76: Percutaneous Pinning of Distal Radius Fractures

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Procedure 76 Percutaneous Pinning of Distal Radius Fractures

John T. Capo, Naveen K. Ahuja

imageSee Video 57: Percutaneous Pinning of Distal Radius Fractures

Indications

image Unstable displaced extra-articular distal radius fractures

image Simple two- or three-part intra-articular distal radius fractures

image Displaced distal radius fractures in children and adolescents

Examination/Imaging

Clinical Examination

image The extremity of the patient should be examined for open injuries and neurovascular status, particularly median nerve function.

image The distal ulna should be examined for dorsal prominence or instability.

image The elbow should be examined for tenderness at the radial head and collateral ligaments.

Imaging

image Anteroposterior and lateral images of the wrist should be obtained. These will demonstrate the specific fracture pattern of the injury. (Fig. 76-1A and B shows a 47-year-old woman who sustained an intra-articular distal radius fracture with some angulation and displacement.)

image If there is significant intra-articular comminution, a computed tomography scan will provide more information on the location and displacement of the fracture fragments.

image

FIGURE 76-1

Surgical Anatomy

image The pins are placed dorsoradially in the radial styloid and dorsoulnarly in the intermediate column of the radius.

image The surgical interval is between the first and second dorsal compartments for the radial-sided pins and between the fourth and fifth compartment for the ulnar-sided pins.

Positioning

image The procedure is done on a hand table with the forearm pronated.

image A tourniquet is placed on the upper arm but is usually not needed.

Exposures

image The radial-sided pins are placed first. A 2-cm incision is made over the radial styloid (Fig. 76-2).

image The soft tissue flaps are elevated, and the skin is retracted. Branches of the superficial nerve are identified and carefully protected (Fig. 76-3).

image The tip of the radial styloid is identified, and the periosteum is elevated. The tendons of the first and second dorsal compartments are reflected off the radius enough to safely insert two pins. The tendons are left within the compartments and are elevated subperiosteally (Fig. 76-4).

image

FIGURE 76-2

image

FIGURE 76-3

image

FIGURE 76-4

Pearls

The branches of the superficial nerve are identified and retracted with the skin flaps.

Procedure

Step 1

image The radial styloid pins are inserted using a soft tissue protector. The first pin is placed into the distal fragment only. The pins are typically 0.062-inch Kirschner wires (Fig. 76-5).

image The wrist and distal fragment are flexed over a towel bump to reduce the displacement or angulation of the fracture. With the fracture reduced, a dorsoulnar pin is placed percutaneously. This pin is placed at the dorsoulnar corner of the distal radius (Fig. 76-6).

image

FIGURE 76-5

image

FIGURE 76-6

Step 1 Pearls

The radial styloid can be easily fragmented, and multiple passes of the K-wires should be avoided.

If there is difficulty in reducing the fracture, a blunt elevator can be placed percutaneously. This can be inserted into the fracture site dorsally and used to lever the fracture into a reduced position.

Step 1 Pitfalls

Caution should be taken if the radial-sided pins are placed percutaneously. The tendons of the first compartment and superficial radial nerve can easily be damaged.

Step 2

image With the wrist flexed and the fracture reduced, the pins in the distal fragment are driven across the fracture and into and through the cortex of the proximal shaft.

image An additional pin is placed from the radial styloid and across the fracture.

image Anteroposterior and lateral images should show good alignment of the fracture with restoration of volar tilt and ulnar inclination (Fig. 76-7A and B).

image

FIGURE 76-7

Step 2 Pearls

If the bone is very osteopenic and is not held by the pins well, then an intrafocal Kapandji technique can be used. The pins are placed through the fracture site on the dorsoradial and dorsoulnar side of the distal fragment and thereby buttress the fragment in place.

The fracture is first elevated with an osteotome and levered volarly to restore the volar tilt (Fig. 76-8A). A K-wire is then placed at the same level but driven into the intact volar cortex to hold the buttressed fragment. Additional wires can be driven along the dorsal fracture, and the radial edge of the fracture can also be elevated to restore the radial inclination (Fig. 76-8B).

At times, a combination of intrafocal pinning and pinning through the fracture fragments can be used (Fig. 76-9A and B).

image

FIGURE 76-8

image

FIGURE 76-9

Step 2 Pitfalls

Care should be taken not to over-reduce the fragment. Excessive volar flexion can displace the fragment volarly.

Step 3

image The radial-sided wound is closed with 4-0 nylon sutures, with care taken to avoid the branches of the superficial radial nerve.

image The pins are bent at an angle to avoid skin impingement and covered with a plastic pin cap.

image The pin sites are covered with a nonadherent dressing and then a bulky gauze dressing to push the skin down off the pins.

image A volar or sugar tong splint is placed for added support.

Step 4

image The technique is also useful for displaced pediatric fractures. Appropriate fractures are transphyseal or metaphyseal. Radiographs demonstrate a displaced, nonreducible physeal fracture in a 15-year-old boy (Fig. 76-10A and B).

image Closed reduction and percutaneous pinning are usually easily achieved with general anesthesia and muscular paralysis (Fig. 76-11A and B).

image Pins are removed after 4 to 5 weeks in the clinic. Final radiographs should show a healed fracture with good alignment of the articular surface (Fig. 76-12A and B).

image

FIGURE 76-10

image

FIGURE 76-11

image

FIGURE 76-12

Step 4 Pearls

Pediatric fractures can often be stabilized with a single smooth K-wire.

Postoperative Care and Expected Outcomes

image Patients are seen after 2 weeks for a dressing change and suture removal.

image Finger and elbow range of motion (ROM) is allowed after 2 weeks.

image In adults, the K-wires are removed in the office 5 to 6 weeks after surgery.

image Final radiographs at healing should show good alignment of the articular surface. After the pins are removed, there may be some settling of the distal fragment (Fig. 76-13A and B).

image

FIGURE 76-13

Pearls

Early ROM can begin with the pins in and be increased after the pins are removed. The final clinical result is usually functional wrist flexion and extension as well as forearm rotation (Fig. 76-14A and B).

image

FIGURE 76-14

Evidence

Harley BJ, Schargenberger A, Beaupre LA, et al. Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial. J Hand Surg [Am]. 2004;29:815-824.

This prospective, randomized study showed that in patients younger than 65 years, percutaneous pinning and casting were equivalent to augmented external fixation. Fifty-five patients were enrolled and followed for 1 year both clinically and radiographically. Both groups were similar in terms of fracture type and AO-ASIF class. Specifically, there was no significant difference in radial length, radial angulation, volar tilt, DASH scores, total ROM, or grip strength. (Level II-3 evidence)

Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius: a prospective comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg [Br]. 1995;77:562-567.

This prospective study of 96 patients with extra- or intra-articular distal radius fractures with a dorsally displaced posteromedial fragment were treated with either trans-styloid or Kapandji (intrafocal) fixation. Patients were followed at 6 weeks and 3, 6, 12 and 24 months. Although there was some improvement in range of motion in early follow-up with Kapandji fixation, at 24 months the results were similar in both groups. (Level III evidence)

Naidu SH, Capo JT, Moulton M, et al. Percutaneous pinning of distal radius fractures: a biomechanical study. J Hand Surg [Am]. 1997;22:252-257.

This cadaveric study used 12 fresh-frozen radii with a dorsally comminuted osteotomy 2.5 cm proximal to the radial styloid to test 12 different pin combinations: 4 pin configurations were used with 3 different pin sizes. Rigidity was greatest with respect to cantilever bending and torsion with two radial styloid pins and one pin from the ulnar corner of the radius. Additionally, a minimum pin size of 0.62 inch was required to discern differences in rigidity among different pin configurations. (Level II-3 evidence)

Trumble TE, Wagner W, Hanel DP, et al. Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg [Am]. 1998;23:381-394.

This study subdivided 73 patients into groups according to age, degree of comminution, and whether external fixators were used in combination with percutaneous pinning. In older patients (55 years), the use of external fixators resulted in better range of motion, grip strength, and pain relief. In younger patients, external fixation only resulted in superior results if two sides of the radial metaphysis were comminuted. Additionally, functional results were improved by restoration of palmar and radial tilt as well as radial length. (Level III evidence)

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