Department of Orthopedics and Traumatology, Escola Paulista de Medicina Federal University of São Paulo Trauma Upper Limb MC196

/04 FLÁVIO FALOPPA dr. LUIS RENATO NAKACHIMA dr. JOHN CARLOS Bellotti prof. dr. Editorial It is with great pleasure that we continue the publication of the series "Semina rs in Orthopaedics." Our specialty has been experiencing an extraordinary evolut ion in the development of new treatment techniques and the emergence of instrume ntal and material increasingly differentiated. The objective of this initiative is to update some important issues in daily activities and frequent Brazilian or thopedists. The issues are always developed by colleagues of our Department, spe cializing in several areas of Orthopedics and Traumatology. We thank Merck Sharp & Dohme sponsorship and distribution of this material and greet the EPM Project Publisher Doctors - high quality graphics for this work. Prof. Dr. Walter Manna Albertoni And Head of the Department of Orthopedics and Traumatology, UNIFESP / EPM Volume 7 seminar in orthopedics 1 CONTENTS pp. 3 pp. 15 seminars in orthopedics Scaphoid Fracture Fracture of the distal radius EDITORS prof. dr. WALTER JOSEPH MANNA ALBERTONI LAREDO FILHO prof. dr. EDITORIAL COUNCIL prof. dr. AKIRA ISHIDA DANILO Masiero FLÁVIO FALOPPA REYNALDO JESUS GARCIA-FILHO Vilna MAT TIOLI MILK prof. dr. 2 7 prof. dr. prof. dr. Volume prof. dr.

AUTHORS prof. dr. FLÁVIO FALOPPA Associate Professor and Head of the Department of Trauma, Department of Orthoped ics and Traumatology, UNIFESP - EPM dr. LUIS RENATO NAKACHIMA MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM dr. JOHN CARLOS Bellotti Doctorate in Orthopedics and Traumatology, physician assistant, Discipline of Tr aumatology, Department of Orthopedics and Traumatology, UNIFESP - EPM EPM - Project Medical Publisher Rua Leandro Dupret 204, cj. 91 - Vila Clementino Tel (11) 5084-3576 • 5575-3450 - São Paulo e-mail: CORRESPONDENCE Department of Orthopedics and Traumatology, UNIFESP - Escola Paulista de Medicin a Rua Borges Lagoa 783-5 º andar CEP 04038-031 - Vila Clementino - São Paulo Tel ( 11) 5571-6621 • 5579-4642 E-mail: @ This publication is provided as a service from Merck Sharp & Dohme to doctors. T he views expressed here reflect the experience and opinions of the authors. Befo re prescribing any medication may be cited in this publication should be consult ed to Prescribing (bull) issued by the manufacturer. Scaphoid Fracture Flavio FALOPPA Associate Professor and Head of the Department of Trauma, Department of Orthoped ics and Traumatology, UNIFESP - EPM Vilna Mattioli Leite Full Professor and Head of Surgery of the Hand and Upper Limb, Department of Ort hopedics and Traumatology, UNIFESP - EPM João Baptista Gomes dos Santos MD, Head of Clinical Surgery of the Hand and Upper Limb, Department of Orthopedi cs and Traumatology, UNIFESP - EPM Carlos Henrique Fernandes MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM Fabio Augusto Caporrino MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM Luis Renato Nakachima MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM John Carlos Belloti

Doctorate in Orthopedics and Traumatology, physician assistant, Discipline of Tr aumatology, Department of Orthopedics and Traumatology, UNIFESP - EPM I. Introduction The importance of scaphoid fracture lies in the fact that the carpal bone most c ommonly fractured, often difficult to diagnose and require prolonged periods of immobilization, due in part to its peculiar vascularization. The poverty of sign s and symptoms makes the patient look no assismedical assistance, and when he does, in some instances the clinical and radiogr aphic diagnosis is not made for the same reason. This type of fracture can not p resent evidence on plain radiography until four weeks after the trauma. Fracture s of the scaphoid have healing rate over 90% when diagnosed early and treated pr operly. Those with diversion or associated with carpal instabilities have a poor er response to medical treatment. Volume 7 seminars in orthopedics 3 seminars in orthopedics II. Anatomy and Pathophysiology The scaphoid is€by their anatomy and location, the carpal bone most vulnerable t o injuries in impacts with an open palm and the wrist in extension (Fig. 1). Thi s situation is observed in almost all falls in the unconscious attempt to protec t other segments of the body. Approximately 80% of the scaphoid is lined by cart ilage, the remaining areas, there is the penetration of vessels that ensure the unique nutrition scaphoid. There are three groups of vessels converging toward t he scaphoid bone, entering the level of the tuberosity or the waist. Were called latero-volar, dorsal and distal, all from the radial artery and / or its superf icial palmar branch at different levels (Fig. 2). The intraosseous blood supply is accomplished by vascular arcades are becoming thinner as they approach the pe riphery of the bone. The vascular systems latero-volar (apparently the principal ) and dorsal are responsible for supplying the proximal two thirds of the scapho id and the distal system is responsible for supplying the region of the tuber. D ue to poor circulation in the proximal pole, fractures located in this region ha ve a worse prognosis and a greater chance of evolving with aseptic necrosis. Radial artery Ventral Superficial palmar branch of radial artery DORSAL 4 Volume 7 Dorsal carpal branch of radial artery Figure 2 - Nutrition scaphoid. Figure 1 - Injury to the wrist extension. III. Classification They orient with respect to the type of treatment and prognosis. Depending on th

e location and type of mapping of fractures, can expect different trends. seminars in orthopedics 5 Figure 3 - Location of the fracture. Volume 7 A) The location of the trace (Fig. 3): - Third proximal - Middle third (waist) distal third B) The type of stroke (Fig. 4): - Transverse - Horizontal Oblique - Oblique Vertical fractures of the third proximal, with poor vascularization, a nd those with oblique stroke vertical, unstable, have a poor prognosis with rega rd to the consolidation and development of complications. Distal third Middle third Proximal third Transverse Oblique horizontal Oblique vertical Figure 4 - Type of fracture line. seminars in orthopedics IV. Diagnosis A) Clinical - Swelling - Pain on anatomical shape (Fig. 5) - Pain on palpation o f the tuberosity of the scaphoid (Fig. 6) - Pain to maneuver Pistoning (Fig. 7) B) Complementary tests - radiographs (Figures 8, 9, 10 and 11) - Computed tomogr aphy - Magnetic resonance imaging (Fig. 12) Figure 6 - Palpation of the scaphoid tuberosity. 6 Volume 7 Figure 7 - Maneuver Pistoning. Figure 5 - palpation of the anatomical snuffbox. Figure 8 - X-ray in PA with ulnar deviation. Figure 9 - Radiography in absolute profile. Figure 11 - internal oblique radiograph in 60 °. Figure 10 - internal oblique radiograph in 30. Figure 12 - Radiograph of the wrist with no evidence of scaphoid fracture after two weeks of trauma. MRI performed on the same date, showing the lesion. Volume 7 seminars in orthopedics 7 seminars in orthopedics

V. Treatment Conservative Fractures of the distal tuberosity or without deviation - plaster forearm, inclu ding the thumb, releasing the interphalangeal joint, for four to six weeks, with 20 ° extension and 15 ° of radial deviation of the wrist. Fractures of the prox imal and middle third without deviation - axillary-palmar plaster, including the thumb, releasing the interphalangeal joint for six weeks (Fig. 13), followed by three weeks short of plaster, or even consolidation. VI. Complications Nonunion (Fig. 15) - Most often occurs due to lack of diagnosis or treatment, ty pe or downtime inadequate. Fractures of the proximal or associated with carpal i nstability are more prone to non-consolidation. 8 7 Treatment: - Matti-Russe grafting cortico-cancellous iliac or distal radius. - Vascularized graft of ventral or dorsal distal radius. - Osteosynthesis with screw and graft (sandwich). Volume Surgical Fractures with bypass - Closed reduction and percutaneous fixation - Open reduct ion and internal fixation (Fig. 14) Figure 13 - Gypsum palmar-axillary, including thumb. Figure 15 - Pseudarthrosis of the proximal scaphoid. Figure 14 - Open reduction and internal fixation with Herbert screw. Aseptic necrosis (Fig. 16) - is not seen as often as pseudarthrosis, and occurs in most cases, fractures of the proximal pole and possibly fractures of the midd le third, due to the peculiar vascularization of the scaphoid. Osteoarthritis (F ig. 17) - Growth expected for fractures,€aseptic necrosis and nonunion of scapho id non-treated. Occurs due to loss of harmony in the complex mechanism of moveme nt observed between the carpal bones, associated with anatomical abnormalities, shortening of the scaphoid and proximal migration of captato. Figure 16 - Increased bone density in the proximal fragment. Treatment: - Estiloidectomia. - Resection of the proximal row with or without the interposi tion of the capsule. - Partial arthrodesis. - Arthrodesis total. seminars in orthopedics 9 Volume 7 Figure 17 - Osteoarthritis of the wrist secondary to scaphoid nonunion. Case Study seminars in orthopedics ID: CG 32, male, general assistant, born and raised in São Paulo. Complains Time : severe pain in the right wrist for six months. HPMA: patient states that there are about six months, had a fall from height, during the fight capoeira, with h yperextension injury in the right wrist. Searched orthopedics service, which und

erwent forearm cast immobilization for a week, was discharged to follow. Due to persistent pain and decreased strength, though not accompanied by edema, tried o ther services, without improvement of the framework. Figure 18 - Pseudarthrosis of the scaphoid waist. 10 7 Conduct: Patient underwent surgical treatment of scaphoid nonunion with vascularized bone graft distal radius, based on branch radial palmar carpal arch, the technique d escribed by Mathoulin & Haerle. He underwent fixation with a screw microfragment s diameter 2.0 mm (Figures 19, 20, 21, 22 and 23). He stayed with cast immobiliz ation for eight weeks, underwent X-rays every two weeks until the eighth week, w hen the consolidation was observed (Fig. 24). Then the patient was referred for rehabilitation. Volume Orthopedic Physical Examination: Pain on palpation of the anatomical shape Edema lightweight Force grip D: 42 Kgf Force grip E: 40 Kgf Flexural D: 60 º flexion and 90 º Extended D: 55 Extension E: 90 ° Radial deviation D: 6 Radial deviation E: 15 ulnar deviation D: 48 º ul nar deviation E: 50 ° Complementary tests: X-ray of the right wrist: scaphoid nonunion in the middle third (waist). No sign s of osteonecrosis. No signs of osteoarthritis (Fig. 18). Figure 19 - Removal of the bone graft. Figure 20 - Preparation of the scaphoid. Figure 24 - Bone healing at the eighth postoperative week. Figure 21 - osteosynt hesis with a screw. Evolution: After eight months of rehabilitation, the patient was without pain, having retur ned to work activities and poultry without limitation, the following examination (Figures 25 and 26): Strength of seizure palmar: 48 Kgf Flexural: 90 Extension: 80 ° Radial deviation: 15 º ulnar deviation: 40 º 11 Volume 7 Figure 22 - Removal of the withers to observe bleeding from vascularized graft. Figure 23 - Placing the graft in scaphoid. seminars in orthopedics BIBLIOGRAPHY seminars in orthopedics ANDREWS, J., MILLER, G.; HADDAD, R. - Treatment of scaphoid nonunion by volar in lay distal radius bone graft. J. Hand Surg., 10B :214-216, 1985. Belsol, RJ; HIL BELINK, R.; LLEWELLYN JA, DALE, M., GREENE, TL; RAYHACK, JM Analysis of the Comp uted pathomechanics of scaphoid waist nonunion. J. J. Bone Surg., 16A: 899-906, 1991. BERNE, JD; ABALEDEJO, F., SANCHEZ-CAÑIZARES, MA; Chavarro, G., PARDO, A.; PELLICER, A. - Scaphoid fractures and nonunions: a comparison Between panoramic radiography and plain x-rays. J. Hand Surg., 23B :328-331, 1998. CAPORRINO, FA -

Surgical treatment of scaphoid nonunion with vascularized bone graft from the d orsal distal radius, based on intercompartmental artery supraretinacular 1.2. Sã o Paulo, 2001. Thesis - PhD - UNIFESP - Paulista Medical School]. Dehn, E.; Deff , P.A.; FEIGHNEY, R.E. J. Trauma, 4:96-113, 1964. HILL, N. A. Orthop. Clin.North .Am., 1:275-287, 1970. LEITE, NM - Surgical treatment of nonunion and delayed un ion of the scaphoid by Matti-Russe technique. São Paulo, 1992. [Tese - Doutorado - UNIFESP Escola Paulista de Medicina]. LOGROSCINO, D. & Demarchi, E. Chir. Org ani Mov., 23:499-524, 1938. MACK, CG; BOSSE, LCMJ; GELBERMAN, HR, YU, E. - The N atural Histoty of Scaphoid Non-Union. J. J. Bone Surg. 6A: 4: 504-9, 1984. MATHO ULIN, C. & Haerle, M. - Vascularized bone graft from the palmar carpal artery fo r treatment of scaphoid nonunion. J. Hand Surg., 23B: 3:318-323, 1998. MATT, H. - Technik und meiner pseudarthrosenoperation resultat. Zbl. Fur Chir., 63: 144253., 1936. McLAUGHLIN, H.L. J. Bone Joint Surg., 36A: 765-774, 1954. Molen, ABMV D; GROOTHOFF, JW; VISSER, GJP; ROBINSON, PH, Eisma, WH - Time 12 Volume 7 Figure 25 - radial and ulnar deviation. Figure 26 - flexion and extension. off work due to scaphoid fractures and other carpal injuries in the netherlands in the period 1990 to 1993. J. Hand Surg., 24B :193-198, 1999. NAKACHIMA, L.R. Surgical treatment of scaphoid nonunion with vascularized bone graft ventral di stal radius based on the radial branch of the palmar carpal arch. São Paulo, 200 1. [Tese - Doutorado - UNIFESP - Paulista Medical School]. OBLETZ, B.E. & HALBST EIN, B.M. J. Bone Joint Surg., 20:424-428, 1938. Rayan, GM - Fractures and nonun ions of the scaphoid. J. Okla. State Med Assoc., 89:315323, 1996. REIS, F.B. - U se of screw "Herbert" in the scaphoid through the dorsal. São Paulo, 1990. [Tese - Mestrado - UNIFESP Escola Paulista de Medicina]. RUSSE, O. - Fracture of the carpal navicular. J. Bone Joint Surg., 42A: 759-768, 1960. SOTO-HALL, R. & Haldeman, K.O. J. Bone Joint Surg., 23:841-850, 1941. STEWART, J . M.J. Bone Joint Surg., 36A: 9981006, 1954. TALEISNIK, J. & KELLY, PJ - The ext raosseous and intraosseous blood supply of the scaphoid bone. J. Bone Joint Surg ., 48A :1125-1137, 1966. Verdana, C. & Naraka, A. Surg. Clin. North Am, 48:10831095, 1968. WEBER, E. R. Clin. Orthop., 149:83-89,1980. 13 Volume 7 ZAIDEMBERG, C., SIEBERT, J.W.; ANGRIGIANI, C. - A new vascularized bone graft fo r scaphoid nonunion. J. Bone J. Surg., 16A :474-478, 1991. seminars in orthopedics SCHUIND, F.; HAENTJENS, P.; INNIS, FV; Marren, CV, GARCIA-ELIAS, M.; Sennwald, G . - Prognostic factors in the treatment of carpal scaphoid nonunions. J. Hand Su rg., 24A :761-776, 1999. 14 Volume 7 seminars in orthopedics FRACTURE OF THE DISTAL END OF RADIO

Flavio FALOPPA Associate Professor and Head of the Department of Trauma, Department of Orthoped ics and Traumatology, UNIFESP - EPM Vilna Mattioli Leite Full Professor and Head of Surgery of the Hand and Upper Limb, Department of Ort hopedics and Traumatology, UNIFESP - EPM João Baptista Gomes dos Santos MD, Head of Clinical Surgery of the Hand and Upper Limb, Department of Orthopedi cs and Traumatology, UNIFESP - EPM Carlos Henrique Fernandes MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM Fabio Augusto Caporrino MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM Luis Renato Nakachima MD, attending physician in the Department of Surgery of the Hand and Upper Limb, Department of Orthopedics and Traumatology, UNIFESP - EPM John Carlos Belloti Doctorate in Orthopedics and Traumatology, physician assistant, Discipline of Tr aumatology, Department of Orthopedics and Traumatology, UNIFESP - EPM The fracture of the distal radius is one of the most frequent, accounting for ab out 10% to 20% of all fractures, affecting mainly females, after the fourth deca de of life, white. In the UK, in a recent publication, estimated that the popula tion over 35 years, there is an annual incidence of distal radius fracture of 9/ 10.000 37/10.000 the men and women. Most fractures occur by low energy traumas s uch as falls in the home environment, which demonstrates the relationship betwee n this type of fracture to Although this type of fracture was first described by Abraham Colles in 1814, to day we still find a large number of publications on the various treatment method s, which demonstrates the difficulty of establishing a single standard for treat ing these fractures, as well as its complications and associated injuries. Volume 7 I. Introduction loss of bone density (osteoporosis) and increased number of falls suffered by ol der women. In younger patients, these fractures are often caused by high energy trauma, such as those that occur in traffic accidents. 15 seminars in orthopedics seminars in orthopedics II. Anatomy Ossification of the distal radius begins at the end of the first year of life an d its fusion occurs at around 19 years old. In adulthood, when we observe a coro

nal section of the radio, we note that the transition between the distal metaphy seal and diaphyseal region, there is a marked thinning of cortical bone, which b ecomes a thin layer surrounding the metaphyseal cancellous bone, making this reg ion more susceptible to fractures (Fig. 1). The distal end is flattened, has a distal articular surface is concave, with vol ar tilt of about 11 degrees in the sagittal plane (Profile), and about 22 degree s in the coronal plane (anteroposterior)€which is divided by a ridge into two sm ooth articular surfaces: a larger triangular and laterally to the scaphoid and a smaller square to the lunate medially (Figs. 2 and 3). 16 Volume 7 The B Figure 2 - X-rays demonstrating the position profile (sagittal plane), the volar radius (2a). In the anteroposterior position (coronal plane), the radio has a s lope of about 22 degrees (2b). Radio Ulna Articular surface for the scaphoid Figure 1 - Coronal section of the distal radius. Demonstrates a progressive decr ease in thickness of cortical bone of the radius from its shaft to the metaphyse al region where there is only a thin layer of cortical bone surrounding the canc ellous bone. Articular surface for the lunate Distal joint ulnorradial Figure 3 - distal end of radius and ulna: the articular surfaces of radius and d istal radioulnar Extensor carpi ulnaris Extensor own pinky Common extensor of the fingers and the indicator itself Long extensor of the thumb Long and short radial extensor carpi Extensor pollicis Radio Ulna Abductor pollicis longus Figure 4 - Cross section of wrist, dorsal aspect at the level of the extensor re tinaculum. Anatomical relationship of the distal radius and ulna with the intradorsal retinacular tunnels and the training of six extenders. Superficial flexor tendons of fingers deep flexor tendon of finger flexor tendon

radial artery ulnar carpal flexor tendon of the thumb ulnar vein Radial artery Tendon Flexor carpi ulnaris Median Palmaris longus tendon Pronator quadratus muscle Figure 5 - Cross section of wrist, volar aspect at the level of the flexor retin aculum. Anatomical relationship of the distal radius and ulna with the anatomica l elements intra-volar retinacular. 17 7 Medially, also has a concave articular surface - the ulnar notch of the radius in conjunction with the head of the ulna. Laterally, the radio ends with a prom inence called the styloid process. Dorsally, the radio has a convex shape, has a tubercle (tubercle of Lister) and grooves that serve as beds for the passage of the extensor tendons, and, along with the extensor retinaculum form four of the six extensor compartments (Fig. 4). The volar has flattened for m, presents an intimate relationship with the pronator quadratus muscle and prox imity to the radial artery, with the median nerve and flexor tendons - especiall y the deep flexor tendons of the fingers and thumb flexor tendon (Fig. 5). Volume seminars in orthopedics seminars in orthopedics The distal ulna has a spherical shape, the head of the ulna, which presents, in continuity with the posterior edge of the ulna, a prominence called the styloid process of the ulna associated with the dorsal extensor retinaculum compartments form the last two extenders. At its distal face, receives the triangular fibroc artilage and its circumference is articulated with the ulnar notch of the radius (Fig. 6). In the wrist, there are two joints: the distal radiocarpal joint and ulnorradial. The radiocarpal joint (Fig. 6) is formed proximally by a concave su rface formed by the articular surface of distal radius and triangular fibrocarti lage and distally by a structure with convex shape - ellipsoidal or condylar - f ormed by the scaphoid bone, 18 7 Volume semilunar and pyramidal. This joint is surrounded by an articular capsule, which has called thickening: dorsal and volar radiocarpal ligaments, which depart fro m the edge of the radio correspondent in distal and ulnar to the scaphoid bone, lunate and triquetrum, and ulnar and radial collateral ligaments, which originat e mainly from the styloid process of the corresponding bone, inserting into the carpal margin on each side. The radiocarpal joint performs all types of movement except the movement of rotation. Nutrition pressure on this joint is made by do rsal and palmar carpal arterial arch and is innervated by the anterior and poste rior interosseous nerve and deep dorsal branches of the ulnar nerve. Ulna

Radio Distal joint ulnorradial Scaphoid lunate joint radiocarpal joint intercarpal Fibrocartilage articular Trapezium Trapeze Carpometacarpal joint Intercarpal joint Figure 6 - Coronal section. Anatomical aspect of the radiocarpal joint and ulnor radial distal articular and fibrocartilage. The 19 7 B Figure 7 - radiological aspects (7) and clinical - "back to Fork" (7 b). Typical Colles' fracture Volume seminars in orthopedics The joint ulnorradial distal (Figure 6) is formed by the ulnar notch of the radi us and the articular surface of the ulnar head, and as the ceiling triangular fi brocartilage, which falls laterally and medially on the radio in the ulnar stylo id process. Makes movements of pronation and supination of the forearm, and the longitudinal axis of motion passes proximally through the center of the radial h ead distally through the center of the triangular fibrocartilage and the distal shaft of the fourth finger. During the movement of pronation and supination, the ulna remains relatively stationary due to their attachment to the proximal hume rus, which takes the radio to move around his head, which remains relatively fix ed. This link has arterial supply of the posterior and anterior interosseous art ery and dorsal and volar carpal arterial arch, the innervation is done by the po sterior and anterior interosseous nerves. III. Classification Although several contemporary classification systems are described for fractures of the distal radius, even today, some types of fractures are known universally according to its eponym, who described below: Colles' fracture - Abraham Colles (1814), is the fracture of the distal radio presenting the typical clinical def ormity of diversion and dorsal angulation, radial shortening and dorsal cominuçã o (Fig. 7). seminars in orthopedics Fracture "Barton" - John R. Barton (1838), is the fracture of the distal radius shows that trait with intra-articular subluxation of the carpus following the di version of the articular fragment, which may be volar or dorsal. (Fig. 8). Fract ure of "Smith" - Robert W. Smith (1847), is the fracture of the distal radius wi

th volar deviation of the distal fragment of the fracture, the fracture is "Coll es" reverse. Thomas (1957) proposed a classification for fractures of "Smith" in to three types, as described below in Figure 8. Fracture "Die-Punch" - Scheck (1 962), is impacted intra-articular fracture with dorsal depression of the lunate fossa of the radius. Fracture of "Chauffeur" - Harold C. Edwards (1910), is the fracture of the distal radius with intraarticular oblique stroke, forming a tria ngular piece, with a prominent styloid process of the radio. R Smith Smith II / volar Barton 20 Volume 7 Barton dorsal Contemporary Reviews Although we find in the literature several classification systems for distal rad ius fractures, we chose three classification systems that we consider most appro priate to establish the treatment plan of fractures: the AO / ASIF classificatio n, the classification of Fernandez and Universal, which is described following: Universal Rating (Rayhack / Cooney) - This system classifies the distal radius f ractures into four main groups considering the presence or absence of stroke and joint fracture dislocation. Subdivided fractures with deviation (types II and I V) in the other three subtypes, according to the criteria of reducibility and st ability of fractures (Fig. 10). Smith III Figure 8 - Classification of fractures to Thomas Smith, includes a description o f the fracture with volar Barton and comparison with the dorsal Barton fracture. The B Figure 9 - A) Fracture Chauffeur. B) Fracture Die-Punch. Type I Extrarticular no deviation Type II Extrarticular with deviation Type III Intrarticular no deviation A, B and C Type IV Intrarticular with deviation The B C Figure 10 - Universal classification for fractures of the distal radio. [A = red ucible (stable), B = reducible (unstable), C = irreducible] Fractures of the distal radius are among the most common orthopedic injuries, an d his treatment has changed in the past two decades. Many of these fractures are really simple and can be treated with closed reduction and cast immobilization. However, fractures that are unstable or that involve the articular surface may endanger the consistency of the structured

Volume IV. Treatment tion and its function, so the main goal of orthopedic treatment should be to res tore functional anatomy. Over the past twenty years we have witnessed great prog ress in studies of new techniques for internal and external fixation. The new co ncepts of percutaneous fixation, external fixators, plates for internal fixation , arthroscopically assisted reduction and new materials to replace bone loss hav e provided considerable improvement in our therapeutic armamentarium, especially for unstable fractures of the distal radius. 21 7 seminars in orthopedics seminars in orthopedics Allied to the technological advancement, one should consider the biological age of the patient,€their activity level and criteria of instability to follow a cla ssification method that allows to trace the most appropriate therapeutic plan fo r each kind of fracture. of bone mass, degree of joint involvement, angular displacement of the fracture and the severity of radial shortening are of fundamental importance to predict t he instability of the fracture. Villar (1987), in a prospective study evaluated 900 patients, followed up from three years, noted that the radiographic paramete r that most influenced the functional outcomes of patients in relation to range of motion and grip strength, was the presence of shortening One week after radia l fracture reduction. Altissimi in 1994, in a study of 100 patients with Colles fractures underwent closed reduction and cast immobilization, showed that the se verity of radial shortening factor is more indicative of unstable fracture. Lafo ntaine, in 1989, in a study of 167 distal radius fractures, found a close relati onship between certain radiographic findings and age of the patients with the ri sk of loss of fracture reduction, which describes the presence of three or more radiographic factors are highly indicative of instability requiring surgical sta bilization (Fig. 11). We consider as the main factor of instability in the magni tude of the initial radial shortening, followed by musical cominução and articul ar fracture, biological age and consequent osteoporosis patient and cominução do rsal fracture. 1. 2. 3. 4. 5. 6. Dorsal deviation higher than 20 degrees Cominuç ão Involvement of the dorsal radiocarpal joint fractures associated with comminu ted fracture of the ulna Age over 60 years Lafontaine, 1989. CONSERVATIVE TREATMENT In the systematic review on the types of conservative treatment for distal radiu s fractures, Handoll (2003) analyzed 36 randomized trials and 4114 patients and found no definitive evidence on the best method and ideal position for immobiliz ation of these fractures. However, in our experience, fractures or those with no deviation deviation, reducible and stable, can be treated with immobilization w ithout the need for surgical stabilization. We describe below the main parameter s for conservative treatment: 22 Volume 7 Criteria for Instability We consider those unstable displaced fractures, even after undergoing closed red uction and cast immobilization, have not preserved the reduction achieved, requi

ring surgical stabilization. The displaced fractures caused by shear mechanism ( Barton fractures), or avulsion of the extremely comminuted, resulting from traum as of high kinetic energy, are consensually unstable and require surgical stabil ization. The fractures produced by impact mechanism or angulation ("Colles fract ure") are usually caused by trauma of low kinetic energy (accidental fall) and m ay be stable or unstable. Some factors such as patient age and consequent possib ility of perSeverity of radial shortening. Villar, 1987. Altissimi, 1994. Figure 11 - Criteria of instability of the fracture of the distal radius. Need for Reduction As we saw earlier, part of the distal radius and radiocarpal joints distal ulnor radial thus is of fundamental importance for the function of the wrist joint to maintain its anatomical architecture. Several authors, in clinical and biomechan ical studies have demonstrated that malunion of the radius is associated with de creased mobility and pain in the wrist, the ulnorradial subluxation of the dista l carpal instability medium-and post-traumatic arthritis. Some authors demonstra ted that the deformity with articular step greater than 2 mm results in post-tra umatic arthritis in 90% of patients. Therefore, we think the key point to succes sful treatment is based on the anatomical reduction of the fracture. We consider fractures without displacement, which does not require reduction, those with ra dial shortening of up to 3 mm of articular step up to 2mm and the loss of volar tilt beyond 15 degrees. The fractures with radiographic change beyond these desc ribed, need reduction (Fig. 12). Classically, there are two techniques for reduc ing fractures of the distal radius: a reduction by manipulation of the fracture with traction and counter traction (Fig. 13) and reduction by traction with "mes h" Chinese. Handoll in 2002 published a systematic review on methods of closed r eduction for treatment of distal radius fractures, concluding that there was no enough evidence to decide on how best to reduce these fractures. In our service, usedFigure 13 - Method of reducing incrutenta manipulation with traction and contrac tion. zamos the technique of reduction by manipulation successfully. Type of Anesthesi a: Handoll in 2003 published a systematic review, which demonstrated that the ty pe of anesthesia used can influence the outcome of closed reduction. Analisando1 8 randomized studies, involving about 1,200 patients, which were compared with l ocal anesthesia (hematoma block), general anesthesia, brachial plexus block and intravenous regional anesthesia (bier), no definitive evidence about the type of anesthesia more effectively and safe for treatment of fractures, however, there was indication that the local anesthesia (hematoma block) produces analgesia wo rse than the intravenous regional block (Bier), which may compromise fracture re duction. In our experience, we noticed that the local anesthesia (hematoma block ) can be used in acute fractures that do not show large deviations or local edem a, however, in fractures with more than 12 hours of evolution or with edema and significant deviation, we chose to perform closed reduction with anesthesia to t he brachial plexus, which provides better analgesia and muscle relaxation, which facilitates the reduction of the fracture. 23 Volume 7 • radial shortening> 3 mm • Step articulate> 2 mm • Loss of volar tilt> 15 degre es Figure 12 - radiographic parameters indicative of the need to reduce the fractur e. seminars in orthopedics

Standstill seminars in orthopedics Position of immobilization - in fractures "Colles", we use the position of sligh t palmar flexion, ulnar deviation and neutral pronosupinação. Smith fractures, w here there is a component of pronation of the distal fragment, we used the posit ion of wrist extension and supination, neutralizing the initial deviation of the fracture. so bloodless, bloody or arthroscopic view. Surgical stabilization can be accompl ished with percutaneous pins, external fixation, internal fixation plates, intra medullary fixation and associated methods. The bone graft or other alternative m aterials can also be used in some types of fractures. When we chose the surgical method of treatment, we must consider the patient's clinical conditions, presen ce of associated injuries and the expectation of demand for activity and patient motivation are critical in our decision. After the initial assessment of these factors, we believe that surgical treatment of fractures of the distal radius is indicated in four clinical situations: Group 1 - cominução metaphyseal fracture s with large and / or articulate. Group 2 - Fractures caused by avulsion mechani sm or shear. Group 3 - Fractures caused by engine compression or angulation show ing clinical and radiographic signs of instability (Figure criteria of instabili ty and reducibility). Group 4 - Associated injuries that make it impossible cons ervative treatment (open fracture, median nerve injury, tendon injury). Type and Time of Immobilization For fractures without displacement, we used the axillary-radial palmar splint fo r three weeks and radial forearm splint for three weeks. Fractures with deviatio n, reducible and stable, we use the axillary-radial palmar splint for four weeks and radial forearm splint for another two weeks. When we consider the downtime of the fracture, we observed that the biological age and psychosocial conditions of patients should be considered and it was always the average periods of deten tion. 24 Volume 7 SURGICAL TREATMENT Over the past 100 years, the majority of fractures of the distal radius was trea ted conservatively with closed reduction and cast immobilization. However, in re cent decades, the orthopedic community has recognized that such treatment is not consistently satisfactory, especially in elderly patients with osteoporosis. Th is has resulted in efforts to develop new strategies for surgical treatment, suc h as reduction and minimally invasive surgical devices or new types of internal fixation to allow stabilization more efficient and better reduction of fractures . Currently, we consider that the fractures may be reduced Treatment Approaches: GROUP 1: In this group, the fractures are caused by high kinetic energy trauma ( traffic accidents, falls from height) and affect the young adults and rarely chi ldren. Often found associated injuries. Generally, these fractures are unstable and irreducible, requiring open reduction. The combined methods of attachment ar e the most intients,€may be used in internal fixation (plate) or external fixation associated with percutaneous wires "Kirschner. The use of bone graft material or other sub stitution may be necessary. Group 2: In this group, both are unstable and may pr oduce subluxation of the carpus, invariably require surgical stabilization. The shear fractures correspond to fractures "Barton" (volar or dorsal) or to the "Ch auffer" in adults, and fracture "Salter-Harris" type IV in children. Avulsion fr

actures are rare in childhood. Both may have associated injuries, mainly radioca rpal or intercarpal ligament injuries. Treatment with open reduction and fixatio n with plate / screw is the method of choice for fractures and fixation with she ar pin / bolt to the avulsion. Case Study I Patient: JMFS, 41 year old male suffered a crash bike for about two hours, with pain and deformity of the wrist. When initial radiographs (Fig. 14): anteroposte rior X-rays: the presence of fractures in the metaphyseal region of distal radiu s with shortening, loss of joint space and the radiocarpal joint congruence ulno rradial distal. X-ray profile: fracture of the distal radius with stroke and art icular fragment triangular volar, volar subluxation of the radio. Diagnosis: Fra cture of volar Barton. Fracture of "Barton" is caused by shear mechanism, is uns table and therefore require surgical stabilization. The surgical technique devot ed to this type of fracture is open reduction, with access road and volar plate fixation of support (Fig. 15). GROUP 3: These fractures can be reducible stable or unstable, requiring surgical stabilization only those that are deemed unstabl e or that fail surgical treatment with loss of reduction. Fractures caused by an gle correspond to fractures "Colles" and "Smith", in adults, and the "Salter-Har ris" type II, in childhood. Generally, it can be reduced so bloodless and stabil ized with percutaneous pinning or external fixation. Compression fractures have diversified in the adult setting, including fracture die-punch "and, in childhoo d, fractures correspond to the types III and V of" Salter-Harris. " Both types o f fractures may require closed reduction, either open or with the aid of arthros copy. For surgical stabilization, we can use the percutaneous pinning, external fixator or internal fixation with plate. 25 Volume 7 Figure 14 - Radiograph of the initial fracture. Figure 15 - Post-operative fracture of volar Barton, with plate support. seminars in orthopedics Case Study II seminars in orthopedics Patient: MSC, female, 62 years, was falling to the ground for about four hours, with pain and deformity of the right wrist. The initial radiographic examination , the patient (Fig. 16) in posteroanterior projection, metaphyseal fractures, an d comminuted radial shortening. In profile, we observed dorsal deviation and dor sal cortical cominução radio. Diagnosis: fractures "Colles" reducible unstable. This type of fracture requires reduction and surgical stabilization (Figs. 11 an d 12). We opted for the closed reduction and percutaneous fixation technique of "De Palma", which is held as described below: Figure 16 - Chest X-original patient M.S.C. 26 Volume 7 Closed reduction and percutaneous pinning (Technique "De Palma") The technique of percutaneous fixation transulnar was first described by DePalma in 1952 and modified by Toledo in 2000. Patient under anesthesia to the supracl avicular brachial plexus in a supine position, performed the sterilization and a ntisepsis of the upper limb, which is positioned on the operating table from han d to elbow flexed to ninety degrees, is held closed reduction of fracture by the method of handling with traction and counter traction, after which, with the ai

d of image intensifier, we verify the criteria for reducibility of the fracture. Then, the fracture is fixed with the introduction of the Kirschner wires, aided by an image intensifier and using a punch low and gradual rotation. For introdu ction of the pins, we started with a punctiform incision in the ulnar side of th e forearm, Figure 17 - To release the wire, after exceeding the ulnar cortex of the radius, the punch is withdrawn and ends with the introduction of the wire with the hamm er orthopedic (250gr) by radiological control with an image intensifier. 4cm proximal ulnar styloid process, the cortex of the ulna is exposed, and with the aid of radiological image intensifier,€transfixed in both cortices of the ul na, directing the wire to the radial styloid process. After overcoming the corti cal medial cortex of the ulna and radius, the punch is withdrawn and the introdu ction of the pin on the radio is finished using the orthopedic surgical hammer ( Fig. 17), taking care not overcome its lateral cortex. Depending on the configur ation of the fracture, we used two or four "Kirschner wires" from 2.0 to 2.5 mm in diameter. When using two Kirschner wires, the first wire is introduced at about 4 cm and 6 cm proximal to the ulnar styloid, both co nverging to the radial styloid, the first and second dorsal toward the volar met aphyseal area of the radius (Fig. 18). Fractures of type IV b, we use four wires , and the first two as was described for type II b, a third wire placed about 2. 5 cm proximal to the ulnar styloid with direction tangential to the articular su rface of the radio until its styloid and the fourth wire being introduced just a s the previous one toward the scaphoid, which is fixed (Fig. 18). After fixed th e fracture, the wires are bent and cut close to the skin and secured with steril e dressing with gases. Then, we applied plaster splint, palmar-axillary type. seminars in orthopedics 27 Volume 7 Following post-operative dressings and revaluations are made weekly, and the pla ster splint and pins are kept for at least six weeks, taking as parameter for it s withdrawal to radiographic consolidation of the fracture (Fig. 19). Figure 18 - Patient MSC, Colles fracture. Aspect intraoperative and postoperativ e radiographs. The wires are placed at about 4 and 6 cm proximal to the ulnar st yloid process, one toward its volar metaphyseal region and a second with dorsall y. Figure 19 - Patient M.S.C. Colles' fracture - technical DePalma - Final radio graphic appearance (eight weeks after surgery), after removal of the implant. seminars in orthopedics GROUP 4: Patient Associated injuries - the majority of patients with fractures o f the distal radius is met initially in the emergency room. It is important that this be included in the initial care of trauma history to determine the degree of kinetic energy that caused the fracture and a specific clinical examination o f the fractured limb to diagnose possible associated injuries, which may be more serious than the fracture itself. In this group, the choice of surgical techniq ue is subject to injury associated fracture. As an example, we describe the clin ical case III. Figure 20 - Patient JMS, open fracture of the radius. Volar bone exposure. 28 7 Associate of Median Nerve Injury Lesions of the median nerve can be caused by mechanical compression of fragments

shifted the volar region of the radio. When this occurs, symptoms begin during the acute phase of immediate fragment compression, the compression symptoms mani fested by intense pain and paresthesia, hypoesthesia in the hand and fingers in the region innervated by the median nerve, and shock in the region volar wrist w here there is compression. In this situation, whenever possible, we performed im mediate closed reduction of fracture immobilization splint and observe for 24 to 48 hours of the development of symptoms. If symptoms of nerve compression progr essively regress, treatment can be maintained. If symptoms worsen or improve ver y little in the first 24 hours, or the fracture is not reducible, we proceed to open reduction of fracture and open carpal tunnel for decompression of the media n nerve, as used in the clinical case III (Fig. 21) . Volume Case Study III JMS patient, male, 18 years, falling victim to high for about two hours, with pa in, swelling and deformity of the wrist. Bone exposure in the volar region. Pare sthesia and hypoesthesia in the area innervated by the median nerve (Fig. 20). Patient Symptoms Associated Injury Most patients with fractures of the distal radius is met initially in the emerge ncy room. It is important that in this initial treatment should include a histor y of trauma to determine the degree of kinetic energy that caused the fracture a nd a specific clinical examination of the fractured limb to diagnose possible as sociated injuries, which may be more serious than the fracture itself. In this c linical case, the patient underwent open reduction and surgical exploration. Med ian nerve as illustrated in Figure 21. Figure 21 - Patient JMS, open fracture of the distal radius and symptoms of medi an nerve injury. Appearance after open reduction of fracture with signs of nerve compression injury. Conclusions The treatment of fractures of the distal radio still has many controversial aspe cts. However, based on current evidence and our experience, we recommend that: 1 ) fractures with no deviation or diverted reducible stable, should be treated co nservatively (reduction and immobilization). 2) The deviation reducible unstable fractures should be stabilized surgically with percutaneous pinning, external f ixation or plate. 3) The irreducible fractures or those caused by shearing or av ulsion should be treated with open reduction and internal fixation. 29 Volume 7 seminars in orthopedics seminars in orthopedics IV. References 1 - Altissimi, M., Mancini GB, Azzara, A.; Ciaffoloni, E. Early and late displac ement of fractures of the distal radius.The prediction of Instability. Internati onal Orthopaedics 1994, 18 (2) :61-65. 2 - Cooney, WP, Dobyns, JH, Linscheid, RL complications of Colles'fractures. J. Bone Joint Surg. 62 (4) :613-619, 1980. 3 - Cummings, SR; Kelsely, JL; Nevit, MC, O'Dowd, KJ Epidemiology of osteoporosis and osteoporotic fractures. Epidemioly Reviews 7:178-208, 1985. 4 - De Palma, A .F. Comminuted fractures of the distal end of the radius treated by ulnar pinnin g. J. Bone Joint Surg 34A :651-662, 1952. 5 - Doi, K., Hattori, Y.; Otsuda, K., Abe, Y., Yamamoto, H. Intra-articular fractures of the distal aspect of the radi us: Reduction Compared with arthroscopically assisted open redution and internal fixation. Journal of Bone Joint Surgery [Am] 81 (8) :1093-1110, 1999. 6 - Earns

haw SA, Aladin, A., Surendran, S.; Moredan, CG Closed redction of Colles fractur es: comparison of manual manipulation and finger-trap traction: a prospective, r andomized study. J. Bone Joint Surg 84-A (3) :354-8, 2002. 7 - Fennel, CW, Husba nd JB, Cassidy, C.; Leinberry, C., Cohen MS, Jupiter, J.; Norian, SRS Versus con ventional therapy of the distal radius fracture treatment. Journal of Bone and J oint Surgery [Br] 82 (2): 101-104, 2000. 8 - Fernandez, D., Jupiter, J. Fracture s of the distal radius. New York: Spring-Verlag. 2652, 1996. 9 - Fernandez, D.L. ; Palmer, A.K. Fractures of the distal radius. In: The Green DP, Hotchkiss, RN, Pederson, WC editor (s). Greens Operative Hand Surgery. 4th Edition. New York: C hrchill Livingstone: 929 985, 1999. 10 - Hahnloser, D.; Platz ª; Amgwerd, M.; Trentz, O. Internal fixation of distal radius fractures with dorsal dislocation: Pi-Plate or two quarter plates tubes? A prospective randomized study. Journal of Trauma 47 (4): 760-765. 11 - Handoll , H.H.G.; Madhok, R. Surgical interventions for treating distal radial fractures in adults. (Cochrane Review). In: The Cochrane Library, Isse 4, 2002. Oxford: U pdate Software. 12 - Handoll, H.H.G.; Madhok, R. Conservative interventions for treating distal radial fractures in adults. (Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software. 13 - Handoll, H.H.G.; Madhok, R . Anaesthesia for treating distal radial fractures in adults. (Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software. 14 - Handoll, H.H.G.; Madhok, R. Rehabilitation for distal radial fractures in adults. (Cochr ane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software. 1 5 - Hutchinson, DT; Strenz, G.; Cautilli, RA Pins and Plaster vs external fixati on in the treatment of unstable radial fractures. A randomized prospective study . Journal of Hand Surgery [Br] 20 (3): 365-372, 1995. 16 - Kapoor, H., Agarwal, A.; Dhaon, B.K. Displaced intra-articular fractures of distal radius: a comparat ive evaluation on results Following Closed Reduction, Open Reduction and externa l fixation with internal fixation. Injury: 31 (2) :73-79, 2000. 17 - Kreder HJ, Hanel, DP, McKee M, Jupiter, J.; McGilivary, G.; Swiontowski, MF Consistency of AO fracture classification for the distal radius. J. Bone Joint Surg 78B: 72 631 , 1996. 18 - Lafontaine, M., Hardy, D.; Delince, P. Stability assessment of dist al radius fractures. Injury 20:208-210, 1989. 19 - Muller, ME Comprehensive clas sification of fractures. Pamplhlet 1. Bern, Switzerland: Muller Foundation, 1995 :1-21. 20 - Nissen-Lien, H.S. Fracture radii "typica". Nord. Med 1939, 1:293-303 . 21 - Nguyen, TV, Center JR, Sambrook, PN, Eisman, JA Risk factors for proximal hu30 Volume 7 merus, forearm, and wrist fractures in elderly men and women. The Dubbo Osteopor osis Epidemiology Study. American Journal of Epidemiology: 153 (6) :587-95, 2001 . 23 - O'Neill, TW, Cooper C, Finn JD, Lunt, M., Purdie, D., Reid DM. Incidence of distal forearm fracture in British men and women. Osteoporosis International: 12 (7): 555-8, 20001. 24 - Rayhack, J. Symposium: management of intrarticular f ractures of the distal radius. Contemp. Orthop. 1990; 21:71-104. 25 - Toffelen, D.V.; Bross, P.L.€Closed redution versus Kapandji-pinning for extra-articular di stal radial fractures. Journal of Hand Surgery [Br] 24 (1) :89-91, 1999. 26 - To ledo, LFQ; Albertoni, WM; FALOPPA, F. Treatment of fractures of the distal radiu s by the technique of De Palma modified. Rev Ibero Cir Mano 27:22-28, 2000. 31 Volume 7 seminars in orthopedics 27 - Winnie A.P.; Collins, V.J. The subclavian perivascular technique of brachia l plexus anesthesia. Anesthesiology 25:353-363, 1964.

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