UPPER EXTREMITY UPDATE
From 22nd Annual Upper Extremity Update, Department of Surgery Faculty of Medicine, University of Toronto
| RATIONALE FOR OPERATIVE MANAGEMENT OF DISTAL RADIUS FRACTURES —Terry S. Axelrod, MD, Associate
Professor and Chief, Division of Orthopaedic Surgery, Faculty of Medicine, University of Toronto; Sunnybrook and
Women's College Health Sciences Centre, Toronto
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| Colles fracture: “broken wrist” first described by Irish surgeon Abraham Colles (1814); conservative management thought to
guarantee good result; Colles thought full range of motion (ROM) would return in 2 yr with no pain but some deformity; however,
specialists know Colles fracture does not do well; many patients do not achieve movement and maintain severe deformity
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| 3-pronged approach: need to understand patient, limb, and fracture; need to understand components of injury; distal
radius fractures come in many varieties (simple and complex)
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| Classification systems: to be effective, must depict type and severity of fracture and serve as basis for treatment and
evaluation of treatment outcome; for distal radius fractures, many classification systems over last 25 to 30 yr, starting
with Frykman system (1967; does not apply today); AO (Arbeitsgemeinschaft für Osteosynthesefragen)—universal
classification system; complex; poor inter- and intraobserver agreement beyond type and group; useful for research but
not for day-to-day clinical management; Melone classification (1984)—looks at intra-articular injury, classifying fractures
into 4 subtypes based on amount of displacement of fragments; disruption of distal radioulnar joint by fragments
leads to problems with flexion and extension as well as with rotation of forearm (major complaint of patients)
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| Jupiter and Fernandez classification (1987): bases management on mechanism of injury (4 types); type I—
bending fracture; simple Colles fracture; occurs when elderly person falls on wrist and presents with dinner-fork deformity;
overall, closed treatment remains mainstay of management; “closed” does not mean simply reduction and casting; manipulate
with external fixator supplemented with K wires (particularly through styloid) to help reduce settling; in young person,
simple pinning often sufficient; type II—shearing fracture; classic Volar-Barton’s fracture; sometimes maltreated (articular
surface subluxes with volar fragment), leading to shortening and rotation problems; usually treated operatively with volar
exposure and cannot be managed with external fixator; buttress plate (new or older; simple and inexpensive) only way to
neutralize shearing forces; other shear fractures, eg, chauffeur’s fracture, managed with lag screws; type III—joint compression
fracture (die punch fracture); in young patients, articular surface must be reduced within 2 mm of level (controversy on
how best achieved); sometimes soft tissue attachment to impacted fragments and ligamentotaxis not enough for successful
reduction, and other means needed (eg, percutaneous manipulation, open reduction-internal fixation [ORIF]); type IV—
avulsion or fracture dislocation where entire wrist with ligaments has come off radial styloid (dorsally more common); relatively
unusual; hold styloid back on by internal fixation with screws or sometimes small buttress plate, then ligamentous
repair; type V—combination injuries involving shearing, compression, and severe articular damage; combination of treatments,
ie, external and internal fixation and bone grafting often required
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| Acceptable reduction: age- and patient-dependent; very young and very elderly more forgiving, but young active
adults not so; over years, publications provided guidelines; ideally, surgeon wants length within 2 mm when measuring
from articular surface of lunate facet to distal aspect of ulnar head (normal); dorsal tilt or alignment of articular surface
relative to shaft; normally 7º to 11º of volar tilt (neutral or back-up to 5º usually acceptable); radial inclination relative to
shaft normally 23º, but if inclination 10º, patients usually happy; length, radial inclination, and interarticular step-off issues
for long-term prognosis; step-off <2 mm desirable in young person; in older individual with low demand for bone quality,
step-off less crucial
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| New concepts: in last 5 to 8 yr, 2 major advances in management of bending, joint-compression, and combination fractures;
1) small locking plates that can be applied to distal radius; 2) concept of palm-specific fixation
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| Locking plates: in form of pi plate (mimics Greek letter ‘pi’); Dr. Jupiter and hand group from AO developed plates and
volar version of locking plate; around same time, dinner-fork plate also developed; plates allow for pins to lock into plate,
giving angle stability; implants smaller with smaller, better screw design, and locking interface between plate and screws
eliminates toggle; fixation no longer relies on friction or compression of plate against bone; allows surgeon to buttress
small joint fragments and helps to prevent collapse of metaphyseal fragments; standard screws have round smooth heads
that squished plate down onto bone for stability; if fracture highly comminuted or bone quality poor (as in osteoporosis),
insufficient friction between plate, screw, and bone allows toggle and collapse of metaphyseal fragments; locking pins or
screws have secondary thread that locks into plate, creating rigid angle between plate and device that works like fork or
rake which locks in (bone cannot push rake backwards) and buttresses articular surface and small fragments; so now able
to buttress and fix small fragments previously unfixable and control dorsal fragmentation with dorsal plate; dorsal collapse
of fragments now controlled from palmar side
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| Volar plates: older implants did not allow management of dorsal fractures from volar side, but new locking plates do;
case—woman, 54 yr of age, had closed reduction of distal radius fracture; lunate facet missing and dorsal comminution
present; computed tomography (CT) shows pulverized lunate facet, and major piece of articular surface driven in; difficult
to fix, but with first-generation volar locking plate, can reconstruct; articular surface reduced, palmar tilt restored, and dorsal
comminution controlled (pins do not move relative to volar plate)
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| Palm-specific fixation: distal radius in normal anatomic position relies on radial column (ie, radial styloid) and lunate
facet as well as ulnar column; major role of radial column to support scaphoid and rotate it into position; purpose of ulnar
column to provide axial stability
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| PROXIMAL HUMERUS FRACTURES: THE ROLE OF HEMIARTHROPLASTY — Robin R. Richards, MD, Professor,
Department of Surgery, Division of Orthopaedic Surgery, University of Toronto Faculty of Medicine, and Surgeon-in-
Chief, Sunnybrook and Women's College Health Sciences Centre, Toronto
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| Edinburgh fracture center: study of translated 2-part proximal humeral fracture defined natural history; reported healing
of fracture (surprising) and assessed functional outcome; researchers adhered to philosophy all clinicians should have,
ie, treating patient, not x-ray; patients older, but use of internal fixation not advocated, regardless of degree of initial displacement
(based on data); 2001 Edinburgh study—treatment of impacted valgus fracture of proximal humerus where humeral
head tipped up onto end of humerus; detailed study with extensive follow-up; concluded little evidence that operative
management confers benefits in elderly patients (contrast to practice in North America); speaker’s approach to elderly
patients—treat expectantly, let fracture heal, treat person not x-ray, and observe outcome
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| Locking plates: with conventional fixation, screws toggle in plate and callus formation occurs; locking plates improve
fixation in proximal humerus; in fracture dislocation, consider whether hemiarthroplasty best for patient or whether reduction
and fixation of native humeral head with new devices indicated; locking plate involves increased cost; bone may
pull away from plate during healing process; study required to determine role of locking plate fixation
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| Current role of humeral hemiarthroplasty: speaker believes often better to go with natural healing and follow patient;
in certain instances, eg, fracture dislocation, surgery indicated, and surgeon must decide whether to fix humeral head
or perform hemiarthroplasty; depends on bone quality rather than age; hemiarthroplasty does not provide normal shoulder
function
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| Hemiarthroplasty: indications—head-splitting fractures; 3- and 4-part fracture dislocations; goal of procedure—
position metal humeral head in place of original head; orient and fix solidly in humerus; bring tuberosities underneath prosthesis
and close wound; contraindications—large open injury; damaged glenoid (perform total shoulder arthroplasty);
multiple injuries where shoulder becomes secondary concern; better to do hemiarthroplasty sooner rather than later; delay
longer than few weeks results in stiffening and adherence of structures (like “pouring cement around tuberosities”)
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| Operation: result heavily technique-dependent; arm not normal, ie, swollen, blood inside, tissue softened and in poor condition;
have patient semi-sitting; drape arm free; outcome depends on how well tuberosities repaired; support arm on stand
while working on tuberosities; incision distal from coracoid; infiltrate skin with adrenalin and saline to reduce bleeding; need
to see tuberosities clearly, so lengthy incision required, partly releasing insertion of pectoralis major and origin of conjoined
tendon; critically important to maintain coracoacromial arch intact to avoid anterosuperior escape of shoulder through top of
arch; key to identify biceps tendon and put tape around it; split tuberosities apart, apply heavy clamps and pull up to dissect
them free for easy movement; debride, debulk, and mobilize tuberosities; place heavy traction sutures (preferred over wire or
tape); extricate humeral head; keep instruments away from brachial plexus
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| Prosthesis: many kinds; speaker not sure type makes much difference; speaker uses first-generation prosthesis designed
in 1972; choose prosthesis of same size as patient’s natural humeral head (do not oversize); anterior dislocation of
“megahead” prosthesis second biggest complication of hemiarthroplasty; if glenoid cartilage damaged, replace
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| Fixing tuberosities: sew tuberosities to humeral shaft, to each other, and to prosthesis; positioning humerus easy, difficult
part humeral height and orientation (reference elbow 20° to 40º retroverted); must leave space for tuberosities; do not drive
humerus too far down, making it too short and altering mechanical relationship to deltoid; cement prosthesis proud in anatomic
position, leaving enough space for tuberosities; inject cement down into shaft, away from tuberosities; keep arm at side
and adjust rotation; prosthetic humeral head should be tight and snug, not rotating and twisting; rehabilitation consists of active
assisted ROM, stretching, and strengthening after 6 wk
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| Complications: prosthesis put in backward; dislocation, which usually means tuberosities not correctly prepared; nonunion
of tuberosities; most complications avoidable
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| Results for pain, motion, function, and longevity: Goldman study (1995)—3 of 4 slight or no pain (speaker’s
experience concurs); do not get overhead motion (maybe up to 90º-100º); can rotate but not normally; limitations for lifting
and carrying heavy weight; none of speaker’s patients can effectively do above-shoulder activities
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| HAND STIFFNESS: COMMON PRESENTATIONS —James L. Mahoney, MD, Associate Professor, Division of Plastic Surgery,
Department of Surgery, University of Toronto Faculty of Medicine
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| Stiffness defined: in diagnosing stiffness, measurements of function increasingly available, eg, Disabilities of the Arm,
Shoulder, and Hand (DASH) outcome measure; monitoring patient progress just as important, using such measures as fingertip-to-palm,
ROM of relevant joint, active and passive motion
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| Surgery: balance of factors needed when considering, eg, swelling controlled, pain virtually gone, patient highly motivated,
structural repairs successful and complete; in general, do not consider until 6 mo to 1 yr after initial problem
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| Interphalangeal (IP) joints: collateral ligaments fan-shaped and tight in all positions; case—primary problem middle
phalanx sitting dorsally on proximal phalanx, ie, subluxed middle phalanx; present >6 mo; flexion problem (patient
locked in extension); extensor release needed, not only for dorsal capsule extensor tendons, but also for collateral ligaments;
major problem getting these back in early (within 3-4 wk); flexion leads to volar capsular contracture and adhesion
as in Dupuytren’s contracture; over time, if patients in flexed position related to soft tissue contracture, they develop
secondary proximal interphalangeal (PIP) contractures; in most situations, extension leads to tightness in extension; however,
with very strong flexors, can work around this; real issue after 6 mo that remodeling of proximal phalanx head precludes
satisfactory ROM, even when better joint continuity restored
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| Dupuytren's contracture: when PIP joints down >6 mo, warn patient to expect longer rehabilitation because PIP joint
release required; take all Dupuytren’s off in area of PIP joint; initially release check rein ligaments and follow these along
into collateral ligaments to get joint straight; speaker accepts some elasticity
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| After trauma: volar plate and collateral ligament injury; frequently splint in flexion for pain and stability; speaker’s goal
to achieve full extension at 3 to 4 wk, thus minimizing flexion contractures; many patients do not realize severity and
present at 4 and 6 wk with tight PIP joints, usually fixed at 45º; even when relatively fixed and pain-free after course of
therapy, still have significant contracture problem; in cases without associated fractures, can do simple check rein release
through small volar incision and get joint straight; if scarring present, release of collateral ligaments required
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| Boutonniere deformity: if fixed, 2-stage procedure required, ie, release of volar plate followed by extensor tendon reconstruction
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| Fixation of finger fractures: newer techniques available, eg, plating; in most circumstances, preferable to avoid fixation
crossing joint; avoiding immobilization of joints helps avoid stiffness
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| Trigger finger in elderly: speaker’s group considered swelling, triggering, locking, tenderness, and nodule; patient
may hold in flexion to avoid pain, and joint becomes locked in flexion; speaker settles pain with injection and works
more quickly on PIP contracture (long-term concern)
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| When to operate: get inflammation and swelling under control first; ensure collagen production mature and past myofibroblast
stage where potential for contracture exists; usually means no discomfort on passive ROM within limited range;
make sure collagen remodeling and reduced inflammation fixed and stable before introducing new inflammation and reactivation
of scarring process
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Educational Objectives
| The goal of this program is to educate the listener about developments in management of distal radius and proximal humerus
fractures, and common presentations of hand stiffness. After hearing and assimilating this program, the clinician will
be better able to:
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 | 1. Utilize a 3-pronged approach to injury of the distal radius.
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| 2. Cite 2 major developments in the management of distal radius fractures in the last 5 to 8 years.
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| 3. Review data on the management of proximal humerus fractures.
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| 4. Identify the advantages of the new locking plate in proximal humerus fracture management.
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| 5. Identify common clinical presentations of hand stiffness.
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Suggested Reading
Al Mukaimi A et al: The use of locked nails in the treatment of humeral shaft: delayed union and nonunion. Med Princ
Pract 14:245, 2005; Becker R et al: Strength and motion after hemiarthroplasty in displaced four-fragment fracture of
the proximal humerus: 27 patients followed for 1-6 years. Acta Orthop Scand 73:44, 2002; Boileau P et al: Tuberosity
malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus.
J Shoulder Elbow Surg 11:401, 2002; DeFranco MJ et al: Evaluation and management of valgus impacted
four-part proximal humerus fractures. Clin Orthop Relat Res 442:109, 2006; Drobetz H et al: Volar fixed-angle plating
of distal radius extension fractures: influence of plate position on secondary loss of reduction--a biomechanic study in a cadaveric
model. J Hand Surg [Am] 31:615, 2006; Frankle MA et al: Techniques and principles of tuberosity fixation
for proximal humeral fractures treated with hemiarthroplasty. J Shoulder Elbow Surg 13:239, 2004; Freeland AE et al:
Biomechanics and biology of plate fixation of distal radius fractures. Hand Clin 21:329, 2005; Gainor BJ et al: Humeral
shaft fracture with brachial artery injury. Clin Orthop Relat Res:154, 1986; Iannotti JP et al: Nonprosthetic
management of proximal humeral fractures. Instr Course Lect 53:403, 2004; Jebson PJ et al: Combined Internal and
External Fixation of Complex Intra-articular Distal Radius Fractures Using Dorsal and Volar Approaches. Tech Hand Up
Extrem Surg 4:161, 2000; Koh S et al: Volar fixation for dorsally angulated extra-articular fractures of the distal radius:
a biomechanical study. J Hand Surg [Am] 31:771, 2006; Loebenberg MI et al: The effect of greater tuberosity placement
on active range of motion after hemiarthroplasty for acute fractures of the proximal humerus. Bull Hosp Jt Dis 62:90,
2005; Mittlmeier TW et al: Stabilization of proximal humeral fractures with an angular and sliding stable antegrade
locking nail (Targon PH). J Bone Joint Surg Am85, 2003; Nana AD et al: Plating of the distal radius. J Am Acad Orthop
Surg 13:159, 2005; Naranja RJ Jr et al: Displaced three- and four-part proximal humerus fractures: evaluation
and management. J Am Acad Orthop Surg 8:373, 2000; Nicolosi M et al: Treatment of fractures of the humeral head by
cemented and cementless hemiarthroplasty. Our experience. Chir Organi Mov 90:171, 2005; English, Italian. Orbay J et
al: Volar fixed-angle fixation of distal radius fractures: the DVR plate. Tech Hand Up Extrem Surg 8:142, 2004; Rozental
TD et al: Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the
distal radius. J Hand Surg [Am] 31:359, 2006; Ruch DS et al: Volar versus dorsal plating in the management of intra-
articular distal radius fractures. J Hand Surg [Am] 31:9, 2006; Schmidt AH: OPINION: proximal humeral hemiarthroplasty.
J Orthop Trauma 18:123, 2004; Skoff HD: The surgical treatment of Dupuytren's contracture: a synthesis of
techniques. Plast Reconstr Surg 113:540, 2004; Slade JF 3rd et al: Combined fractures of the scaphoid and distal radius:
a revised treatment rationale using percutaneous and arthroscopic techniques. Hand Clin 21:427, 2005; Rayan
GM: Dupuytren's disease vs non-Dupuytren's contracture. J Hand Surg [Am] 30:1019, 2005
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Axelrod, Richards, and Mahoney spoke at the 22nd Annual Upper Extremity Update presented April 7, 2006, in Toronto
and sponsored by the University of Toronto, Faculty of Medicine, Department of Surgery. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation in the production of this program.
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