly acceptable way to treat. You don't have to worry about any implant-related problems down the line. She's only 22 years old, so she has about 65 years of potentially having a problem with the hardware. So in someone like her, good bone stock, minimal displacement, if you can achieve a good close reduction, intraoperatively, percutaneous pinning and casting is acceptable in my practice. Dr. Hanold? Yeah, this is, my approach to distal radius fractures is I don't really care how you get there as long as you get there, and so I do, I start with the simplest. If I could reduce this fracture and I thought I could maintain it in a splint, I would, I don't think I can. So my next step is to do a reduction in percutaneous pinning. If I don't think I can do that, then my next step would be fuller plating. Or plate fixation of some sort. Or this would be a perfect candidate for a non-spanning external fixture, as described by Margaret McQueen, because you could take two pins on either side of the radius through the 1-2 interval and then through the 4-5 interval and just rock that forward, put a second pin behind it, and you'd have a perfect reduction. Now you'd have to put up with a small external fixture for four weeks, but you could do that. It'd be an excellent result. Dr. Greenberg. You're the one that taught me it doesn't matter how you get there. It really doesn't. And I think any method that you get to get an adequate reduction and hold it there, but each method has implications for the patient. And I think the important thing is, aside from what your comfort level is, is the, you know, make sure that your patient understands what their comfort level is. You know, there's some patients, you know, you could obviously treat this. There's so many different methods to do that. You know, you could percutaneous pinning, as Pedro said. You could use John Tarras's T-pin, which is basically a glorified percutaneous pinning and a non-spanning fixator, a volar plate. You could do a dorsal plate. I mean, it really doesn't matter here. I just think that you have to be clear with the patient preoperatively what to expect. And some patients, you know, just have, you know, do not want to be in a cast at all, you know, for whatever reason, and you have to have, hopefully, you know, somebody you can have an intelligent conversation with. There's some patients you can have a conversation with, because they just can't understand, and you just have to make your own decision. But the methodology here, I don't think really matters. So. So I did have that. Yeah. Why don't you, yeah, see what the, sure. For each of the panel members, if this is your x-ray, what would you want on your wrist to say? You've got to, hopefully, that's what I'm saying. If you fall into that particular x-ray, what would you want for yourself now? I don't think you can get any more than that, but thank you very much. Yeah. So, you know, I love when that question is answered, because then it throws down and say, you know, if this is my wife, if this is my wife's friends, and about a dozen of their friends' kids, they're getting pinned, and they're going to put up with that cast, and they're going to love it, because they're going to have three or four little hash marks on the back of their wrist. And so I'm like the team physician for everybody's extra-articular fracture and pin fixation. So that's what they get. If this is my cardiologist, which it was, okay, he's getting plated, because he's an invasive cardiologist. If he's an intensivist, if it's somebody that is a very, very handed and depends on their life using their hands, yeah, I'm going to go to the next step. And that goes back to the conversation that Jeff was talking about. You have to find out really what the patient can put up with, and as much as what the patient will put up with. Dr. Bramjek-Leon, is it your wrist? If it was my wrist, I would get a volar plate. And again, you know, it's all, I'm not a 22-year-old snowboarder, never was. But, you know, in someone like me, or any, as Dr. Hammel was saying, any professional that is dependent on their hands for function, then you go do whatever you can to avoid, or to minimize post-operative mobilization. And obviously, plate and screw fixation is the way to go here. Yeah, I mean, for me, I'd want to get back in the operating room, and back in the wood shop and on the golf course with the least amount of post-operative mobilization. And I think if you look at those criteria, that having volar plate fixation probably gets you there quicker, so. Just by a show of hands, is everybody fixing this in one manner or another? Everybody? Anybody? Anybody not fixing this? So, when do you see them next, after your reduction? Yeah, I think that's, if you're going to, if you're going to treat them closed, you have to follow them every week. And you have to make sure that that first x-ray, your best reduction x-ray is the x-ray you're comparing to. You're not comparing week two to week one, and week three to week two. You have to compare week three to week one. And if it's not acceptable, or if it's drifted, it's going to continue to drift. I have a, Dr. Kitt, this person is going to have no. or race down the road. That costs him $150. He should give him a plane ticket to Seattle. Everybody's got insurance. This is the Socialist Republic of the United States right here. I just have a comment about that reduction and follow-up on a weekly basis. I mean, I think theoretically it makes great sense, and it's sort of what we're taught to do, and it's perfectly reasonable on paper. The problem I have with that approach is that you get a good reduction week one, see them the next week, they kind of fall apart a little bit, but they still look okay. Second x-ray the week after that looks terrible. The problem with that, though, is, at least in my hands, fixing this fracture three weeks later and fixing it at time zero is a completely different animal. And every time I do this, and I have done this and I'll probably do it again, when I'm in surgery trying to fix this three and a half weeks later, breaking up callus and having a difficult time getting a good reduction, I kick myself and wish that I had pinned it three weeks ago. Yeah, that's a good point. So I'm glad that there are two of us like-minded folks in the room today. So I did talk to her about the variety of options, and we agreed on an attempted closed reduction in the office. I do want to make sure we have time to move on to our next case. But Dr. Hanel, if you were going to reduce this or in the operating room, if you're going to reduce and pin this, how do you do that? Actually, anybody that has ever listened to me lecture on distal radiuses, the second step in distal radius fractures is the reduction maneuver, and I just call it the Agee reduction maneuver. And it's a reduction maneuver that was lost in an article on external fixtures in the orthopedic clinics of North America in the 70s. But I always quote it and I always illustrate it. But John Agee is right here. But in it, he described longitudinal traction, volar translation of the hand relative to the forearm, and slight pronation, not supination, slight pronation of the hand relative to the forearm, not the forearm relative to the elbow. And when you do that, what ends up happening is you just and it's a very gentle maneuver. And what it does is it just translates the whole hand over. And it's well described, and it's an easy maneuver, and I use that more than CT scans to identify the personality of distal radius fractures. It's 10 pounds of longitudinal traction, and then the reduction maneuver, palmar translation of the hand relative to the forearm, pronation of the hand relative to the forearm. And that's what happened. That's what you did there. Indeed. And so we talked about the post-reduction protocol, weekly x-rays. I don't have her follow-up film. She was eventually treated non-operatively. It actually fell off, and then you had to fix it. You paid real sign. In the office? In the office. Using a hematoma block. Because my feeling about this, I mean, obviously it's an anatomic reduction, but if I have to take somebody to the operating room to do a closed reduction, then the additional morbidity or additional time of just putting a couple of pins in is no issue for me whatsoever. I agree completely. Yeah. If they're going to get anesthesia, I don't want them to have it twice. Yeah. Yeah, I agree. Is that you reduce these in the office or you reduce these in? Anybody using vitamin C routinely for distal radius fractures? Yeah, good number, maybe 30%, 40%. I do. Why? I guess the question I ask myself is why not. The information is out there. The AOS guidelines are out there. And the morbidity of vitamin C is negligible to zero. So maybe it does nothing, maybe it's voodoo, and it probably is, but it also does little harm. So the same guys that said use vitamin C to prevent reflex sympathetic dystrophy have said no, it really doesn't in the same study. But I agree that, especially I'm in Seattle, where patients come in, well, the 12 things that they are also taking, that they got over the international district, so always vitamin C is part of that. And I think we all face south and bow to Linus Paul because that was supposed to take 1,000 milligrams a day. So I agree with you. No harm comes to you by taking that. But if you really think that you're preventing your patients from having reflex sympathetic dystrophy, because of it, you're not. And where does that come up? That comes up when the patient who had reflex sympathetic dystrophy comes and sues you and you didn't put them on the vitamin C. And so this is now in the court records in the Pacific Northwest that it isn't. It has no effect on reflex sympathetic dystrophy. And that's where I think it's important. Because you have the AOA, you have the academy saying that this is their guideline. And you have lawyers that say the reason that this happened is because you didn't follow your organization's guidelines. And so it's important for us as a body to make sure that we cover each other's back in what we do. Just one brief mention here. I think as a group, I think we don't do a good enough job of evaluating patients for low bone mineral density. And we can be the gatekeepers of this. Oftentimes we're the first people to evaluate patients for this. And I think we as a group, and certainly myself included, don't do a good enough job of doing this. Any questions specifically related to this case or nonoperative treatment? Yes, ma'am. Yeah, that's a good question. It varies dependent on the patient, their willingness to try a clothes reduction or unwillingness to go to the operating room, and my sense of what their toughness is. And so ideally, I think this works best and is most comfortable within a day or two, three days maybe. I've done it five or six days out, but it really depends on the comfort level of the patient. And as Dr. Hanno mentioned, it's a gentle maneuver, and I tell patients if they decide they want to try it, that if it's too uncomfortable for them, then we bail and go to the next option. Do you practice in Great Falls, which is a population that's not quite as tough as people from Wisconsin? So in your practice, how long will you do it? You'll do a hematoma block up to a week out? Because now the patient has been in the emergency room, and then three days later there's a hematoma block, and then three days later there's a hematoma block. Just to repeat that, this is the national trend. The national trend is the patient gets seen in the ER, then it gets referred to an injury center. The injury center then clears the patient through whatever health network you are so that we are seeing, for the most part, patients at six to seven days post-op. And you used hematoma blocks at seven days out? Okay, and it was successful? And no, it wasn't. Okay, so when do we call back? I mean, I don't use hematoma blocks. Why don't I use hematoma blocks? Because I'm a residency director. I don't have to. So I don't know how to advise that because it's not me that has to put up with a screaming patient. But I think that beyond the first couple days, I think that beyond 72 hours, it's not going to work. I'm not sure if what you're calling a hematoma block at five days is really just local infiltration of anesthesia. Because once your hematoma is coagulum, you're not going to, I mean, when you do a hematoma block, you're actually, you know, you're aspirating hematoma and substituting lidocaine for the hematoma. So, you know, as residents, we used to do that all the time. But you got those people within a few hours of their injury, and you aspirated 100 cc's of hematoma and put in, you know, 50 cc's of lidocaine. So it's not a hematoma block, I think, after probably 48 hours. Yeah, I agree completely. And that's why it's in large part for me, especially in those later time points, dependent on the toughness of the patient and really just how patently unwilling they are to go to the operating room. Kevin, what's your general experience with these blocks? I mean, how often, at least anecdotally in your practice, how often do they work? Work in terms of obtaining a reduction or work in terms of maintaining adequate analgesia to try? Work in terms of either getting a reduction, an adequate reduction, plus maintaining that reduction afterwards. So, you know, I do this in the office in the patient exam room, and so there are, you know, patients in the exam rooms next to them. So, you know, I have a pretty, you know, it's pretty important that the patients are not screaming in the exam room because, you know, obviously it's not great for the other patient's confidence when that happens. But I would say patients are generally very comfortable when I do it. I use 10 cc's of lidocaine. I will hang them from finger traps with a little bit of counterpressure for about 10 minutes while I go and do something else and, you know, see another patient. Roll out the splint and, you know, get things ready. The reduction maneuver, as Dr. Hanel described, and, you know, done very gently. And so I would say it's generally been my experience that patients are very comfortable with doing it. The success rate, I think, is variable, and anecdotally I would say most of the time the fractures are better. I would have to guess maybe 50% to 70% of the time I'm able to get the fracture acceptably aligned. All right, this is case number two, 61-year-old, right-hand dominant female, fall downstairs, has a closed injury. She's nerve-vascularly intact. I'm sorry that I don't have her pre-reduction films, but these are her post-reduction x-rays. Dr. Greenberg, how would you approach this injury in this patient? And I'm assuming this is just isolated injury. Isolated, isolated. And nerve-vascularly intact. Nerve-vascularly intact, closed injury. So this is a different animal than the previous case we saw, obviously. This is a patient that has an impaction with a big intra-articular split, incongruency of the radiocarpal joint, loss of inclination, loss of tilt. And this would be one where, once again, all the socioeconomic and physiologic factors play into this. But, you know, without any mitigating circumstances, this is one that I probably would not need any additional diagnostic studies, and I would fix this one. When do you obtain any additional diagnostic studies, particularly CAT scan? I mean, that would be the most common next step. If I need additional information that's going to potentially change an approach, then I will get a CT scan. If it's not going to affect my surgical approach, then I really don't think that it adds a lot of additional information. I mean, I think you can get most information that you need from fluoroscopy and multiple views intraoperatively with fluoro. You know, I tell patients all the time that, you know, most of the time, you know, we'll approach this with Volerle, but I say, you know, we might have to go dorsal. And there's many patients where they have two incisions when they come out of the operating room. I think you could pick up the lunate facet deformity after fixation intraoperatively and address that however you need to, either dorsal or Volerle combined. Yeah, I think the use of CT scans is directly proportional to the number of years out of training. And so the first five years out of training everybody got a CT scan. Every one of my patients got a CT scan. And now in any given year I probably get one. Or it's a serendipitous CT scan because they happen to be in the scanner because they're getting a trauma workup. Or the ER doc got one for whatever reason. So I think more and more and more and more. We use less and less CT scans. But if you if we took a poll of our faculty, my 40 year old faculty is getting a lot of CT scans. The 50 year old faculty not so many. And I'm 65 so I rarely get a CT scan. And that's not to condemn CT scans. It's just that pretty soon you become familiar with pattern recognition. I think we get driven by pattern recognition. And that's what Jeff is talking about here. Because he's looking at this and he's going, you know, I think I can get this for everything from Voler. But there's this dorsal ulnar fragment that is going to drive me nuts. And I'm going to be very very quick to jump on that with a secondary incision. I will just make a comment that and I'm sure that many of you have the same experience. But it is unbelievably disturbing how many times I see a patient from the emergency room with no other injuries. Not a trauma activation or anything. Just a patient with a distal radius fracture that comes to my office with a CT scan that the ER physician ordered with no intention to treat based on that information. You know I think that's something that should be condemned. So. Dr. Jekyllen, is that your approach as well? You make that that decision kind of on the fly in the OR based on the intra- I mean obviously your assessment of the x-rays and then your assessment of the fluoro intraoperatively? I absolutely agree with Dr. Handel. You know we wrote a bunch of papers on CT scans early in my career. And the reason for that is because I would scan everybody. And so we had a lot of scans to evaluate. I rarely do it now. Although certainly for the younger members in the crowd, fellows, residents, you know getting a CT scan it can be you know allays your anxiety preoperatively because at least you have more information. As Dr. Handel also said you know the personality of the fracture really can be very well determined intraoperatively with fluoroscopic evaluation. Although if you know this ahead of time if you're in your first year of practice and you have all your hardware all the metal that you think you need, you may sleep a little bit better the night before. If you look at and read and you should read Pedro and the co-author and the senior author was Dave Vazenka. It's those papers are really really important because it taught all of us that the sigmoid notch is really important. And it was those papers now 15-20 years ago that drove us to the point that said if you fix the sigmoid notch, if you recognize that the sigmoid notch and sigmoid not fractures need to be repaired, you don't have to fix the ulnar styloid. You don't have to deal with that. That by its nature is the reason why Mark Ross who's in Australia hasn't fixed any ulnar styloid fracture in the last 20 years because of that. And it's because of the information that was driven by those papers. And so if you need that in your CT, if you need a CT scan to prove that you need to do that, then I'd continue to do that until you get into the form of pattern recognition. They say I don't, I'm gonna recognize that by my my fluoro, my fluoro views and my interoperative findings. So we talked about some of these these studies as as Dr. Hanno mentioned. CT scans can have some effect. I'm only 39 so I got a CAT scan here. So with this information, Dr. Hanno, how would you approach this fracture? I'm still a guy who does vulnar plates and tries to put these things together. And I come from an institution, I have partners that would immediately on this fracture looking at this fracture and is presented here that they would actually span this. They would do, they would take just straightaway reduction maneuver, a spanning plate through the second compartment and put together some of the articular fragments. And I still take my time and try to put them together. But those are those are the two options that that they're up here. I don't think that this is something that is amenable to pins alone. I don't think it's amenable to to Kapanji pinning techniques. I think that something that that sustained longitudinal traction, either an external fixture or an internal fixture, and pin fixation of articular fragments could be an option that some people use. Or fragment-specific fixation. And I'm sort of a fragment-specific fixation guy. So and I'm not a fragment-specific fixation guy, but one of my concerns in looking at this fracture was the the dorsal fragments here and the relatively small and somewhat distal volar lunate facet fragments. So if you were going to approach this from the volar side, how would you stabilize, reduce and stabilize those components of the fracture? So just going back with the thing that that I think is really really helpful for me is in doing my reduction maneuver, when you do AG's reduction maneuver, the thing that's really really alarming is as you translate the hand volarly, that the carpus just keeps going volarly. And it keeps going volarly because of that fragment that you see. Right where the arrow is, is that's the volar medial corner. And that is the key stone, the cornerstone of the distal radius. And so the most important fracture fragment that you can fix, the one that has to be fixed best, if for want of a better term, is that particular fracture fragment. And so I like to open those up. I'm still of the belief that looking at that AP, you know, getting a hold of that and being able to control that. My incision is going to be a medial incision and I'm going to go through the interval between the ulnar neurovascular bundle and the carpal tunnel. So I'm looking directly down and I'm able to to put in my fixation through a direct approach as opposed to a bit of an oblique approach. And every time then I'm on a panel with with George Orbey and Jorge will say, you know, no you don't need to do that. And I go, you don't need to do that. I do. And I still use it and I use that approach to get to that particular fracture fragment. And so then I would use that to reduce my volar ulnar corner. And then I'd go over to the radial side of the wrist and complete my reconstruction. And I may go dorsally. Now the other thing that happens with these is that you get in there and you fix the volar ulnar corner. And then you've gone over and you fix the radial styloid or the radial column. And everything's there but it is just, I see this huge hole in it. And do you reinforce it with bone graft? I do. And you've done that. And then after you've done all your fixation, you are obligated to repeat your AG reduction maneuver. And if anything moves, then that's where my bailout would be to add some sort of longitudinal fixation. And that would be a spanning plate in that particular set. And that's one of my indications for for using spanning plates. Dr. Berejiklian? Given the amount of articular involvement, given the amount of significant dorsal fragments in my hands, I just cannot fix this from the volar side. I think you need to pay attention to the volar ulnar corner. You need to make sure you fix that. But in this case, I absolutely would be prepared and ready and very likely to go dorsally to add a buttress method of fixation for the large dorsal fragments. And also to look at the joint surface. Because even your flora will lie to you. And one of the benefits of the forgotten art of the dorsal plate is that it really allows you visualization of the articular surface. And in a young person or in a person that has a significant amount of articular deficit, recognition of that via direct inspection from a dorsal capsulotomy, I think, can really make a difference in restoring the articular surface. Dr. Greenberg? I would approach this, my initial approach to this would be would be volar. And I think, I mean, I've been able to get to the volar ulnar corner from a radial incision. There's nothing wrong with using a different inner muscular interval from that same incision, you know, if you need to get over there. So you could still sneak over to that side. But when I encounter, I mean, I think you have to get that volar piece fixed. And I'm just not talented enough to fix that in a fashion that I'm comfortable with from the dorsal side. Now that is a really distal small piece. And the difficulty with, I mean, granted some of the manufacturers say that, you know, they have plates or they've modified plates where they can go right up onto the articular surface. But it's, you know, it's bulky hardware that you put distally. And when I see these small pieces like this that I can't fix with a plate that's in the appropriate position, what I frequently will do is, you know, Jesse Jupiter has a whole series of, it's more for the fracture dislocations of all different creative forms of fixation for these small volar pieces. And I'd probably, if I could not get a volar plate on that, I would probably tension band that little piece and then go dorsal and put a dorsal plate on. Just one more thing. As Dr. Handel mentioned, you know, having the ability to span this, to put a spanning plate or a bridge plate as a bailout in this case, I think is absolutely essential. And I think this is something that I would definitely have available for me in the operating room. For those in the audience who are not familiar with the bridge plating as pioneered by Dr. Handel, I mean, this is one of the paradigm shifts in my practice over the last five years. This really has had a huge impact in how I treat these fractures. And even though going right off the bat to a spanning plate in this case may seem a little excessive, I think it's not wrong and I think you can get an excellent radiographic and clinical outcome if you treat this patient with that plate. As mentioned, as you sort of alluded to, it's a very distal piece of the volar ulnar fragment of the ulna. So if you use one of those marginal plates, the very distal plates, more likely than not you're gonna have to go back to the OR anyway and take it out. So this patient, regardless of how you treat it surgically, likely has two operations. One to fix it, one to remove some sort of hardware. So in this particular case, with what I know now, the spanning plate is going to be sitting in the back bench ready to be utilized. So there's one other thing that, and every time I come here and listen to people that are a lot smarter than me, which is most everybody, is Dave Davison would reduce the volar fragment and then he took and just right down, like he was using like a trimad pin plate, he would take two 035 wires, pass it right down the apex of that teardrop, almost to the far cortex, and then by hand just bends those wires over and takes his volar plate and pushes it against that as a buttress. And he presented a series here, and it is really clever. It's a very clever, dumb, simple, I mean it's so simple and so obvious that we would do this. We do this in hips, pelvis, and this, you know, using push plates that just take two, three, five wires and then he just bent them down. He directed them dorsal and radial as he passed them down and then he pushed them down then just incorporate that into his into his volar plate. That's an extremely clever, simple way to do that. I'm doing it with maybe one spoon, with a plate, but I've seen many cases that actually you just lose and you end up losing everything, so as he said before, it's very important to have some kind of planning, either with a plate or a plate. And what I've done a few times is very similar to what he said. I've put on one or two tape wires in the tip. I pass it through the other side, the dorsal side. I bend it, and then through the dorsal side, I just drive it down so I can put it very near to the, very flat to the cord. Yeah, right. So basically, it's reduction, allocate wires, and make your definitive fixation, and it goes back to the issues. I don't care how you get there, as long as you get there. That's the point of the series on the fracture dislocations, is that you have to be creative and the method doesn't really matter. We all have materials and options in the operating room, you just have to get this reduced and then stabilized in some fashion without causing secondary problems, like a boulder plate that hangs over the radiocarpal joint, or is distal to the watershed line. So with all that in mind, this is what I did. So I treated this with a spanning plate, I felt that that would give me good stability and allow me to get a good, I was able to get a good reduction indirectly of the articular surface and maintain this with some stability. Dr. Hanel, you've really taught us about the spanning plate and that was not your first choice for this fracture. What are your thoughts on this? So here's the only, and it's what I say here, and probably what my reality is. My reality is I would have gone bowler first, and I would have fixed that bowler on a corner and then looked at that, it would have been probably very obvious that I had all this combination in an unstable fracture, and then I would have gone to this fixation. Just a couple comments about this particular implant, is as they heal and they get better, they're going to put a lot more stress on that. See that central hole, that hole number three? That's a stress, that's a huge stress riser. And if they break that, they will know, obviously, they'll have wrist motion and such. And that is a surgical urgency, not an emergency, but a surgical urgency. As soon as somebody breaks that plate right there, if you leave that in there for a week, 10 days, they're going to start tearing tendons apart. I would never use this implant in the fourth compartment. I use this implant only in the second compartment. If I'm going to span through the fourth dorsal compartment, I'll use anything. I'll use something that's a 2.7, I'll use a 3.5 for doing that. But mostly because there's a hugely catastrophic case that was presented to me where a patient has this implant in the fourth compartment, breaks it at that third screw hole, calls the doctor's office. The doctor happens to be on vacation, sees a PA. The PA says, you know, it's broken, it'll be fine. Ten days later, ruptures all of her fourth compartment tendons. And then on 12 days, 14 days later, she then finds somebody who will take care of her tendons. And so I really wouldn't use that. There are three plates available now by three different companies, all of which are very, very good, all of which now are part of their armamentarium of distal radius fractures. And one of them has eliminated these central holes. I think that's a reasonable thing. Great. Yes, sir? Okay, so the question is, is this more effective than an external fixture? And the answer is absolutely. And we've proven that, and we've proven that now in very large statistical numbers that are up in the 500s. And just taking a cohort of patients and looking at them for a year. And this was a bet. People were saying that, you know, we don't need to do this internal fixation. I go, yeah, we do. And so I had one partner who went directly to this, followed all these patients for a year. This was presented by Alex Lauder, L-A-U-D-E-R. It's in this month's issue of the Journal of Hand. And if you look at the results, the grip strength of the injured hand is 95% of the contralateral hand. If it's a dominant hand injury, it's 95% the range of motion, flexion and extension, of the non-dominant hand. If it was a non-dominant hand, they only got 75% of their flexion back. And so it's truly remarkable how these patients have behaved. And I think it has a lot to do with sort of the minimalist approach to the soft tissues and soft tissue management. So the argument for why is this better than an external fixture? It's better than an external fixture because it is the stiffest external fixture you can have. It keeps the pins apart. You have your crossbar is as close to the bone as you can. It keeps you from volar translating. It actually reduces the carpus into the fossa and holds it there better than that. And without extra pins, this alone matches all of the numbers that were demonstrated biomechanically by Scott Wolf. And there's another Wolf, a guy named John Wolf, who is now a foot surgeon, foot ankle surgeon in Boise, Montana, was a medical student here that demonstrated all of those biomechanically that it actually was and is a better implant. Thank you. So that's actually all the time that we have. But just in light of that, Dr. Hanel and the rest of the panel, I would ask you, is external fixation obsolete? Is this something we should no longer be teaching our residents and fellows? Is this something that still has a role in the treatment of distal radius fractures, spanning external fixation? I don't think anything's obsolete. And I think that everybody should still know how to do external fixation, especially if you find yourself in other parts of the world where you're trying to take care of these injuries and you have to invent something based on what, I think you still have to know how to do external fixation. I personally have, in my practice, have abandoned routine external fixation for internal external fixation using a spanning plate. But I don't think external fixation is obsolete. And if anybody wanted to treat that particular fracture with a traditional spanning external fixator, I would say that's perfectly reasonable treatment. Do you think that spanning external fixation will become obsolete by necessity, given the fact that you train residents and fellows and are not using external fixation? I mean, I've put on a handful of external fixators in my practice. I'm sure if we asked Dr. Barajiklian, I don't know how frequently you use it. It's not something that trainees are exposed to frequently anymore. I think just like close reduction techniques are kind of falling by the wayside. I think we talk about it a lot, but I think that there's a lot of things that we used to do that are not being taught. And I'm sure there are some residents that come out after five years of orthopedic residency that probably never put on an external fixator. Yeah. Yeah. If you want to strike fear into a hand fellow, just tell him that you want to do a dorsal approach to a wrist. I mean, it's unfamiliar territory, as Pedro alluded to, but people don't know how to go to the dorsum of the wrist. So I think that is the external fixator obsolete? Absolutely not. And yes, we use it with less frequency, and because of that, you have to pay attention to the detail of doing them and doing them well. But yeah, it's still a tool, and I continue to use it. I live at Harborview, so our residents know how to put external fixators on all kinds of things. Yeah. Yes, sir? How about a very difficult injury, like a fracture, very demanding case, imminent, professional decision? Do you basically do a wrist arthroscopy as part of your practice? No. So Jeff is not. Pedro, are you doing wrist arthroscopy? So the only time that I actually do, okay, a little bit, but I use a dry scope. And what I do is it's an open. If I'm doing Volar, okay, and my X-ray, my fluoro is just doesn't look right, and I don't have a reason to go dorsal, I don't have this big dorsal ulnar fragment, then I'll actually do a dry scope through a Volar approach. So there's one fracture pattern where I will do arthroscopy, and that's a big, like, chauffeur's fracture, like a big, just a radial stylet, and I do that for two reasons. One is that it's a relatively simple fracture pattern, so I think you could do that pretty quickly, and the other is that that's a fracture that's associated with carpal instability. So in that situation, it'd be nice to actually visualize a scapula ligament, even if nothing is present radiographically, that would indicate that that's a greater arc type of injury. But I think arthroscopically, that's relatively easy to see that single fracture line, and just that I usually fix with just cannulated screws, so. In all, every attempt I've made at arthroscopically evaluating the joint surface in a distal radius fracture, I have yet to be able to see anything with any clarity. Maybe I'm just not a good arthroscopist, but I can never see anything, so I tend to make a small capsulotomy and do it by direct inspection. I have been able to have the privilege of watching Will Geisler do these arthroscopically, and it's genius. I mean, it's an art form, and unless you're Will Geisler, I haven't been able to get to that level of quality in my arthroscopic skills to do what he does, but if you are, it goes back to that issue. If that helps you get that fracture reduced, then use that technique, if there's any message to take from this. Great. How many people do, how many people in the audience use arthroscopic-assisted reduction of distal radius fracture? Arthroscopic reduction? Assisted reductions? Anybody? The most difficult to cure. Yeah? Okay. Say again? Just for the most difficult, many pieces of injury to cure. You would use it in that situation? I would. Okay. One? Basically. Cool. All right. Thank you. All right. Thank you guys very much.

hand surgeons

distal radius fractures

treatment options

closed injury

fracture stability

percutaneous pinning

casting

volar plate fixation

patient factors

diagnostic studies