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  • Summary
  • Epidemiology
  • Etiology
  • Anatomy
  • Classification
  • Presentation
  • Imaging
  • Treatment
  • Techniques
    • Closed reduction and immobilization
      • technique
        • reduction
          • requires adequate anesthesia
          • apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment
        • immobilization
          • can be in below elbow cast or splint depending on fracture pattern and patient
          • avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position)
            • due to risk of carpal tunnel syndrome
        • rehabilitation
          • no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization
        • outcomes
          • repeat closed reductions have < 50% satisfactory results
          • LaFontaine predictors of instability
            • radial shortening is the most predictive of instability, followed by dorsal comminution
            • severe osteoporosis
            • associated ulnar fracture
            • dorsal comminution > 50%, palmar comminution, intraarticular comminution
            • dorsal angulation > 20°
            • initial displacement > 1cm
            • initial radial shortening > 5mm
          • higher loss of reduction with 3 or more of LaFontaine criteria
          • Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old)
        • complications specific to this treatment
          • acute carpal tunnel syndrome
          • EPL rupture
    • CRPP
      • technique
        • Kapandji intrafocal technique
          • K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius
        • Rayhack technique with arthroscopically assisted reduction
      • complications specific to this treatment
        • radial sensory nerve injury
        • pin tract infections
    • ORIF
      • technique guides
        • distal radius extra-articular fracture ORIF with volar approach
        • distal radius intra-articular fracture ORIF with dorsal approach
      • types
        • volar plating
          • preferred over dorsal plating
          • associated with irritation of both flexor and extensor tendons
            • rupture of FPL is most common with volar plates
              • associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons
          • can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius
          • new volar locking plates offer improved support to subchondral bone
        • dorsal plating
          • indicated for displaced intra-articular distal radius fractures with dorsal comminution, polytrauma patients, or elderly patients
          • can allow immediate post operative weight bearing (front wheel walker assistance)
          • avoids complications associated with wrist-spanning external fixators but similarly must be removed via second surgery
          • historically associated with extensor tendon irritation and rupture
      • technique
        • can combine with external fixation and percutaneous pinning
        • perform bone grafting if complex and comminuted
          • the utilization of calcium phosphate demonstrates radiographic evidence of successful incorporation into the host bone at 1 year postoperatively
          • calcium phosphate possesses osteoconductive and osteointegration capabilities allowing for incorporation into host bone 
        • study showed improved results with arthroscopically-assisted reduction
        • volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure
      • complications specific to this treatment
        • screw penetration into the radiocarpal joint or DRUJ
          • assess intra-articular screws with a 23 degree elevated lateral view
          • assess dorsal cortex penetration with a skyline view
        • tendon rupture
      • outcomes
        • Formal hand therapy has been shown to improve DASH scores and active range of motion at 6 weeks but not at long term follow-up when compared to self-directed home exercise programs 
    • External fixation
      • technique guides
        • distal radius fracture spanning external fixator
        • distal radius fracture non-spanning external fixator
      • types
        • spanning ex-fix
          • useful for fractures with small articular fragment
        • non-spanning ex-fix
          • useful for fractures with large articular fragment
      • technique
        • relies on ligamentotaxis to maintain reduction
        • place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
        • avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation
        • limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
      • complications specific to this treatment
        • malunion
        • nonunion
        • stiffness and decreased grip strength
        • pin complications (infections, fractures through pin site, skin difficulties)
          • pin site care comprising daily showers and dry dressings recommended
        • neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
  • Complications
  • Prognosis
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