All right. Welcome, everybody, and thanks for being here late in the day like this. I think there's some adjustment to the start time. Is it 5 o'clock? Is it 5.15? It never got changed in the app. It looked like it got pushed back to 5.15, but I think we're just going to get started. It seems to have plateaued with entry into the room coming from the general session, so we'll get started. And again, thank you for being here. We've got an incredible faculty to share their thoughts on distal radius fractures. And please don't leave after this first one, because this is really why everybody is here, to find out about the osteoporotic distal radius fracture. What do I do next? But I'd like to introduce my friend Jake Brubaker, who is an associate professor at the University of Kansas, to get us all up to speed on osteoporotic distal radius fractures. Okay. So this is the sexiest topic, and I'm pleased to be talking about it, but we did promise you kind of a comprehensive talk on distal radius fractures, and so I wish I was here to talk about bridge plating of these challenging fractures, but instead we're going to talk a little bit about what do you do with the human that's attached to the interesting wrist fracture, and what do you or I, in this perspective, do? And so I'll try to convince you that this is an important topic to know about, and why it's important for hand surgeons in particular, and this is a big problem. Two million fractures a year, over $17 billion worth of healthcare spending. One out of every two Caucasian women will have an osteoporosis-related fracture. So again, two million fractures, probably half a million now of half a million hospital admissions, medical visits, nursing home admits, and this is going to be a $25 billion problem in the next couple of years, and expected to grow by a significant amount. So this is a huge problem, but we're having a small response. So patients with a fragility fracture have an 86% higher risk of a second fracture, and despite the tools and technology to do something about it, only 20% of those patients with a fracture are screened for osteoporosis, and once they're screened, only 20% of those get the needed therapy for osteoporosis. So this is a mandate from the National Osteoporosis Foundation, just stating that, look, this is an entity that can be prevented, diagnosed and treated before fractures occur, and after your first fractures occur, there are effective treatments that can decrease the risk of further fractures, and prevention, detection, treatment should be a mandate of primary care providers. So I know what you guys are thinking out there. Great, primary care providers. So why are you telling me about this? Well, our own specialty orthopedics is starting to take more and more responsibility for this. You see in the top right here what an epidemic this is. If you look at fragility fractures compared to the fearsome triad of MI, stroke, and breast cancer, the numbers are huge for fragility fractures. The AOA has started this Own the Bone initiative, which is a post-fracture, systems-based, multidisciplinary approach to taking care of this issue. So it's a quality improvement program that this is just a brief look at what are the different ways that they come in and work on counseling and testing, diagnosis, pharmacotherapy. We as hand surgeons, I think, play a particularly important role in this, as distal radius fractures are the most common symptomatic fracture, and they occur before the more debilitating and costly hip and vertebral fractures. So this puts the hand surgery clinic and us as providers at a valuable point of intervention, and we're not doing a great job. So only 5 to 20% of patients are receiving subsequent medical consultation or pharmacotherapy after they get the distal radius fracture. So knowing the enemy, what is osteoporosis? So this is low bone mass, disruption of bone architecture, compromises bone strength, leads to fractures. It's the most common bone disease in humans. So we all know that bone remodels. Older bone is replaced with new bone, and the bone loss if it's unbalanced, you have greater bone removed than replaced. And advanced age, menopause, this all increases the bone remodeling and magnifies the impact of the imbalance. Okay, so how do you diagnose osteoporosis? One is with a DEXA scan and the measurement of the bone mineral density. So that's one way. Second way is if you get an adulthood hip or vertebral fracture in the absence of major trauma, you have osteoporosis. So one of those two factors. If you do, there are some laboratory testing that can be worked up to exclude secondary causes. So this is from the World Health Organization. So this is the most standard kind of definition of osteoporosis. So if you get a DEXA scan and that bone mineral density is two and a half standard deviations below a normal reference range, that's osteoporosis. So that's the T-score. The T-score is compared to a normal healthy young adult. So what are the guidelines? So this is actually the reason, I think one of the reasons that we're having a hard time getting off the ground with really focusing on this is that the guidelines are actually a little bit confusing and there's multiple endocrine organizations that are giving out guidelines. But this is a position paper from a multidisciplinary group in the National Osteoporosis Foundation and this is what's important. So who should be screened? Who should be screened for osteoporosis? So turn our attention to the last one. Women and men age 50 and older who have had an adult age fracture. So that's a distal radius fracture. So anybody who's above 50 and has a wrist fracture should be screened for osteoporosis. This is work out of Beth Israel, JBJS in 2014. They took a look at their clinic. Once again they were trying to follow this mandate, age 50 years or older with distal radius fracture and how are they doing with the DEXA scan and subsequent follow up. And what they found, they were doing pretty well actually. They had 53% of women having a DEXA scan after injury but only 18% of men. So they found that when we think about osteoporosis, male sex was an independent predictor of failure to undergo bone marrow, sorry, bone mineral density testing. This is out of the Mayo Clinic. They recognized the problem and tried to start this fragility care program that was aimed at just capturing these patients and trying to get them screened. So at their baseline before they initiated this endocrinology referral and attempt to capture them, there were about 15% of patients were getting screened which is right around average. After that, after they started paying attention and trying to grab these patients and get them into the appropriate care, that went up to 80% getting screened and 64% were diagnosed with osteoporosis. The thing to note about this is even in this situation where you have a, you're paying attention, you know that you need to refer these patients, they still were missing like 40 or 45% of the patients, you know, weren't referred appropriately. So this just shows you how hard this can be to implement. And this is out of University of Kansas. We looked at the Medicare database, 37,000 patients with distal radius fracture, only 26% of folks were undergoing DEXA scanning after the fracture and once again, males have a pretty dismal screening rate and females were doing better. We tried to follow those patients forward to see if screening made a difference and patients who had screening, although we couldn't tell whether or not they were being treated appropriately or not, but there was a significant fracture-free, a longer fracture-free interval for those that underwent scanning with DEXA. So who gets pharmacotherapy? So if you have a hip or vertebral fracture, you get treated. And if you have osteoporosis, so once again, someone has distal radius fracture, they get a DEXA scan, that DEXA scan meets the definition of osteoporosis, then they get started with treatment. And there's also folks with osteopenia and who have a high risk factors. And I won't get into the weeds here even more than I am, but there's a free calculation tool that you can do online with your patients that can give you their 10-year probability of a hip fracture with a few variables. And that could mean that they would get treated. Because we're having such difficulty with the multi-step process of seeing somebody, screening them, getting them referred, treated with the, or having a DEXA scan testing, and then treatment on pharmacotherapy, the Endocrine Society is now coming out with a clinical practice guideline and stating that anybody at high risk of fracture, so that would be somebody who's had a subsequent fracture, including distal radius fracture, they're now advocating just starting them on bisphosphonates rather than the formal screening process. I haven't seen that from the other societies, but that's starting to be kind of the movement. And we did look, Thomas Jefferson did a study, just an economic analysis on bisphosphonates. So what if you treated everybody that got a distal radius fracture with a bisphosphonate? What was the economics of that? And they were looking at women over the age of 65, but that would cost $2 billion annually. The break-even point for bisphosphonate therapy on an annual basis would be about $70. So that's more than the cost of what most bisphosphonates are, so there's some thought about that. So okay, we made it through. Here's the conclusion. Osteoporosis, big problem, poorly diagnosed and treated. Hand surgeons, valuable point of intervention. We're seeing these patients at a time point where they're presenting with a distal radius fracture, but before they've had the more debilitating and costly hip or spine fracture. Distal radius fracture, if they're over 50, they should be screened. The screening's with the DEXA scan. So we all come from different healthcare systems, different practice models, but the future is to figure out how you're going to handle getting that patient either a DEXA scan or referred to the appropriate person in order to get screened. Thank you. Thanks Jake. That was really good. I mean, it can't be overstated that the distal radius is the most common fracture that we see, and it has this entry point into overall total health for these patients. So we'll have questions and answers at the end. We're going to get a little bit out of order just because Rob Kamal had another talk at NICL at the same time, so when he gets back we'll have him do his, and Dr. Mihir Desai from Vanderbilt is going to talk to us about other approaches to the distal radius beyond the FCR. Thank you, Mark, and thank you all for sticking it out with us and attending this ICL. So I will expand on our knowledge of distal radius fractures and just speak a little bit about some other options in addition to the FCR approach and standard Voller lock plating for these injuries. Pertinent disclosures. All right, so I'm going to start with a case. Looking at these radiographs here, we can see that we've got a right intra-articular distal radius fracture. It looks to have a fairly large radial styloid component as well as a Voller-Bartons-type Voller-displaced fragment. And this fracture was stabilized by one of our trauma partners in Nashville, and when you look at these post-op films, and this is I think about two weeks post-op, you can see that the fracture itself looks perfect, right? The overall reduction looks terrific, but I think we would all recognize that the plate is just sitting a little too radial. And based on this AP radiograph, at least, it looks like there may be a small fracture in the Voller-Lunate facet as well, but on the lateral x-ray, you can see that everything appears to be well supported. Well, now we fast forward a few weeks, and this patient returns to clinic and now is following up with me because they have what we see is escape of that Voller-Lunate facet. So because the plate was placed a little too radial, they lost containment of that Voller-Lunate facet, and the fracture is translated Vollerly and has taken the carpus with it. So now what? Well as we know about distal radius fracture fixation, we've got a lot of options. We're all very familiar with these options, and we have the Voller-Locked plates, we've got dorsal plating as well as combo plating, we've got pinning, we've got these X-Fixes which can be used, we've got fragment-specific fixation, and we've got dorsal bridge plating without any real known superiority of one technique or the other. So what is the best technique? Well, the short answer is it really depends on the fracture, and a lot of this comes down to the surgeon's training, their comfort with these different fixation treatment options, and their experience. So oftentimes how we're trained will dictate how we end up practicing medicine. If we look at fragment-specific fixation, comparing that to Voller-Locked plates, again for an example such as this, this was a randomized trial where patients were randomized to either Voller-Locked plating or fragment-specific fixation, and a long-term follow-up which was one year in this study, there was no difference in grip strength, range of motion, or dash scores. But if you look at the complications, the complications were significantly higher in the fragment-specific population with 56% of those reporting some complications versus 21% in the Voller-Locked plating group. And these complications ranged from things like complex regional pain syndrome to painful hardware and tendon injury. And so even though this technique has been touted as a very effective option, it's helpful to know that it's not without its own criticisms and potential for complications. And if we look at functional outcomes with bridge plating, so bridge plating is obviously something that we're using more and more. It's been an excellent bailout for the highly comminuted distal radius fractures, many of which occur in the osteoporotic patient population where some of the other treatment options may not be helpful. These treatment options can be very useful. And this was a study that looked at 100 patients treated with bridge plating of highly comminuted fractures. The plates were all removed at three months, which again requires that second surgery which typically is the biggest criticism of this technique. But watching these patients out to one year, the authors showed that they had functional outcomes similar to historical data for other treatment options with no infections, tendonitis, or tendon ruptures. And so the patient that we saw before was treated with a bit of a combination. So understanding that we've got these options available to us, we can sort of put together a couple different potential techniques to fix these fractures. So that patient who had that escape of that volatile lunate facet was treated with a combination of a fragment specific type plate. This was done before we actually had fragment specific plates at our institution, as well as a bridge plate. So the bridge plate helped neutralize the forces that were taking that carpus volarly, but that small plate, that little mini frag plate and the K wires were used to just buttress that volatile lunate facet fragment in place. And this was able to hold the fracture stable until the plate, the bridge plate was eventually removed. So I think it's helpful just to point out what the critical corner is. I think Rob, when he comes in to give his talk, we'll talk a little bit more about this as well. But the critical corner is that volatile lunate facet. And regardless of what technique you use to fix the distal radius, it's important to recognize that if you've got a fracture that involves that piece, it needs to be stabilized. And the importance of that, for those of you who don't know, is the short radial lunate ligament originates from that fragment and attaches to the lunate. So wherever that piece goes, the lunate's going to follow and the rest of the carpus is going to go with it. And there are a couple requirements for a good reduction. So we'll start with the approach as well as radiographs. So the approaches that we can use for stabilizing distal radius fractures are the FCR approach, which is by far the most commonly used. There's the volar approach that just is a little bit more ulnar between the ulnar bundle and the FDS and FTP tendons that allows direct access to that critical corner. We have the dorsal approach, which would allow us to place a dorsal plate or a bridge plate. And then there's any combination of these. So you can combine them. You can go volar-dorsal for many of these fractures, or you can just do volar or dorsal. Good reduction also requires good radiographs. The DREJ view or the sigmoid notch view is critical and that requires supinating the radius, which you'll see in a second. And I think Rob's going to talk about that in quite some detail when he gives his presentation. But looking at the standard FCR approach, which is the image on the left, you can see I've marked out the distal pole, the scaphoid, and the black line represents the FCR tendon. So that's our standard approach for utilizing the FCR approach to the volar distal radius. And the image on the right is the more ulnar incision. And by utilizing this incision, you can actually have direct access to the intermediate column. And if you've got a patient that just has a small fracture of the volar lunate facet and you're interested in using just a volar lunate facet plate, this approach just gives you direct access to it without having to come more radially and then sweep the soft tissues ulnarly. So this is an example of the FCR approach, which we're all familiar with here. So this is the DREJ view or the sigmoid notch view. And when I was a fellow at Duke, Mark showed me this technique. I wish I could take credit for this, but this has really changed my ability to manage these fractures. By placing a lobster claw clamp approximately on the radius diaphysis, you can actually supinate the forearm appropriately to get that DREJ view. So if you think about how the arms typically position on the hand table, it's going to slightly pronate. And when you get your images from what you think is A to P and you place your plate and you center it based on that image with that semi-pronated view, your plate's always going to sit more radial. And so in order to really get a good radial to ulnar alignment of your distal radius plate, if you're using the volar approach, you need to supinate. And so you can get this nice sigmoid notch view that gives you that box right down the sigmoid notch. And that allows you to really dial in your radial to ulnar alignment for your volar plate placement. All right, so dorsal plating. The indications for this are, as seen here in my hands, it's going to be for somebody who's got a lot of dorsal metaphyseal comminution or has a dorsal shear fracture without any involvement of the volar cortex. It also provides direct visualization of the articular surface. So if you've got a fracture, for example, a dive punch fracture that's a little too difficult to, or you think is going to be very difficult to align the articular fragments, the dorsal approach gives you the ability to do that. There are some problems associated with this. There can be some issues with extensor tendon irritation since the plate's going to be sitting so close to the extensor tendons. And it can be difficult to correct the volar tilt. In one study back in 2011, the newer lower profile dorsal plates, which every company basically has some iteration of, really have less tendon irritation and less issues compared to things like the old pie plates that were used. There's also less neuropathic pain after using these compared to volar lock plating, which makes intuitive sense because there's less dissection around the palmar cutaneous branch, the median nerve, as well as the median nerve itself. So this is the approach using a standard dorsal approach, just ulnar to lister's tubercle between the third and fourth extensor compartments. We'll typically do this sort of Z plasty type incision across the extensor retinaculum. That allows you access to the tendons to move them out of the way. And then you can repair that retinaculum back over the tendons once you've completed your fixation. So this is an example of a patient that has a pretty comminuted but very clearly this dorsal shear fracture. There's any number of ways to fix this. I think you could argue that you could try it from a volar approach. You could also do a bridge plate. But we elected to do dual plating. There was a little bit of an issue with the radial styloid, and that's what the volar plate is attempting to capture there. But the dorsal plate is really doing the lion's share of work to buttress that fragment and keep it volar and avoid that from continuing to displace. So we'll move on to bridge plating. The indications for bridge plating really are going to be for the severely comminuted fractures, the fractures that are just a little too comminuted for you to be able to use either a fragment-specific fixation or a volar-locked plate. The other one that comes up fairly frequently are going to be the very distal fractures where you may just have a little bit of a shearing effect across the subconjunctal bone. Or if you have a radiocarpal dislocation. So if you have a dementia radiocarpal dislocation that really has very small bony fragments that are attached to it, those can be adequately stabilized with a bridge plate as well. And the idea here is that you just want to position the hand on the wrist. And so if I have a distal radius fracture that I treat with a volar-locked plate and I do a volar-dorsal test after I have my volar plate on, and there's still a little bit of instability, then I'm going to opt for placing one of these plates on for supplemental fixation. And that sometimes comes up if you've got a fracture where you approach it volarly, you stabilize it, but they still have a lot of dorsal comminution that's fairly distal, so there's really no support. Or if you had a hard time getting the volar tilt perfectly, they can still slide out the back. The bridge plate does a really good job of holding that reduction. As I mentioned before, the plate is typically removed around three to four months, sometimes a little bit earlier if the patients are doing really well and you can see some early signs of healing. So this is the technique. You can either do two incisions or three. My vote typically is for three incisions. You can also go to the index metacarpal versus the long metacarpal. I prefer the long metacarpal just because it's in the central axis of forearm rotation and allows my patients to start perineal supination without any difficulty immediately. But I think it's dealer's choice. There's really no superiority between the two. The central incision's really helpful because it allows you to make sure the plate is underneath the extensor tendons, so it just makes it much easier to feel confident that you've placed the plate underneath the tendons and ensure that you're not over the top of any of the tendons. So we've placed the plate typically in a distal to proximal fashion. The one thing that I did want to point out here, I put this incision just a little bit more radial because it's a little bit easier once you've got your plate distally affixed to bone to whichever metacarpal you choose. You can use a lobster claw to actually clamp the plate down to the radial diathesis proximally. So if you've got a very unstable fracture, you can adjust your length or your radial ulnar translation and then lock it in place before you put your screws in. It makes it much easier. So if you slide this incision just a little bit more radial, it allows you to put the lobster claw clamp in a little bit easier than if that were centrally placed dorsally over the radial shaft. And this is, again, what it will look like if you use a bridge plate. Most of the, you know, and originally these were just standard small fragment type plates, but now each manufacturer makes their specialty plates which do have clusters of screws which can be placed either over the carpus so that you can put screws into the carpus and reduce them to the plate if there's still some carpal instability or through the fracture fragments distally. So take some time to figure out exactly where you want to place the plate if you want to do something like this that's shown here in this image. So this is an example of a fairly distal fracture. And again, I think you could argue that this could be fixed any number of ways. This is a 38-year-old attorney. He fell while he was hanging Christmas lights at his home. And he's got a fairly distal volar fracture fragment, as you can see there. And then he's got this dorsal, large dorsal piece with obviously this dorsally angulated distal radius. My general preference for this, when it's this distal, I like the idea of a bridge plate, but again, you could opt for putting a dorsal plate on here. So we did elect to put a bridge plate. I don't routinely fix a styloid if it's not unstable. If the styloid isn't moving a lot once we stabilize this, I'll leave it alone. If it is still moving or if there's any carpal translation when I stress test the styloid, I'll put a headless compression screw or some K wires across it. This one was fairly stable once we reduced his fracture with the bridge plate. And this is where he is six weeks after plate removal. So he had his protosupination immediately. He was able to get that back. He was also able to get his finger flexion back immediately. So he was able to actually be fairly independent almost immediately. But what's really impressive about these patients is they actually get their wrist flexion extension back fairly quickly after they start a therapy program once the plate comes out. So at six weeks, he has almost all of his range of motion, just has the last few degrees to work on. So again, just to summarize, the choice of approach really is going to be, I think, driven primarily by surgeon preference and experience. But an understanding of the fracture characteristics can really help guide which one of these you want to use or if you feel like you need to have a combination. So it's helpful to be familiar with all of these approaches and all of these techniques. Thank you. Alright, so I will go next with tips and tricks for challenging fracture patterns. I really did want to give the osteoporosis one, but Jake begged me, so I let him have it and then I decided that I would share my tips and tricks. And then what we'll do is, I see Rob walking in now, leisurely, so we'll have him do his imaging one after that, and then we'll have Chris bring his home with other associated injuries. So, bag of tricks, some of this you've heard about, and I'll give some slightly different spins on some of it, but these are things that I like around when I'm doing a distal radius fracture. So, the lobster claw, which we heard about, and I'll show you a couple instances. The large pointed tenaculum, which we affectionately call the King Tongue, and I think our trauma people call the Prince Tongue, they think it's the small one, but for us it's the big one. The bridge plate, the laminar spreader, and then the 16-gauge hypodermic needle. Alright, so let's first talk about the lobster claw. You know, Rob is going to talk about the sigmoid notch view and the importance of getting that perfect view, and how we want to make sure that we're perfectly lined up, and me here was talking about the same thing. If you look in this image on the left, you can see that lobster claw in there on the bone. It does actually three things for us. One, it's a retractor. You need some form of a retractor anyways, and having that in keeps the soft tissues away and gives you less worry than things with sharp points like gelpes and wheat landers and that sort of thing. But the other thing it does is it gives your transference of energy to the bone, or motion to the bone, a linear one-to-one relationship. If you're trying to get that perfect view that Rob's going to talk about, and rotate the arm, and you're just doing it by moving the forearm, some of the motion that you give is imparted to the soft tissue envelope around it, and then some of it to the bone, and you don't have a good sense of that very micro-movement, hand surgeon, OCD type, I want this amount of motion, and here I am. So it does give you a very linear, incremental ability to fine-tune that x-ray and get a perfect one. The other thing is when you're doing your reduction maneuver and you want to maximize your reduction maneuver, being able to grab the lobster claw and pull proximally on the shaft of the bone and do your reduction to the plate, it's going to give you a one-to-one transference of all your energy going to that bone instead of, again, under the soft tissue sleeve and feeling a little weaker in the OR that day than you wanted to be. So it's a good tool for many reasons. Next is the 16-gauge needle. It's the hand surgeon's friend because its inner diameter is just slightly larger than a 0.045-inch K-wire, which is probably the most common one that we use. So it gives you the ability to use it as a soft tissue protector if you're trying to put some provisional pins in that radial styloid piece. It's good for trying to get a starting point for finger fractures, metacarpal fractures, really anything around the carpus. It gives you the soft tissue protection effect, and it also gives you a very good starting point so that you have that bevel imparted into the cortex of the bone and you don't slide downhill as you're trying to get things started with a spinning K-wire. So it's a good tool. And just kind of coming through a case, you can see in this case here, in this picture alone, we have a lobster claw, we have the King Tong, and we have the 16-gauge needle. But you can see I chose to provisionally pin the radial styloid in this one so that 16-gauge both protects me from the radial artery and the superficial radial nerve and just gives me a good starting point that I can rely upon to get that K-wire started. So now the King Tong, the large-pointed tenaculum. This is a 64-year-old with a fall and a displaced distal radius fracture, post-reduction, get a CT scan, and it's a little bit of a combination of like a Smith's, a Vohler-Barton's combo because it's complete articular but it does have a Vohler shear component. And there's two ways to fix distal radiuses, and I bet if we did a poll in this room we'd see a lot of hands for each. Some people will put their Vohler plate on the distal fragment first and then bring it back to the shaft. Other people put the plate on the shaft first and then bring the fractured fragments distally to the plate and the shaft as one piece. So either way, the pointed reduction clamp is going to be a good tool for making sure that those distal fragments are firmly fixed against the plate at the distal end of your fracture. So here you can just see a little bit more an axial coronal split, large dorsal fragment. I tend to put the plate on the bone proximally first and then reduce to it. So I have my lobster claw on so that I can do my reduction maneuver, make sure all my energy is imparted to the proximal piece that I want to pull on. And then there's that King Tong going from the, in this point, on the Vohler side, it's on the jig, and then it's percutaneous through the back onto the distal dorsal cortex to be able to hold that plate all the way down to bone as we get our distal fixation. And there's our final construct in this case. All right, malunion correction. This is a nascent malunion, 50-year-old, that is three months out, already hates it, said that she wanted an operation before, and she already hates this three months out. So it's an easy one to fix. I have a low threshold for fixing these on the front side, but she's got carpal mal alignment, is already displeased. I think still pretty salvageable at this point. And this is not to talk about the malunions, it's to talk about the tools to get you there. So there you can find, through the FCR approach, the nascent malunion site. You do have to remember the 2D imaging of the 3D problem that Rob will talk about. In this case, the Vohler side is more distal, and the dorsal side is more proximal because of that dorsal tilt. So make sure that you do that math in your head when you're looking at those 2D images. There we're gonna take down that nascent malunion, and there's a whole bunch of different ways to do it, and other people would do it different ways, and I get that and respect that. But we're just gonna make this a fracture and do a reduction. You do have to do a dorsal periosteal release to get all that attempted early healing soft tissue sleeve off the back. We're gonna use a little kickstand device here, but this is the one time that I will put the plate on distally first. And the two ways that I'm gonna make sure that I'm all the way down against that Vohler cortex is to use my kingtong to hold it there as much as I can, and then to put in a purposefully long cortical screw to help try and suck down that distal fragment to the plate as well. And there you can see that one long screw in, and we'll fill the distal cluster with locking screws. Come back and use our lobster claw to help bring that plate down to the shaft now and get our correction. And you can see that correction there. I've now taken the pointed reduction clamp. I'm gonna go from the tip of the styloid to the ulnar shaft and try and make sure I correct in the coronal plane as well. So it could be helpful in more than one plane. There's all of those little tools in there. And then there's our proximal fixation and then trade out that non-locking screw for the shorter locking screw distally, and we've got our final construct. There are other ways of getting around that coronal plane malalignment. It's really common to have the distal fragment pulled radial on you because of the soft tissue attachments there. You commonly release the brachioradialis, but you still have the whole sheath of the first dorsal extensor compartment there that can help to pull it that way, and it's a little bit hard to correct. So the laminar spreader can help push the shaft back underneath that piece rather than trying to pull the distal fragment more ulnarly. So here's a pretty bad high-energy fracture in a 39-year-old who's a non-operative sports medicine doc in town. You can see it's a subtle difference there. If you look very critically at that sigmoid notch view, it's not much. It's only a couple millimeters, but there's a number of biomechanical studies. Scott Wolf had one. There's one out of Japan that shows even a millimeter or two of displacement in translation can affect the stability of the DRUJ because it imparts laxity there. And if you remember her original injury, she's got an ulnar styloid fracture that involves the base. So I'm going to try and get this DRUJ as tight and appropriate as I can on my radial side to hopefully not have to fix the ulnar side. So you can see the shadow of the laminar spreader in there approximately pushing gradually. With click-by-click, we're going to try and push that shaft underneath. And there we've got it all the way out, so I have one cortical line now. It only moved a couple millimeters, but that's all it needed to. And then we'll get our fixation there and secure everything, do our complete fixation, and examine the DRUJ, and she's still unstable, which is not terribly surprising because she has a basilar ulnar styloid here. So we'll go ahead and fix that. I used to do tension bands. I used to put gay wires in and do fancy tension bands, and then one day I was just looking at it and realizing I already had my guide wire for a headless compression screw if I wanted it. So now I just do two out-of-plane wires, and I put my headless compression screw over the one that goes right down, and that's typically how I fix these if they're a big fragment, which comes up maybe once a year. But there's her final x-rays and a stable exam in the end. Bridge plate we heard about, but it is good to have as broad an armamentarium as you can. This will get you out of trouble. Even when you're not doing it primarily, you'll be glad that you have it in the room. As you go to fix some of these, here's a 58-year-old woman with a fall from a horse. Osteoporotic fracture, so I already know down the line what I'm going to do with her. But in the OR, in game day here, post-reduction CT scan, she's got this intercalary volar cortical piece, which I'll show you a little case at the end, that these can be hard because they are really unstable as you try to balance them all back and come from the volar side. So she's got a separate lunate facet fragment. She's got bone loss. When we get her out to length and try and get all those pieces where they need to be, we don't have much to fix into. So filler with whatever the bone void filler is that you have your preference for. Plate in good position. Really, I can only get two screws in, that styloid screw and the volar lunate facet screw. And that's going to not be enough for me to be comfortable letting her have that as her sole means of fixation. So we're going to add a bridge plate and let her heal underneath, and then come back and take it off when she's healed. So the bridge plate saves the day again and gets you out of trouble in this one. And there she is. There she is after plate removal, and she's consolidated. And just glad to have that other tool in my bag of tricks. Another thing to be careful of is previous distal radius fractures. The plates that we all know and love, there's a million of them that are really good. They're very anatomic, and that's why we love them. But they're very anatomic, and they fit anatomic distal radiuses. And if you have somebody that broke their wrist when they were 15 and treated in a cast, or broke their wrist back in the days where people would X-fix, and they healed in a non-anatomic but functional way, and then they break again, they no longer have the normal anatomy of their distal radius. And those plates don't fit. And I'd be embarrassed to tell you how many of those I had to go through before I figured out what the problem was. So if I have that case, this is a 22-year-old male who had broken his wrist about five or six years before, treated in a cast. They all kind of have this bulbous look, and they tend to break extra-articularly proximal to that big bulbous ball of callus. But you can just look at that lateral and know that a Vohler plate is not going to fit. This is a paper by Mel Rosenwasser's group looking at these unstable extra-articular distal radiuses. And radial column plates did equally as well and were equally as strong as Vohler plates. This was a randomized trial. So usually you're still preserved on that radial column. To put a radial column plate on, you don't have a lot of deformity there. And that's what we did in this situation. It lets you avoid that mismatch of an anatomic Vohler plate. There are still some straight T plates that many sets have, and you can bend your own and do that. That's not another good option. Not a bad choice. But this is easier in many of these situations. So a small Vohler lunate facet fragment. Just a couple more here. This is Amy Moore and Dave Dennison's paper. There's other plates that have little add-on hooks and that sort of thing. But sometimes you find yourself not appreciating how small that fragment was. Or that there's a second fracture more distal to where your plate lies. And having the ability to put small K wires, usually 0.035 inch K wires, and bend them down and then put your plate on top to buttress those pins in can be a good way to get out of trouble in the operating room. I've gone to, I used to try to do this in situ. I find that when you try to bend them in situ, you start levering that piece and it's very futsy. So now I will put a couple of my pins in and I'll mark where I'm going to bend it. I'll take it out. I'll bend it ex situ, if that's a phrase. And then I'll tamp it back in and I'll do my other one. And you can pick your length perfectly when you do that. And it's a lot easier than trying to bend it in situ and then tamp it down a little bit and have it sticking out the back and then just put your plate right over the top. Last one, segmental volar cortical disruption. We talked about it before. But when you have multiple pieces on that volar side, it's really hard to get the reduction balance as a 24-year-old, high energy with a motorcycle collision. This is what it looks like. Just really, really mobile in there. And a lot of times you can get it provisionally fixed, but then it's in the way of your plate that you're trying to put on. So one of the things that you can do is get it provisionally fixed and then just drive those K wires out the back temporarily and cut them a little bit short with a plan to take them out after you do all your fixation. So you can see in the lateral view, we're just going to drive those through the back. You do need to make a little bump of towels there so that you're not breaking through your sterile field and bringing all the bad juju into your wound. So be careful of them coming out the back, but just cut them just below the dorsum of the skin. Do all your volar work after you back them up to the cortex. There you can see what it looks like radiographically. There's the plate that we chose going on over the top. And then once you have it all fixed, you can just pull those out the back and nobody knew that you were even there. So there's our final construct. Thank you very much. All right. So fresh from talking about patient-reported outcomes, here's Rob Kamal from Stanford to talk to us about imaging of dysradious fractures and how it can be a guide to decision-making in the operating room. Great. Thank you. I'm so excited to be the caboose to this train here. So I'm not. I'm not. I'm not the caboose. Sorry. Well, excited to have you all here and look forward to talking and learning from you all as well if there's time for questions later. So I'm going to talk about radiographic parameters and how we use them to make decisions and some of my tips and tricks. So obviously with these, the radiographs are oftentimes all you have, right? So it's, at least in my practice, uncommon to get the CT scan. So you really kind of focus a lot of scrutiny on parts, et cetera. And so what I'll walk through is some of the ways in which I look at an X-ray and sort of figure out approaches and things like that and go from there. One of the most important things, as I'm sure you all in the audience realize as hand surgeons, is just the importance of the other structures that don't show up on X-rays like the intrinsics and extrinsics of the wrist. And certainly when we talk about boulder lunate facets and the short radial lunate ligament, there's no other scenario where it becomes more important to appreciate some of this. So we'll go through some of the implications, but it's worth at least mentioning. It's also worth mentioning the Academy Enhanced Society has a clinical practice guideline on dysthoradias fractures that is worth taking a look at that can guide some of the decision making when you have patients in front of you. So first thing we'll go over is imaging to inform fixation techniques and decision making and go through some sort of treatment options. Pre-op imaging, we'll look for instability, intra-articular fractures. We'll ask are the screws prominent dorsally, are the screws in the DREJ, and are the flexor tendons at risk? So those are some of the questions we'll answer from the talk today. So first, pre-op imaging. So one of the first things we look at is other injuries to the carpus. I think we all see sort of this high energy intra-articular fracture with metastatic comminution, but we start beginning to ask is there intercarpal ligament injuries here and is there something else I'm going to be tackling while I'm in there fixing the dysthoradias. The other thing we ask is with the comminution, can I reliably fix the parts? And so this is a question I think for anybody that uses bridge plates, it's one of the first things you ask is can I reliably get a piece of hardware in that part, or can I not, and do I need to have something that holds this person out to length, and I start using K-wires for my fixation. What approach do I need to use to look at the joints, and I'll give some descriptions as to what I do for that. Is there a volar or dorsolunate facet that Mark alluded to as important to just realize at the beginning, so you either have the implants available or you have backups or some awareness of what to do if you see it intraoperatively. Is there metaphyseal comminution, do I have plates that are long enough to span that comminution, et cetera, and then what other injuries there may be. So just the basics on the AP views, so I think this is review for all of us in terms of radial inclination. The sigmoid notch, and Mark already mentioned some of the views you can do to see the sigmoid notch on rotation to make sure that when you place a screw like we have here that it's radial to the sigmoid notch and not in the joint. The dorsal radius is usually beyond the volar rim, but as Mark showed in apex volar deformity that relationship is inverted, and so you always have to look at your lateral to make sure what you think is volar on your AP is actually volar. And then is there intraarticular extension, and do I need to capture that in some way. So here's, again, just lines for the volar rim and the dorsal rim that you see distal to the volar rim on a standard AP. Next is the lateral view, and here's just some numbers from the literature on what you can expect from the AP distance on a lateral. This informs, for me, kind of screw links and the ballpark for screw links. I generally put 18s and 16s only, and if I'm thinking about putting something longer than 18, then I get a little concerned about something being off in what I'm doing. But I do get concerned if the lunate facet is wider than this or wider than these sort of standard measurements. If I look on the lateral and I see intraarticular extension, it does inform if I go dorsal or volar. So Mark had a case of a volar Barton's, but certainly we see dorsal shear fractures, and we know that biomechanically those are stronger, the fixation is stronger if it's fixed dorsally in buttress mode. We look for intercarpal ligament injuries, so here I can look at my SL angle, et cetera. And at the bottom here, I have a case of DRUJ instability from an open distal radius fracture where you can see the ulna on the lateral is dorsally dislocated. So some things, and just x-ray moves you can make in the OR. So if I'm concerned about a scapholunate ligament tear from imaging or the pattern suggests that I should be aware of an SL tear, this is a traction view you can do in the OR, which is just traction on the fingers under fluoro, and you look for diastasis scapholunate. And if you see that, then this may be an indication for pinning, for example, the scapholunate for at least a dynamic carpal instability that you would see with a distal radius fracture. If I have an intraarticular fracture, and if I have volar dorsal lunate facets, what do I do? So the first thing to remember, and the reason I put 18s and 16s in wrist fractures is this risk of tendon rupture when you're sort of placing your plate and placing really long screws. And Calfee's group has done a great job, both biomechanically and clinically, showing that you need about three quarters of the length of the distal radius. This is an extraarticular, and this is a sawbones model, but they again showed it clinically when they studied patients and found similarly that when they followed their own advice and did it clinically, they didn't have any failures or anything like that. So for me, this is why I put 16s and 18s in. I don't try to get close to the dorsal cortex, and if I am, then I instead should be doing something else, like a dorsal approach, because I'm trying to capture something dorsally for a different reason. So I drill two, but not through the dorsal cortex, 16 and 18 millimeter screws. That's basically based on stature and size that we just kind of make a guess when we put them in. If I'm concerned of dorsal subluxation of the carpus, either on a preoperative x-ray or an intraoperative x-ray, then I either do a dorsal approach or I do some sort of integrated dorsal screw. I don't try to capture the dorsal cortex from my volar plate, and that's just preference. I think there's some debate to that, and a lot of people really try to get their screws all the way there and confirm they're not peeking out of the dorsal cortex, but for me, I make a separate approach. Here's a case of this high-energy intraarticular fracture. You can see if you pass a line along the volar cortex of the radial shaft, that should really intersect the lunate, and you can see here dorsal displacement and subluxation of the carpus dorsally. Here's a 3DCT, and you can see on the dorsal part of the dysradius, there's this comminution that the carpus is moving with. So for me, this is an example of something that I need to place dorsally because I would be concerned with postoperative dorsal carpal instability, which I have been burned with before. So here's us approaching that case. We're starting volarly. We're putting a lot of just K-wires through our plate and fixing, and then we, after putting definitive fixation volarly, went dorsally, put this plate. This is arguably very prominent, and I'm going to have to take it out in the future, but I know that this person's carpus isn't going to escape dorsally anymore, and I know it's pretty rigidly fixed. For volar lunate facets, this is the classic paper from Neil Harness and Diego Fernandez on sort of the importance of capturing the volar lunate facet, and I think everybody by now is very familiar and critical with paying attention to this and making sure that we capture this piece. Just biomechanically, the reason this happens is that that piece is, one, where the lunate is sitting and most of the forces of the carpus are going through the lunate, and two, it's the attachment of the short radial lunate ligament, which again is a strong capsular ligament that the carpus is pulling on that piece in the distal radius. So this is just the sort of kinetic reason that that happens. You can see again, if you pass a line through the scaphoid and lunate, especially on the lunate and lunate facet, you'll see it passes down through the volar cortex of the radial shaft, and so that's how you can get then escape of that critical corner and see cases like this that come into your clinic. There's a couple ways to scrutinize that volar lunate facet. Here's one description, 10 degree lateral, where you can see generally there's a seven degree angle from the radial shaft up through the volar lunate facet, and that can be a way in which you can sort of get a sense of if you've captured that piece and fixed it in the right place. This is a great study, a retrospective review that just looked at the size of that fragment and when they had cases that failed, what the size of that fragment was. So how small was it when the cases failed and there was escape? I know it's 15 millimeters in size or five millimeters of initial displacement. And it's a pretty small piece. This is on average like five millimeters wide, so it's pretty small in terms of its width. I do what Mark mentioned in terms of if I see this, even if I see a pre-op and I know I'm gonna plan, I just plan for putting K-wires in if I need them, or if I find it intraoperatively, I'll put K-wires in. Similar to Mark, I will place my K-wires and scrutinize my X-rays and make sure I've captured it. I open up another set of K-wires and then pre-bend my wires, and then I just eyeball it. Somebody takes the wire out and I pass it in because it can get a little futsy if you don't find your original track and when you're putting it back in. So here's another example here of a wire just placed in the lunate facet. In terms of the dorsal fractures, and I think this is an area that we're not really sure when something needs to be placed dorsally from a dorsal shear fracture, and so this is a study and a paper we're presenting here at the Hand Society on a biomechanical study of dorsal lunate translation based on osteotomy size of the dorsal lunate facet. So basically we asked how much of the dorsal lunate facet after you osteotomize and remove will lead to dorsal translation of the carpus. In our study, it was somewhere around 40%. That seems kind of obvious, right? So if you see almost half of your dorsal distoradius off, the carpus is probably gonna go with it. But it's a beginning to the conversation in terms of trying to scrutinize your x-ray and figure out what parameters should we start using for having some dedicated fixation for the dorsal lunate facet to maintain stability. What we don't wanna see in post-op is not having a screw long enough and having that carpus translated dorsally because we didn't have the right construct. Other options, instead of a dorsal approach, is on this integrated screw you can place through the volar plate and you can place that on the dorsal lunate facet as well. If you see this pattern and you have a nice big piece that's not common to you, you can use this screw and then capture that as well. So again, the take-homes here are 40%, which seems obvious, or somewhere around there you might consider placing something like this. One of the things I'm interested in is intra-articular fractures and can we view them volarly? So one of our first studies with the Duke group and Dave Rusch was just looking at patients that had really stiff wrists and loss of wrist extension and this is a case series where he basically released the volar capsule leaving the short radial lunate intact. So he basically released everything along the radiocarpal joint but don't uncover the lunate and showed that these patients did well, got more wrist extension back and didn't have any carpal instability. I mean, really the concern people have had historically is the concern of ulnocarpal translocation if you release those strong ligaments and at least in this study, that didn't happen. Now these patients are pretty stiff and things are scarred down so they may not be the right population. We looked at this biomechanically and then we started saying, well, how much of the volar capsule and the dorsal capsule can you release before you start getting some translation of the lunate? And so here we started on the dorsal side on that left graph and as you can see, we released the dorsal radiocarpal and then we went volarly and released some of the volar capsule and you slowly see this translation of the lunate and similarly, if you start on the volar side and release the volar capsule and then go dorsally, you'll see the slow translation of the lunate. But we started asking, well, in cases where you, there's not a lot of dorsal comminution, you think the dorsal capsule is intact, can you open the volar capsule and start looking at the joint volarly instead of making a completely separate approach dorsally just to look intra-articularly? So this is a case we wrote up and a technique that's in press for JHS. This is a case in the Yellow Journal where we describe this technique. So here's a case, it's intra-articular fracture. You can see a lunate facet and scaphoid facet fractures and this is the approach that we describe where you make this oblique cut in the volar capsule. I typically make it, try to make it between the long and short radiolunates but really, you make it right where that fracture is entering between the two facets and you make it obliquely as to not cut one of the volar ligaments completely and then you put stay stutures and retract and you can usually get a joker in and kind of lever up the joint and look at the articular surface. So one description here of a case like that and I'll walk you through another case here. So here's an AP fluoro view. Here's my lobster claw as Mark taught me. You can see some depression at the joint and a styloid fracture. On the lateral, the volar cortex is actually intact and the depression is really central and so it's not something that your typical fracture where you can just elevate by staring at it extra articularly from the volar side. So we made an interarticular approach and then levered up the articular surface here and then placed our plate. I usually place the plate and fix the intermediate column and then reduce the, here we reduce the scaphoid facet and the styloid and then our final fixation construct there. So the next question, I think many people are not like me and don't put 16s and 18s in and put longer screws and ask sort of how do I make sure my screws are not prominent dorsally. So here's a case on a lateral where you could say well maybe that screw might be too long. Here's the skyline view and a picture. You know the original description I think is on a larger image intensifier and wrist flexion and the small mini C and wrist extension actually works really well. And so here's Cal Shaw, one of our fellows that loves doing this and still does this I think in his cases, showing that view. And so here's where you can see the dorsal distal radius, you can see listers there, you can see this prominent screw and so then you can change that screw out. If you're fixing wrist fractures, I think this is one of Mark's cases, it's definitely not my case, but you see this really prominent screw that he placed right in the DRUJ and this is easy to do and I've definitely done this and Mark and I were trying to figure out well how do we have an x-ray view that when we leave the OR we know that there's not a screw right there and this doesn't happen. And so we both described the sigmoid notch view where you're basically under live fluoro trying to get the dorsal and the volar lips of the sigmoid notch to overlap on this basic true AP of the sigmoid notch and that's where that lobster claw really helps and that's where we really scrutinize our x-rays in the OR. And when you get that, as long as those are perfectly overlapped, as long as your screw is radial to that overlap, then you're clear. And so we wrote that up and certainly I use it now in the OR and it's been really helpful for me opposed to just live fluoroing or feeling crepitus or something like that. I just get this view and can sleep at night. So here's an example of that and you can even see the sigmoid notch on a skyline view as well if you want to do this as a second test. The next question is are the flexor tendons at risk? I think this is something that people were hyper aware of for a while and the literature is really mixed not only in what risk factors exist for flexor tendon irritation and rupture. So many people I think use Max Soon's classification here in terms of prominence along the watershed. I would argue that I think this is an oversimplification and I think that's why when you look at the literature and people classify risk fractures and the Soon classification, it hasn't always borne out in terms of being a risk factor for flexor tendon irritation and rupture. There's a number of papers in JHS that sort of go against some of that classic teaching. There have been a lot of anatomical studies on different plate types, et cetera, and generally the conclusions are that if you place the plate too radially, you're going to place the flexor tendons at risk. And that's just, there's one thing you take for my talk, it's that. And the other is the distal edge of the plate will be more prominent if you don't have your volar tilt completely reduced. Seems like common sense, but it's one of those things that you just kind of have to make sure to scrutinize on your own x-rays. So one of the things I do to prevent this is when I put my plate on that, I use the backpack on my plate and then the most ulnar hole sits right at the volar lunate facet, right in that corner. I use my sigmoid notch view to make sure I'm not in the DRUJ. And as long as that screw is in that corner, I know I'm safe, my plate's pushed pretty ulnarly, I won't have a flexor tendon irritation issue. One of the things I think that there's some issue with the sum classification is that the volar lunate facet actually sits more volarly than the scaphoid facet does. So when you get a plate distal and you get it in the right sort of corner in the volar lunate facet, it will look pretty prominent. And so if you look at most of my lateral x-rays, they all look pretty prominent and yet I don't have flexor tendon irritation because I make sure I'm not radial. I think when you're radial, that's when you get into trouble. Here's another study that kind of shows that. So here's where you see the FPL and the distance between the lunate facet and scaphoid facet and how a plate should sit. And if you place that plate too radial, it can become more prominent. So this is where it sits a little bit more proud on these anatomic plates and can cause some problems. So recommendations are plate placement to the volar lunate facet first and then ensure the plate is distal enough based on the lunate facet size. K-wires as your backup if you need to use that and put those on, but really avoid a distal and a radial plate placement. So you can kind of mix and match, but if you do both those, that's when you may get into some trouble. So hopefully this has been a good summary in terms of using radiographic landmarks to plan your next case. Some examples of special fluoro views that you can use if you have questions about intraarticular hardware in the OR. And always beware of the small volar lunate facet and have some backup plan for it. So thanks so much. All right, now the caboose. So last we'll finish up with Chris Chatterton from Ortho Carolina in Charlotte. Gonna speak to us about everything else that can be injured with the distal radius fracture and what he does. Thanks Mark. Thank you. Thank you all for staying. It's getting late in the evening. I know I see some stifled yawns out there and some fidgeting in the seats, pretty typical. So I'll try to be as succinct as possible so we can leave some time for questions at the end. So here's what we're gonna cover. Injuries and problems with the median nerve, periogenic instability, associated fractures, some of which have partially been addressed so far, and ligamentous injuries. So first, median nerve dysfunction. These come in certainly different flavors after distal radius fractures. Numbness after a distal radius fracture is common and that is very often a contusion or neuropraxia and not specifically carpal tunnel syndrome. So this is usually present within minutes of the injury. It's not typically progressive and it's not typically painful. They don't get the typical painful fingertips and that's a really important thing to distinguish the neuropraxia after an injury from progressive carpal tunnel syndrome. Then there's acute carpal tunnel syndrome. That's not the day of the injury. It's often not the day after. It's two, three, four days after. It tends to worsen with days and it's painful. That's the big distinguishing feature. So I always document two-point discrimination. And then there's another category, the subacute or the delayed. That can come after surgery, which we'll talk about. That can be weeks to even months later. So very important for patients, particularly with risks that look like on the bottom right here, get those patients reduced in the ER. Try to get whoever is taking care of your patients in the ER, if it's not you, PAs, residents, nurse practitioners, really ask them to do reductions for patient comfort to reduce the risk of carpal tunnel syndrome amongst other benefits. We know that carpal tunnel syndrome has a higher likelihood in these categories in the bottom with open fractures than more comminuted complex fractures. Non-osteoporotic patients, because that implies a higher energy injury to break a non-osteoporotic bone. Risks that have undergone multiple reduction attempts and polytrauma. So for me, my surgical indications to do a carpal tunnel release is if they are failing to improve with their numbness over the first several days, certainly if it's progressive. If they come in at day three or four, say, doc, it's been getting so much worse the last day or two, I'm going to the OR that day or the next. Certainly, abtunded patients, ICU patients who have distal radius fractures, I'm just going to assume they have carpal tunnel syndrome because they can't tell me otherwise. They always get a carpal tunnel release. High energy injuries. And the question is, if they've got preexisting carpal tunnel syndrome, maybe you've treated them, they've been treated elsewhere, they have a distal radius fracture, I consider going ahead and releasing it because it's an extra five minutes of the case and probably will help them out in the long term anyway. So I personally prefer a separate incision. So if I do a standard FCR approach, like Dr. Desai was talking about, I might usually make a separate incision. Kind of dealer's choice here. My reasoning is I'm trying to avoid two things. One is having to cross the wrist crease, which can lead to a little bit of a contracture, and also to avoid any potential injury to the palmar cutaneous nerve. It's been borne out in cadaveric studies that it's safe to do one long incision and protect the nerve. My preference is two long incisions. For me, there's no role for prophylactic carpal tunnel release if those other criteria have not been met. I make a big incision. This is not a mini open for me. This is trauma I like to see. There's often hematoma. The nerve can be displaced. There's swelling. If you get to the fracture a few days later, there's early reactive tenosynovitis. So I make big incisions. I make sure the whole thing is released. I can see the nerve. And also, you want to make sure that you connect the dots, right? If you do two incisions, you want to make sure you release the fascia kind of between the transverse carpal ligament and the antebrachial forum fascia. You don't want to leave a little tiny strip because that'll put a lot of pressure on the nerve and cause problems. So postoperatively, carpal tunnel syndrome can happen even after you fix the wrist. Reported somewhere between five and 20% of the time. So I say about 10%. And again, if they develop carpal tunnel syndrome postoperatively, I take them back. And again, it's an extensile approach for me. Then there's this other category of patients who come in postoperatively with CRPS if you believe in the diagnosis. I know there's a whole camp of people, Dr. Penal, et cetera, who don't believe in this. But whether it's undiagnosed carpal tunnel syndrome, we all know who this patient is, right? They come in uncontrollable pain. They're more stiff. They're more swollen than they should be. So for me, this is carpal tunnel syndrome until proven otherwise. It's often not very impressive on nerve study and EMG. And sending those patients for a nerve study can sometimes be cruel. They are really painful and don't like to get a nerve study done on them. So I'll inject the carpal tunnel, see if they get some transient relief. And I have a very low threshold in these types of patients to take them for a carpal tunnel release in conjunction with whatever your standard treatment for CRPS patients is. What about DREG instability? We've had a couple of references to it. Certainly, it's important to compare to the opposite side, right? So you always have to remember to examine the patient's contralateral hand in pre-op. It's easy to forget, but you save a little face from having to scrub out intraoperatively and walk around to the other side and examine it and scrub back in. So I always try to remember to examine the contralateral side. Very often after wrist fractures, there's a little bit of instability at the DREG, even if there's no fracture. Most often, it's unstable in one direction. And it's usually, it's unstable in pronation. There's dorsal translocation of the ulnar relative to the radius. And the literature has borne out that it's very reasonable with good outcomes to splint that patient in the stable position, so usually supination, plus or minus pins if you want. I think it's dealer's choice. I've started to try to weigh myself and my own practice from pins in this particular situation if it's only unstable in one direction. This is a very loud instability. So if they're grossly unstable, kind of multidirectional instability for various reasons, whether it's bony or soft tissue, then something else needs to be done. So let's talk about the different fractures that can be associated with DREG instability. Certainly, we heard from Dr. Desai about the dorsal sigmoid notch or the dorsal rim. So this can certainly lead to instability. CT scans can be helpful to further delineate these fracture fragments. And there's a lot of ways to fix this. But it's really important to recognize the dorsal ulnar corner, right? That's the insertion point of the strong dorsal, distal, radial ulnar joint ligaments. So there's a lot of ways to fix this, whether it's with independent screws, and there's some good fragment-specific options as well. And you can do this through a standard dorsal approach. You can make an approach directly overlying the fifth compartment, overlying the DREJ. So a lot of different ways to do this. Dr. Richard talked about this slight radial translation and DREJ instability, so I won't harp too much on that. But really critically evaluate that supinated AP because very often your DREJ instability that you examine postoperatively isn't due to a TFCC tear, it isn't due to an ulnar styloid fracture. It's because there's a little bit of slack in that distal oblique band, and the DREJ can be lax. So if you correct that, that can often solve the problem. What if you do have a styloid fracture? We all know that usually it's a fracture through the base, and through the fovea, not the tip fractures that tend to be associated with the DREJ instability. A lot of ways to fix this. Mark, I think you referenced, you used to do tension bands that have gone to screws. I still like tension bands personally. I work at surgery centers and adding another several hundred dollars to a screw with no increased benefit to the patient, I tend to do tension bands. I think it's easy and elegant, and I haven't had too many problems with hardware problems. And then I reassess for stability, and if there's still instability, if it's grossly unstable, then I do consider an open TFCC repair. For me, it's usually a transosseous approach, so I make an approach to the floor of the fifth, and make transosseous tunnels through the ulna, and tie it over a bone bridge, but certainly you can use suture anchors if you want. I've not personally adopted an arthroscopic approach to fixing these particular types of TFCC tears that are associated with this or radius fractures, but there's certainly evidence to back that up as an option as well. You can get DRE gene stability from ulnar head and neck fractures, and for those of you who have fixed ulnar neck fractures before, they are sneaky. They're unstable, there's not often a good cortical read, they can be mal-rotated. So be careful, make sure you get a good reduction on this. Make sure you know what normal x-rays look like. This one walked into our office, and I sent them back to the x-ray tech to take new x-rays, because I thought it was a bad x-ray, and lo and behold, it was correct, but you can see the ulnar styloids flipped 180 degrees. So that patient was struggling with rotation because they mal-reduced the ulnar neck. So don't do that. But there's a lot of options here. For me personally, I like plates here. Sometimes it leads to hardware irritation, but you can see the plate on the right here, and this is another comminuted fracture that did well with a plate and screws. But don't neglect the option of non-operative management for ulnar neck fractures and ulnar head fractures, especially in older patients. There's good data to back that up as well. This is a patient from four months ago that I fixed, so a fairly comminuted fracture. You can tell on the CT that there's a little bit of osteoporosis even. You got that chimney look there. But a pretty comminuted fracture, so we attacked this with a bridge plate and an interval or plate to capture all the fragments. And you can see, once we got that aligned, the ulnar neck looked very well-reduced. And I just left it. And three months post-op, it's healed, and she's got good range of motion. So even comminuted and initially displaced ulnar neck fractures do not need to be treated. With surgery, you can consider non-op, especially in the older patient. We've had a couple of references to interosseous ligament injuries as well. SL injuries have been reported up to 33% of distal radius fractures. Most of these are partial. And this has been looked at arthroscopically. This has been looked at with MRI. And so most of these, and there's good literature to support, overall there's very good results with non-operative managements with SL injuries that are associated with acute distal radius fractures. Be aware of the radial styloid fracture. Maybe that's a different animal, and maybe that's more of a greater arc pattern injury. But I do not open many distal radius fractures that have some concern for partial SL injury, unless it's grossly unstable in a young patient, something like this, right? This is clearly a greater arc injury. You can see the gap on the AP view. Had a grossly positive Watson's test. They were 23. So this, for me, this gets opened and addressed acutely. But this is not a common thing that I see. And you can choose your own technique on how you fix these, so. Now what about scaphoid fractures? So this is something that I do see probably half a dozen, a dozen times a year, a scaphoid plus distal radius fracture. It tends to lower my threshold to operate on the distal radius fracture to begin with, so I tend to fix both. Even the non-displaced scaphoid fracture, which I love doing, percutaneous for those. I usually fix the scaphoid first, so that as I'm hyperextending or hyperflexing the wrist to fix the scaphoid, I'm not malreducing my distal radius fracture that I've already fixed, especially if there's little delicate fragments with fragment-specific plates or K-wires or things like that. Mark, I chose this case for you because the folks at Duke now think it's a great idea to put two screws in the scaphoid. I don't disagree, but I haven't fully adopted it into my practice, but it worked out for this one. One integrated, one retrograde, so. I prefer a single incision if I can, so if I'm gonna go volar for my distal radius and it's a waist fracture of the scaphoid, then I just make one longer incision to fix my scaphoid, and the same for dorsal. If I'm gonna go dorsal for my distal radius, I'll just extend it more distally and put an integrated scaphoid screw in. And we know that the scaphoids heal pretty well. There's some smaller case series recently published that show a very high rate of healing of the scaphoid fracture when it's associated with a distal radius fracture. Don't miss the other associated fractures. Don't overlook them. General principle of orthopedics is one, x-ray a joint above and a joint below. I have definitely identified fractures intraoperatively when I've been fixing distal radius fractures with fluoro because I hadn't met them before, and my PA saw them and the resident saw them, and make sure you bring the mini-CRM up to the elbow, bring it down to the hand. Make sure you look at everything. You don't wanna be that guy in the office, you know, oh, I missed it, I'm sorry. Well, weren't you in the operating room with me? Yeah, I was, but I missed it. So I always look above and below. Some are easily missed. So here's a wrist fracture that you look really carefully. There's a little fleck of bone off the MCP joint. Fortunately, we saw this one and pretty unstable intraoperatively, so we were fortunate enough to identify that one and address it, so. And then I was gonna talk a little bit about osteoporosis, but you beat it up pretty well. Thank you very much. But I'll even admit, I mean, we've got a really busy practice with a lot of smart docs, and we don't have a great algorithm for how we manage patients who have osteoporosis or osteopenia with wrist fractures. So I would encourage you to work on making that aspect of your care of your patients better because I think those patients really do benefit from it. So that's all I got. Thank you very much. All right, well, here we are right at the end of time, and I don't wanna ask questions for the sake of questions, but I don't wanna leave anyone hanging. It's been a good day, but a long day, and now we're at just about 6.30. So if anyone has any questions, please feel free to come up or you can pop up here and we're happy to answer them as well. And then in the apps, it looks like the people getting up are walking to the back. So that's totally understandable, but we'll hang up here for a few minutes. And if anyone has any questions, feel free to pop up. Otherwise, have a good night and we'll see you tomorrow. Thank you.

distal radius fractures

challenging fractures

lobster claw

bridge plate

laminar spreader

hypodermic needle

reduction

fixation

stabilization

carpal tunnel syndrome

osteoporosis management