Good evening. On behalf of the American Society for Surgery of the Hand, I'd like to welcome everybody to this virtual course on distal radius fractures. I'm Tamara Rosenthal, and I'm going to be the course chair today, and I'm excited to be here with Carl Harper, Sanjka Kaur, Mark Richard, and Scott Tintle, and hopefully this will be an educational and entertaining hour and a half for tonight. Just a few housekeeping announcements. Your audio is going to be muted during the presentations. The webinar is being recorded, and we will email it out to all of the registrants. You can use the Q&A section to submit any questions to the panelists, and we'll do our best to address them. There's a Q&A section at the end, and if you have any technical difficulties, please just contact the webinar support at ASSH.org. In terms of CME, this is designated for 1.5 hours of category 1 credits, and so you should claim the credit, measure it with the extensive participation, and you can claim it after November 22nd through your ASSH account. So thank you to all the panelists for joining me here tonight, and to all of the participants. I look forward to a lively discussion. Have a good night. So although this is a webinar that we thought would mostly be focused on surgical treatment of dystereitis fractures and clinical tips and tricks, as well as some case-based discussion, I thought it would be nice to just very briefly review some of the literature that deals with dystereitis fracture treatment in patients who are over the age of 65. And I thought this would be good, mostly because it's still an area that has a lot of controversy. I think it's an area that's unclear. Many residence fellows who I teach regularly will comment on the fact that it's difficult sometimes to determine what the literature is telling us, and while I don't claim to have the answers with this talk, I thought at least I would review some of the highlights. One of the things that I think we all hesitate with is how much do radiographic parameters matter? So when we're looking at x-rays, how much attention should we be paying to this? And obviously there's some studies that show that it's important, and some show that it's not. This particular study, which was published in 2014, looked at 50 patients over a fairly long two-year follow-up, and looked at both clinical outcomes as well as radiographic outcomes. And what they found is that of all the radiographic parameters, Boller variance and Boller tilt are the most important radiographic parameters to predict a good functional outcome. And the variations of other parameters in terms of radial inclination or the radial height mattered a little bit less, had no demonstrated association. So if we can focus on that and say, okay, well, so maybe Boller variance and Boller tilt are the things we should be paying the most attention to. So when we see a patient in the emergency department and the criteria for instability is something that I think most people are familiar with in terms of how do we predict whether the initial fracture pattern is something that might be amenable for conservative management. So the LaFontaine paper initially had 112 patients and the factors that they determined were associated with loss of reduction, were age greater than 60 years, dorsal angulation greater than 20 degrees, dorsal comminution, intra-articular fractures, and then associated ulnar fractures. And if you had three or more of these factors, the injury was considered unstable. The criteria for instability have been studied further. There was a JBJS article in 2006, which did prospective data collection of over 4,000 fractures, and they divided them into early instability and late instability, and they defined that at the one week and six week time points respectively. So the minimally displaced hystereitis fractures at presentation, about 10% of them demonstrated early instability and 22% had late instability, whereas the ones that were displaced initially, 43% had early instability and 47% had late instability. And the predictors of radiographic outcomes that they determined were first and foremost age, comminution, dorsal angulation, and ulnar variance. So this actually matches reasonably well with the Lafontaine criteria. And what it tells us is that if you pick those up initially, you might be able at least to predict what the radiographic outcomes will look like, and then potentially what the clinical outcomes will match up to. This study in JHS in 2016 was a systematic review and meta-analysis. They included 27 studies, and again found that predictors of secondary displacement were age, dorsal comminution, and then female sex. So do we operate or do we not operate on these? And I think this is where the challenge begins. And there's literature to support both camps. And I think initially, most of us are familiar with the Aurora paper that came out in JBJS. I guess now it's been almost a decade ago that seemed to indicate that outcomes were the same in elderly patients, whether you did surgery or did not. But there's been some more recent studies that I think are worth noticing. So this one in particular that was in the JAMA open was a systematic review and meta-analysis that included about 23 studies and had over 2,000 unique patients. The key findings of the study is that the improvement in functional outcomes, that's dash scores, as well as grip strength were better in patients that were managed operatively. They didn't really find any difference in complications, and they were able to analyze patients over 60 and found that in that group, there was really no major difference in functional outcome at median term follow-up. And that the patients who did have surgery in the older age group had a slightly increased rate of complications. This study out of JHS was a similar meta-analysis, a little bit smaller, and they only looked at patients over 60. Their key findings were that better radiographic outcomes at grip strength were identified with operative management. And obviously the risk of complications that required surgical treatment was greater with operative management. And they didn't really find any difference in pain, functional outcomes, and range of motion. So if you look at these three studies, the take-home message would seem to be, well, maybe we shouldn't be doing surgery on all these because they seem to do just about the same. But then a couple of studies that just came up more recently. So this one in particular was a non-inferiority trial where they looked at randomization to non-operative treatment with a cast or volar plate fixation, specifically in patients over the age of 65. And they found that the dash scores and grip strength were better at three months in the operative group. And at one year, those outcomes equalized and they found no difference in complications, but perhaps most importantly, the patients in the operative group seemed to have a faster recovery and they were more satisfied with the wrist function and would choose to do that again. A second study kind of found similar things. So this was published in JVJ Astos the year before, and this was a prospective randomized controlled trial of patients over 70, and they all had unstable dorsally displaced fractures. And they randomized them to a plaster splint or a volar locking plate. And out of 140 patients, they found that the PRWE scores and dash scores and grip strength were all better at three months and at 12 months in the operative group. And that the complication rates were fairly similar, 11 versus 14%, which did not reach statistical significance. So this later data seems to suggest that maybe there is a justification for surgery in this elderly patient group. And both of these studies actually found a fairly sizable rate of patients who were treated conservatively who subsequently elected to undergo an osteotomy. So we looked at our experience. And so this was purely a question of trying to figure out how we make decisions. And if we looked at our patients over 65 and older, and we just looked at which ones were treated operatively and which were not, we were trying to figure out how we went about making these decisions and how we decided on this. And we found that most of the people, at least in our practice, in our group in Boston, were electing operative treatment based on fracture severity on a radiograph and based on dorsal tilt in particular, whereas we were tending to pick non-operative management for patients who were sicker who had increasing Charleston comorbidity index. So I don't pretend that that reflects what everybody else around the country or in the world does, but it seems obviously that there's a little bit of room to make a decision either way based on the individual characteristics of the patient. And that is my just quick brief overview of some of this recent literature. As a next step, I wanted to just review with everybody some tips and tricks for volar plating. And I'm really just going to focus on surgical little techniques that might be beneficial. Again, my disclosures. In terms of anatomy, I'm not going to spend a lot of time with this, but I think obviously important to remember that we're dealing with two joints, the radiocarpal joint as well as the distal radioulnar joint, and that each of these surfaces have some degree of importance because they serve as attachments for ligamentous structures. So on the dorsal side, there's a dorsal radiocarpal ligaments. On the volar side, there's a short radiolunate and long radiolunate, which are important. The three column theory would basically state that on the radial side of the wrist behaves as a buttress for the carpus, and that's where most of the intercarpal ligaments originate. The intermediate column, which is really the radiolunate facet, is where the primary load transmission from the lunate occurs. And then at the ulna is where the rotation axis to the DRUJ happens, and it's a secondary area for load transmission. And I think this will all become important as we discuss other topics, including associated injuries and how to manage the soft tissues in these more complicated fractures. For surgical approach for volar plating, I think, we've used the standard FCR Henry approach. I tend to keep it pretty small, so I like to make mine two and a half to three centimeters. I don't think that you need to make it much larger, particularly if the fracture is not intraticular or very distal. It's important to remember that the pulmonary cutaneous branch has a fair amount of variation and that in 10, 15% of cases, it'll actually pierce through the FCR sheath. So just keep an eye on it as you go through the approach to make sure that you don't injure it. I think you need enough exposure to really be able to visualize the watershed line. The release of the brachioradialis is kind of optional, so I don't do it routinely. I'm curious as to what the rest of the panelists do. Mark, do you release it always? Not always. If it's fighting my reduction, I will admit I'm quick to do it, but I do not routinely do it. My plan is not to do it routinely. So I'm basically the same. I don't do it routinely unless I'm really struggling to reduce the radial column or to correct some translation that I need to visualize better. There's a few tricks to visualize your articular fragments a little bit better. So you can release the brachioradialis. You can even release the first social compartment if you need to. You can extend the approach. I sometimes use a trick of pronating through the proximal fragment, and that will allow you to see the fracture really well and will allow you to reduce some of the articular pieces that are depressed and elevate them. Sometimes you can even bone graft through an approach like that. If you do have to look at the Voller-Ullner approach for a lunate facet, I mean, if you have to look at the lunate facet, you can take a separate approach along the Voller-Ullner corner. I think that's something you use a lot if you're doing more fragment-specific fixation, but you can actually shift your Voller approach to the radius to do this, and you can do this as a limited approach or you can do it as an extended one. A couple of tips on equipment. So I know my partner Carl, who is with us tonight, he likes to use a bump for wrist flexion, and that will help maintain your reduction. I like it less, mostly because I find that visualization is just a little bit more difficult when you have the wrist flexed. Other techniques that you can use is to compress the fracture between your thumb and your index. So if you have an assistant with you, it's easy for somebody to hold the reduction and the plate in place while the other person does the drilling and the screw placement. Another available option is the ball tip clamp. So you can put a ball tip in the screw hole, and that will actually hold the plate and the reduction in place and will allow your wrist to stay in neutral position. This doesn't usually come standard in most of the kits, so it's something that you just have to add to your armamentarium. In terms of temporary fixation, when I was a resident and fellow, I was always taught to use a lot of K-wires. I think I've moved away from that more in my practice now. Traditionally, I think I was always taught, you know, put a K-wire in the radial styloid, that that will help you hold everything in place while you put a plate down. I actually find that to be kind of tricky. You can spend quite a bit of time trying to reduce the fracture, particularly if it's comminuted, and getting the K-wire where you want it and making sure it doesn't block anything. So I tend not to use that unless I have to, or if I have a very small radial styloid piece like what you see on this x-ray. If I am going to use K-wires, I tend to use more subchondral wires like you can see on the x-ray on the right, and that will help maintain my radial length by pinning it to the ulna while I do the fixation. Or sometimes in cases with a lunate facet, I'll use volar to dorsal wires to just hold everything in place while I put a plate down. I think there's two schools of thought in terms of whether you should put the plate and fix it to the shaft first or distally first, and I'll poll my panelists and see how what people like to do. So if you put it in the shaft first, that's what I like to do. So I put my first screw in the oblong hole, and then I figure out where my plate's going to be, and then I fill all the rest of them. And then I will reduce the fracture to the plate by flexing the wrist and using my fingers. Alternatively, you can place it distally first, get your articular surface reduced, and then reduce the place to the shaft to create that roller tilt. Does anybody have one preference over another? I think Tamara, I try, unlike you and Mark, I always release the brachioradialis, and I always try and get the best reduction I can at first with K-wires, and then put the plate on and put it in the oblong hole, and then flex the wrist down, and then try and put an unlocking screw in the most volar ulnar corner. I've tried the technique of putting the screws distally first, and then clamping it down to the shaft. I would just caveat that the patient better have good bone when you're doing it, and put all the screws in, because if it's osteoporotic bone, you can easily rip that out if you're forcing that reduction. I find there's also a little bit less room for error. If you didn't get it perfectly, you might be off on the shaft, and then you have to redo everything distally. So that's kind of why I prefer to do it the other way around. In terms of the plate placement, lots of literature and papers that have looked at this in terms of complications. So the Song Grade, which looks at where you put the volar plate, basically defines the critical line, which you see on the picture here is the red line. It's considered better to have the plate volar to that, and proximal to the rim. I'm sorry, dorsal to that. The more volar you have it, the more proud it is, and the more likely you are to have flexor tendon irritation. So in that paper published initially, they found that if you were more than two millimeters prominent at the volar rim, and less than three millimeters from that volar rim, that your increased rate of hard removal and complications. I will say at the caveat here that this, I don't think this applies equally to all plate designs. There are some plates, for instance, that are more, that extend more distally along the ulnar side. And when you look at a lateral x-ray, they'll look like they're very distal, but in fact, they're not in contact with the flexor tendons in the same way because the prominence is more ulnar. So I don't think you can apply this to every single plate, and you have to know the ones that you're using. Overall, the rate of hard removal for volar plates seems to be from a variety of different papers in the ballpark of about 10%. I know sometimes we'll place the plate purposefully very distal because we need it there. And I think in those cases, many of us will then just routinely remove it, even if the patient's not symptomatic. So when actually doing fixation, so as I mentioned, I tend to like to do the shaft screws first. If the bone quality is decent, I will usually use non-locking screws. Otherwise, I will go locking. Little tips to save time. They all are pretty much the same length. So, you know, measure the first one, and then you don't need to measure the others. You should be all three or four, depending on how many you use should be about the same. I'm very, very picky about avoiding screws that are prominent dorsally. So I tend to actually go short as long as I can get a decent bite if they're bicortical screws. I want to make sure that there's nothing protruding dorsally just because I don't want to have to deal with extensor tendon problems later. Distally, you can consider initially a non-locking screw to kind of suck the plate down to the bone. I don't think that's completely necessary. I think you can probably achieve the same if you're holding it with your fingers and putting in a locking screw. But there's that option. I typically will use only locking screws. I'm not a fan of pegs, although I know a lot of people do like them. We have some pretty good literature that shows that biomechanically, you just need to be about 75% length to the dorsal cortex. So there's no reason that you need to put screws that are very long. They're more likely to penetrate on the ulnar side. And I'll often drill these unicortically. That way, I just decrease the potential risk of screw penetration dorsally. There's some good operative images that I think help intraoperatively to make sure that the hardware is well-placed. So the supinated oblique views, the dorsal tangential view, which you can see right below on the slide where you hold the wrist flexed, and that gives you a nice idea. You can see the screws and see whether they're penetrating dorsally. And then I'm a big fan of using tilt views in the operating room, which you can easily do with the C-arm just by getting a good lateral and then tilting the wrist approximately 20 to 30 degrees. And that'll show you the articular surface to make sure that none of the screws are intra-articular. So just a couple of notes of caution on volar shearing injuries. So these I find to be tricky. I always think these are a little bit harder. The plates do not tend to contour very well. There's a lot of plastic deformation when they occur. So the plate doesn't quite sit down as well as it does in other fractures. And so sometimes it's hard to use it to assist in the reduction. And I think with these, you have to be very careful with the lunate facet and the potential loss of reduction that can lead to volar subluxation of the carpus. So these, I do like to use temporary K-wires. And what I'll do is put them very distal, and I like to go volar to dorsal just to hold everything in place while I select my plate. And then picking a plate, I like something that extends ulnarly. So just to go over a quick case before I hand off to somebody more interesting than myself. This is a 69-year-old woman who sustained a fall during a virtual yoga class. She has a significant past medical history. So she's got two mechanical valves. She's anticoagulant on warfarin. And these are her images when she shows up in the emergency room. And so, do you reduce this? Do you not reduce this? So we tend to focus on getting them reduced initially just from a patient comfort perspective, and also because you never know who you're going to be able to get to the operating room. And then this is what her images look like after reduction. So improvement. And since I can do this to Carl, if you look at these films, Carl, do you think this is going to stay? Do you think it's going to be unstable? Would you operate on this lady, or would you just let her continue her anticoagulation and skip it? From a reduction stability perspective, I would pull up the risk calc and show her that she's got about a 75% risk of losing reduction. And then the next question I would have for her is why does she have two valves and what else is going on? If this was an isolated cardiac issue, I would probably operate through the anticoagulation. I wouldn't have her hold it, but I would be real sure that I had hemostasis when it was all said and done. But if she's doing virtual yoga at 69, I wouldn't hesitate to operate on her. So I would agree. I think that tends to be what we do around here. And so what I did with her volar plate, I think is reasonable. I cheated my plate a little bit ulnarly because if I go back, I think you can see that there's a little volar, I'm sorry, a dorsal ulnar fragment that is visible that I wanted to try and capture. So I cheated the plate a little bit ulnar. I use this plate that tends to be a little more distal along the ulnar side, as I mentioned. I don't worry too, too much about the dorsal comminution around Lister's tubercle, except just to make sure that my screws are not too long so that they're not proud. And just to plug for something I know we're gonna talk about later, as I tend to do in all my patients, I get a bone density afterwards. And this revealed that this patient's risk for fracture in the future was quite high with the risk of a major osteoporotic fracture of 22% and a hip fracture of 6% over 10 years. So this is somebody who should be treated for sure in terms of osteoporosis. So at her first post-op, she started on Fosinex. And with that, I'm going to hand off to Sanj who's going to tell us when we should not treat things with a roller blade. Thank you, Tamara. And appreciate the invite and the Hand Society and this esteemed panel. My role is to talk to you about when you might want to think about other than a roller plate and sort of some of the tips and tricks to focus on. These are my disclosures. And I'd like to acknowledge some of my partners who have provided some of the sort of images that we'll share in terms of the principles that we'll discuss tonight. So as we've heard, there's a myriad of different treatment options that one can use for treating distal radius fractures. We'll concentrate on distraction or bridge plating and fragment-specific fixation. But I think one of the key tenets, this was taught to me by Alex Shin when I was a fellow, and I still think this holds true today as well, is that in terms of your management, you have to obviously individualize the treatment based on the fracture pattern, the patient, and also your skillset. We often don't talk about surgeon skillset, but in some of these more difficult fractures, I think that's important to consider. So as we heard, roller plating really was a game changer, but there's some nuances with this. For example, if the fracture is very distal, as Tamara showed, you'll go past that watershed line and you worry about extensor and flexor tendon ruptures, and also putting screws within the joint. But there's also certain fracture patterns that aren't amenable to just volar plate fixation. For example, if you have these highly comminuted fractures with diaphyseal extension, or as you see in the bottom right, these volar shearing fractures, and we'll touch upon that in a little bit. In terms of bridge plate, well, what is this? It's essentially an internal external fixator that was initially reported as a case report using a wrist fusion plate for distal radius fracture fixation. But the main advantage of this is especially for those polytrauma patients that you can get them weight bearing immediately through their injured extremity. In terms of the biomechanics, Bobby Chhabra did this nice study many, many years ago, looking at internal versus external fixation. And the reason why the bridge plate is more stable than external fixation is that you're decreasing the bone to bar distance, thereby increasing the rigidity of the construct. So let's look at this case of mine. This is a patient that comes in, young patient. And I think one of the things that you'll see through this talk, when you have a young patient with a distal radius fracture, it's not just a typical distal radius fracture. There's something more going on there. So this patient obviously had a bilateral lower extremity injuries as well, so needed to weight bear on crutches. And so when you look at the CT scan, you can see the comminution, but you can also see that little volar rim. And when you see that volar rim, it should go off in your mind that you need to be careful of this type of injury pattern. So I think the crux for me for bridge plating is this picture here. So if you look in the left, we can talk about index or long finger, but on the index finger, you need to sort of develop that plane and go underneath that fascial plane to allow your, first of all, your freer and then your plate to go, because if you're above that, you'll get the extensor tendons. And so here you can see the freer elevator being passed. You'll also notice, and this is something I've learned over time and we can discuss this, that when I'm placing a bridge plate, I'll try and get the best reduction of the articular surface as I can at first, put K-wires in and then put the bridge plate. I used to get into trouble when I put the bridge plate on first. It's great to get your radial length and your height, but it's harder to address the articular surface. So there you can see the plate being passed. So if you look at the x-rays now, Tamara mentioned the importance of getting different x-rays. So when you look at the AP, it doesn't look too bad. But when you look at the lateral and the tilt lateral, I think is critical, you can see that there's a double density here. So clearly I was off with my articular reduction. Indeed, I was. So in this case, I had to go bowler to buttress up that fragment. And so this was a CT scan and you can see we've restored better anatomy. What about this case? So again, young patient, when you see a young patient with these little chip fractures, alarm bell should be going off, but this is just not a simple distal radius fracture. So you can see there's little chips. And when you look at the CT scan, if you look at the top right, you can see there's that coronal split. There's that sort of double coronal split. So here, the way that I tried to address this first was trying to piece this together. So you can see I put a K wire in the radial styloid, I kept it short, and then we went into the arthroscopy tower. So we did the arthroscopic washout and you can see by me moving the K wire up and down, I can get that reduction of that articular surface. Just go back there. So here you can see now I can lift it up and then drive that K wire under direct vision, restoring that radial styloid. So remember there was that coronal split as well. So here you can see with the K wire on the right, I just went in the dorsal half, reduced that coronal split and then drove it volally. And now you can see we've improved the coronal step-off. You're not gonna improve the cartilage injury, but we've improved the step-off. I then went into the mid carpal joint and you can see the LT and you can also see... Sorry, we go back. If you look at the dorsal capsule on this video, it doesn't show, but the dorsal capsule was ripped off and there's a scapholunate. So you can see how reducible this is. So this is a multi soft tissue injury in addition to the bony injury. And so here you can see how I worked together to put the articular surface together and then put the bridge plate to give construct rigidity for early weight bearing. And these are the post-operative radiographs. So this concept that I just showed is called PLIND. It's Perilunate Injuries Non-Dislocated. It was taught to us by Guillaume Hertzberg and Marion Bernier in Lyon in France. And I think next time you see these chip fractures, start thinking that there's more than just a bony injury going on at the same time. So in terms of technical tricks, I personally like to go to the index finger metacarpal. There's been some good articles showing that there's less likely to entrap the EPL if you go to the index versus long finger. I will go to the long finger metacarpal if, for example, as Tamara mentioned, the load bearing area of the lunate facet is injured and I want to offload that. Again, I try and reduce the articular surface as best as I can. And then I put the bridge plate after the articular surface is reduced. But there are limitations with bridge plates. You have to immobilize for at least six to eight weeks, maybe longer if diaphysial extension. And that obviously results in a secondary surgery. So that brings us on to fragment-specific fixation. And we heard Tamara mention the columns of the wrist. And so if you look at this schematic, if you look at Lister's tubicle and draw a line straight down there, everything radial to that is the radial column. Between Lister's tubicle and the DIUJ is the intermediate column and the distal ulna is the ulna column. And so when you have these highly comminuted fractures and you're going to put them together, where do you start from? So one of the teachings from Dick Berger was about the importance of the vola ulna corners. That's critical to the sigmoid notch. So in terms of the order of fixation, this is not by all means the only way to do it, but a sort of way to think about this is go vola, fix the vola ulna corner, then go dorsal, fix the dorsal ulna corner. So you restored the sigmoid notch. Now you can build off this, reducing the intermediate column, the radial column, and then finally the ulna column. So if we put that into practice, let's look at some case examples. So again, young patient, fall off scaffolding, highly comminuted. You can see that there's a radial styloid. You can see the intermediate column, the dorsal ulna corner and the vola rim fractures. In our practice, all of these patients get a CT scan to allow me to really look at the articular surface. And you can see the significant comminution in a young patient. So how are you going to put this together? So initially he was very swollen, so I had an external fixator because you want to let the skin settle down because you'll need multiple incisions. And so here I went vola after the skin had settled down and I fixed that vola ulna corner. It was a sizable piece, but I kept my screws short, thereby not blocking me from going dorsal. Then you need to look into the joint. There's different ways. We talked about arthroscopy, whereas this one, we did a mini dorsal approach. And what you're able to do now is dip it, disimpact the articular surface, pack bone graft, and then fix that dorsal ulna corner and the intermediate column. And then finally the radial styloid. So you can, again, use the understanding of the column theory to put this together. What about this patient? This is an 88 year old lady. We just had a talk about patients over 65, but she had an open distal radius fracture. And when you look at the reduction, you could argue, well, maybe you could put a vola plate on here, but number one, you'd be past the watershed line. And number two, it's pretty hard to not put screws in the joint. So for me, the way I did this was I reduced that vola ulna corner with these hook plates. And I cheated this ulna, and then I put a radial one in. And I, oh, I do use KYs. I think they give you some stability. And then with the addition of screws, this was her construct. Another patient who'd fallen intraarticular distal radius fracture, pretty straightforward. But again, critically look at the x-rays and the CT scan. So you can see this dorsal ulna corner. And now I don't think we have to chase this all the time, but you can see that this is a big piece of the sigmoid knot. So I knew I needed to get good rigidity of that. And I was thinking, could I get that from the vola approach? So there's the plate put on. I put a temporary K wire. And if you carefully look at the x-rays, you'll see that there's a double density of the sigmoid notch. So clearly I'm off with that dorsal ulna piece, which is a critical piece of the sigmoid notch. So Tamara mentioned different views. I like this extended BIUJ view. I find it easier to look at the skyline projection of the screws. It also allows me to look at the congruity of the BIUJ. And so here, what I did is I went dorsal, reduced that dorsal ulna piece, and then I put the plate on vola, but kept my vola ulna screw short, and then used the dorsal plate. Now in the olden days, dorsal plates were a high rate of symptomatic hardware, but I think now they've become thinner. And you can see here where I've been able to cover the plate with the eccentric retinaculum. I want to sort of finish off here about the intermediate column. This is a patient of mine who had bilateral dystoid radius fractures. This was the right side, relatively straightforward, and I fixed him with a vola plate. Now, when you see this type of X-ray, where you see that sagittal split through the lunate facet, be very wary. There's a tremendous amount of weight bearing going on here. So this was me, this was my reduction. I accepted it at the time. I thought it was good enough. And the patient comes back two weeks later, and you can see how that reduction has gone off. So clearly I didn't get enough fixation in that dorsal, sorry, in that vola ulna or that sagittal split. And when I looked at the CT scan, I really only had one good screw in that fragment. So that was a technical failure on my behalf. And so this was treated with a revision fixation. You can see fragment-specific bridge plate. And when the plates were removed overall, he actually did pretty well. So in terms of the literature, this was 25 patients that we looked at, similar order of fixation that we reported on. The take-home points were that the clinical results were pretty good, as well as the X-rays. The teardrop angle should be about 70 degrees. We were off in 55 degrees. But the main take-home point is if you're putting in hardware, you have to follow these patients. And we had four patients who had tena sinovitis, no ruptures, and needed the hardware to be removed. So I really do think you have to follow these patients carefully. So I think in summary for me, these type of techniques, be that bridge plate and fragment-specific, are powerful tools. I think it's important to look inside the joint because fluoroscopy often underestimates the degree of articular incongruities. You can do that either through a small dorsal capsulotomy or dry arthroscopy. And as you've seen, I think it's important to learn multiple ways to fix these because you'll never know when you'll need them. In final closing, I would urge you to go to HandE. As you know, that's the digital platform for the Hand Society. And there's numerous talks and tips and tricks and videos on this topic as well as many others. Thank you very much. Sanj, great cases, great cases. So I think you'll see as we go through my talk and then Carl's talk, especially that there are a lot of the same principles that we're calling different things. So some of the redundancies by design in the sense that they come up in different portions of how we think about these. So I'm gonna talk about dystrophagous fractures. Of course, do associated soft tissue injuries matter? There are my disclosures. But I like to answer those questions first. So yes, very yes, they matter. And I hope over the next 15 minutes, I can convince you of why they matter. It's one of those things. I love dystrophagous fractures. I have two in my schedule for tomorrow and I enjoy taking care of them, the most common fracture we see. But I still have to remind myself and I try and remind the residents and the fellows, I try to espouse this and teach this as well, that we were taught when we were younger that an x-ray of a fracture is a soft tissue injury that just happens to have a broken bone in it. And it's really important not to be distracted and blinded by familiarity of that pattern. We jump right to extra articular volar bartons or volar shear, the very peripheral ones that Sanj is talking about. But you forget to look at all the little subtleties when you're distracted by that big broken bone that's in your way. So I am hoping to go over some of those soft tissues and why they're important over the next little bit. So we got to end of my idioms, I promise, but got to see the forest for the trees in this one and make sure that we're looking all around the wrist. I'll point out the patterns that are most susceptible to some of these injuries that we're talking about. So what are the soft tissues we're gonna talk about over the next 15 minutes? And again, I took a little artistic liberty with this, short radiolunate ligament, DRUJ ligaments slash interosseous membrane, TFCC and scapholunate ligament. And I'll fill in some of those bony equivalents which I incorporated in this talk to make sure that we're all talking about the same thing whether it's a small balsa piece or the soft tissue itself. So let's first start by talking about the short radiolunate or the equivalent of the volar lunate facet. And I think you'll hear about this again. You've already seen it and heard it come up a couple of times, but we know that that critical corner is that volar lunate facet. Really important to get your plate as older as you can so that when it sees you and you don't see it, you still have it captured. And this is Neil Harness's paper with Jesse Jupiter, what, 16, 17 years ago. When you miss that piece and it escapes, the whole corpus goes with it because of that short radiolunate. So the soft tissue we're talking about here is the SRL. And that volar lunate facet is really the keystone of the whole distal radius because that short radiolunate ligament will pull the whole corpus with it. So volar plating is still the most common means of fixation for distal radius fracture, but it still requires attention to fracture patterns and detail. And when we look at those small bony pieces, we've got to be looking at what's attached there. And again, that yellow one there, the short radiolunate is what we're restoring when we get capture of that small volar lunate facet piece. And that helps us maintain the carpal alignment in the sagittal plane. This is an example of what happens when it's missed. You can see the surgeon had the plate way too radial, recognized it interoperatively and tried to salvage it with an independent screw in that one piece, kind of the screw to nowhere, but it did not get capture. And this patient had loss of fixation of that piece and ultimately went on diffusion. So a couple of cases just demonstrating this. This is a 58 year old college professor where I work who's a pedestrian struck crossing the street on campus. Here's the x-rays that this patient came in with. There's some more views. No CT scan obtained. Going back through the retrospective scope because some of these times you see things in the operating room. And again, we're remaining vigilant through the entire episode of care, but there's a volar lip there that's hard to assess in the AP due to loss of volar tilt. And if I'm really critical with the x-ray here, there is a free piece more distal to where my standard plate would be. So in this case, I ended up doing what Amy Moore and Dave Dennison showed us and make a little spring plate, sorry, spring wire fixation, my own little trimed type plate where we can bend wires, capture that and put our volar plate, which is getting a little more proximal on top of it. And this is the final construct at a year. I follow all of my distal radius patients for a year, very reasonable range of motion, but had to rely on what I know from the literature and from these types of webinars and conferences as a salvage in this case, because I did not see it on the front side and did not have different equipment available with me. Now this works well, it's a little bit futzy, but if you are not familiar with this paper, it's worth reviewing because it will save you in these situations. I have a number of times that it saved me. This is another one. This is a 30-year-old male, polytrauma, so four extremity injuries, bilateral distal radiuses. I know a lot of us at trauma centers get pulled into these where you are in another room and they ask you to come in because this patient's getting the X-fix on the knee and the ankle and they've got bilateral distal radiuses and can you help with these? So this is the left side. I ended up bridge plating that one. I'll show you in just a second because it lined up great with ligamentotaxis. This is the right side. Really distal fractures, segmental volar cortical piece on that intermediate column. Here's the left side, lined up great with traction, lower extremity demands for weight bearing, so bridge plate works great here. We can talk about this in discussion. I prefer the third metacarpal for a variety of reasons, but probably good in the discussion section. That one lined up great. Intraoperatively, there was a segmental volar cortical piece and a very small and very distal lunate facet fragment. So there's that free cortical piece. Already spit out the front a little bit and a very small volar lunate facet piece just distal to that. I don't think I can get good fixation on that alone with the plate I had available. There are specialty plates, if you knew about this ahead of time, that are mated with these, designed exactly for this. I didn't have it available running in to do these cases in the more trauma setting. So this is a DIY equivalent of that, the plate that I had available and used. I also took the little hook plate from their handset that's available for mallet fracture, central slips, that kind of thing, avulsive collateral ligament injuries, put that on the piece and then put my plate over. So instead of the little wire fixation, I just had a little claw and I was able to line up the hole for the distal ulnar part of the plate with that one hole plate and get fixation that withstood the forces of weight bearing and had maintenance of fixation at the final follow-up. So some of these are just recognizing the patterns and making sure, like Sanj said, your armamentarium is as broad as it can be to take care of these soft tissue injuries. So what about moving on next to the DRUJ ligaments and the interosseous membrane? You have to examine the DRUJ and compare it to the contralateral side. And if this is, of course, after fixation of your distal radius, so you have some good, meaningful information. If it's stable in one position, which is typically supination, I'll just split it in that position for three weeks. If it's grossly unstable, like you see here, and you can move it all over the place, if it's a bony injury, I go after the bony injury. If it's a radius, maybe the sigmoid notch, maybe radial translation, we'll talk about both of those. If it's the ulna, the styloid, or a head fracture, I'll go after those. If it's none, I'll repair the soft tissues, being this TFCC in this situation. So let's talk through kind of an example of each of those. I like to think about these as an arc of energy coming through, like we see with the Mayfield classification of lunate and perilunate injuries. So when I think about a distal radius, it's always really evident to me where the distal radius fracture is. Sometimes you don't see an ulnar styloid fracture. In that case, that energy still has to get out of the wrist after it's broken the bone, but it'll do it through the soft tissues. And it's a TFCC injury until proven otherwise. We know that the ulnar side of wrist pain can take a year to get better, especially non-operatively treated, and it's because that soft tissue just takes longer to settle down than the bony injuries themselves. If you do see the bony injury on the ulnar side, it's usually coming through the ulnar styloid. And again, it's a form first of a TFCC injury. So we still approach it the same way we talked about in that first slide, but we will be prepared to fix the bony aspect of that injury to repair the TFCC tension if it comes to be. So let's talk about a couple of cases of each. This is a 51-year-old woman who had a fall, and she had a dorsal lunate facet piece like Sanj was showing, about 50% of the DRUJ. I don't think anyone truly knows the size that's too much in this, but remember the dorsal radial ulnar ligament is attached to that. So that's a pretty big piece going obliquely across, may provide some instability at the end of the case. So I do, like Sanj said, I put it on the shaft first, do my distal ulnar screw first, just like Tamara does. And I try to get it as long as I can to hold that piece. I've got a clamp around it, but I don't want to be too long. I proceed with the rest of my fixation. I check her stability. And what do you know? She's unstable, vulnar dorsal when I do it, because I don't have great capture of that piece. I get into oblique view and I see that my screw is long, but not long enough. And I'm not comfortable going bicortical on that for the reasons that we talked about before. So my options here are to add a dorsal plate, which I think is very well tolerated with today's plates. The system I was using has a little mated screw where you can do a little seldinger technique and put a mated screw over the back with a little washer, essentially, that can hold it in. If it lines up perfectly, I'll do that if I have the right system. So this is just an example of that. Able to capture that, settle down that shock and stabilize the DRUJ and a good outcome overall in the end. So now what about radial translation? We talked about release of the BR, which can help correct that. But what about the interosseous membrane? This is more Tomo's paper looking at that. They did it in the lab. Remember the two things that are gonna be attached to that distal segment are the distal interosseous membrane or the distal oblique bundle and the TFCC. So when they section the TFCC, they get a little bit of laxity, but not until they did the TFCC and the interosseous membrane did they allow for true radial translation of about five millimeters in that setting. And at that TFCC and distal interosseous membrane tensioning, you're about five millimeters of radial translation. So you've got to correct that in order to stabilize the DRUJ. And that's something that I've become more attentive to over the last couple of years. So another study done out of HSS showing a very similar finding that radial translation can in the setting of a TFCC injury result in instability of the DRUJ. They found in their biomechanical study that two millimeters was enough to do it. Interestingly enough, four millimeters didn't have the same results. But my take home principle from this is that a little bit of radial translation in the right clinical setting of these soft tissues that we can't always see, but are often injured can result in distal radial ulnar joint instability. And I've become a lot more attentive to making sure that they're corrected with the proper form. So here's just a couple of cases to show this. 40 year old woman fall from 10 feet off of a ladder. She has significant radial translation. Her brachioradialis is fighting me. So like the question earlier from Tamara, I will release that and I'll try to get it back. That doesn't always do it. And when I cannot get it all the way translated, I will use a laminar spreader to try and push my radial shaft back underneath. So here's a clinical picture of that laminar spreader in there. And then I'll show you back on the X-ray. If you clamp down on that and translate that radial shaft, you can really push the radial shaft back under that piece and then get fixation. And lo and behold, when you get that resettled, you have a stable exam a large percentage of the time. You don't need to do anything on the ulnar side of the wrist. So that's my first and go-to move after brachioradialis release for getting that radial translation corrected. Here's one more case. 39 year old woman, sports medicine doctor who's in a bike race and had this high energy distal radius fracture. She had a little bit of radial translation. I kind of like this, like a little flip book cartoon kind of click by click gets pushed underneath. When I get it all the way translated, I secure all my fixation and then I check her. She's still unstable. And when you're looking at the ulnar side, she's got actually a kind of scooped out base of the ulnar styloid fracture. So she's got superficial and deep fiber still on there. So I'm gonna go after the bony side of the injury when I have it. And I've got her reduced provisionally pinned. And then I prefer headless compression screws for this. So I put a headless compression screw in and that gives her stability. In the end, there's her final x-rays with a stable exam. Lastly, what about no bony injury on that ulnar side? I know I'm cheating and pulling into Gagliazzi here, but it's a pattern that we're probably most likely to see this with. I fixed the radius stably and evaluate still globally unstable. No bony injury to fix. So here I go after my soft tissue, which is the TFCC. For me in these cases, fifth compartment is the window to the DREJ. I open the fifth compartment. I can look right into the fovea of the ulnar styloid where the TFCC should attach and put an anchor in and pull that sleeve of tissue back down. I've had really good results doing that in these situations and mobilizing supination for three weeks and then mobilizing them. And here he is in the end with full rotation after healing all that. Last but not least, scapholunate ligament. It's a problem that we really picked up on, I think, with arthroscopic fixation of dysradius fractures when that was in its heyday. You notice that up to 40% have associated SL ligament injuries. Richards et al in 97 showed that extra articular are much less common than intraarticular. And I'll go over a few patterns at the end and leave you with that are most correlative with this injury. So I know Sanj loves the SL, but from general care of the SL, when you find no solution to a problem, sometimes you have to accept the truth that it's a hard one to treat. I put that in there for some of the treatment recommendations that I'm gonna have at the end just to kind of put my thumb on the scale a little there. It's hard to image these when it's associated with the dysradius. Steve Lee showed us that the pencil grip is great for looking at it dynamically when you're seeing this in isolation in clinic. Can't do that with a dysradius. I've had a lot of frustration with imaging of this because it's not in plane. I'll show you that in the next slide. When you send them for special views and your x-ray tech spells skateboard like that, you also lose a little trust for what's going on back there when you're not with them as far as the exact angles they're getting. But for anyone who misplaced their proceedings from the Hong Kong Orthopedic Association meeting in 99, this is actually, I think, really good paper that's helped me. It's hard to visualize because of the carpal arch. The SL interval is really only visible in 36% of patients. It's not parallel to the PA. So you can't look down that interval and it's really hard to measure. So what they did is they looked at trying to get that perfect view to look parallel to that slightly oblique joint. And they found that a little bit of inclination on the ulnar side to about 10 degrees made it visible in 100% of patients who are looking right down the pipe. So you can see here they did a hypothermic cushion. I didn't put it in, but what they do as a surrogate for that is have the patient flex her two fingers and hold it up at that. If they rest their hand flat, that'll hold it up at that 10 degrees and you can get a good view down there. So when I measure now for static, this is what I do. And when I try to get a view intraoperatively, I'll get that little hyper pronation to try and look down that interval. All that being said, what about SL in the setting of distal radius fractures? Sanj looked at their group's experience. They had 42 patients. About half of them were fixed acutely with their distal radius fracture. About half of the second half were fixed late about 21 days or later. And then the last half of that group roughly weren't fixed at all. When they look back at their Mayo risk scores and DASH, no difference between the groups. We looked at our group as well. We did a little bit differently. We just looked at the association. So anyone who had radiographic widening and SL, we looked at how they did compared long-term at one year and two year. We had 192 in the first group, 102 in the second group at two years and really found no association between widening and increased SL angle with final outcome. So there's a little bit of kind of nihilistic view of these SL injuries in this setting. So when should we really pay attention? I'm drawn back to this Mudgell and Hastings paper from almost 30 years ago now, looking at the patterns, radial styloid fracture, comminuted four-part interarticular and these marginal fractures. So let's just look at those. Beware of those three patterns. Sanj had told us a bit about those, was hitting Adam with those other soft tissue associated injuries. So let me just take you through a couple. This is one that Glenn Gaston shared with me. This is a radial styloid fracture. Anytime you recognize a pattern that has a big axial load and it shears off that radial styloid that exits or enters right at the SL interval, that energy arc is gonna be right up between the two. You very well might find SL significant disruption there. Glenn fixed the radial styloid and did just percutaneous pinning across the interval during the early convalescence period. This is one of mine, 56 year old male, poly trauma, very innocuous looking injury. This is the plin that Sanj was talking about, very marginal type fractures, but a high energy injury. So I fixed the little marginal fractures, do a little dorsal capsulotomy and lo and behold, a big full SL tear in the back that I repaired acutely and provisionally pinned. And if you recognize these, they do well. I can't tell you it's always necessary to fix these. I wish I could, but I think when you see these high energy and you're worried about them, you fix them and they do well. Last but not least, and I'll turn it over, 25 year old woman, MVC, extra articular, so it should be a low incidence, but she had widening, she had increased scapula angle. I know she's not fixed there yet. Her contralateral side was not the same. I had my vigilance up in the OR. I fixed her and then dynamically she was still unstable. I did a little arthrotomy. She was torn, she's 25. I didn't feel good about not fixing that in this setting. And that's a debate that we can talk about on the other side. I did, I'll go very quickly through these. I did an all dorsal repair. I don't do this anymore, but my point of this whole thing is that I fixed it in this setting for this patient with that injury. So I did an all dorsal repair with a palmaris graft acutely. And there's her final ulnar radial deviation views after fixation and at the time of removal. So very short term followup, but feel better about fixing it in this situation. And with that, Carl Harper from Beth Israel is after me. So I will turn it over to Carl and we'll talk again in the discussion side. Thank you. All right. So this has been great. I've already learned a lot. So now what we're gonna do is sort of in 15 minutes or less, talk about the complications of distal radius fractures. And admittedly, talking about all the complications that one can see in 15 minutes is a little bit tough. So what we're gonna do is focus primarily on malunion and nonunion, and a little bit of the data that goes along with that. And then hopefully we'll have some time for a little bit more involved discussion of the more esoteric complications and how one can approach those through cases. So I have no disclosures. The first question that one needs to ask with any sort of complication, regardless of what you're doing, but in this case, it's distal radius fractures, is what's the natural history? Like, why do we care? And for distal radius malunions, that's sort of what we're talking about today. The answer is, well, it kind of, you know, it matters and it doesn't, it really depends on the patient. And so, as we've alluded to way back at the beginning with Dr. Rosenthal, you know, the functional sort of status of the patient, for me at least, matters quite a bit more than what the X-ray looks like. You have sort of elderly patients who do great with horrible looking radiographs, and you have younger, fitter, more active patients who can tolerate quite a bit less in terms of abnormalities in their distal radius alignment. So Margaret McQueen has this pretty famous quote that essentially, I'm paraphrasing here, says, for the fit active patient, you want to restore anatomy as close as possible. And that's been borne out in a lot of the long-term follow-up studies out of Scandinavia. Obviously, with distal radius malunion, you're talking about loss of radial length as well as loss of lower tilt. And that's going to have consequences as it pertains to grip strength as well as overall functionality. The other thing that's important to note is that you're also going to get this pretty well-described pattern of carpal instability. And there's actually two types. The first type is sort of the more famous, well-quoted type four carpal instability adaptive, which you see here in figure B, but also this type you see here in figure C, which is radial carpal instability. And so that results in a predictable pattern of arthrosis later on. Interestingly, a lot of biomechanical work out of Belgium has shown that with the distal radius osteotomy, those two types of instability are in fact corrected, which is great. And the last sort of thing to talk about or at least mention is that no study or no webinar in 2020 would be complete without some reference to cost. And not surprisingly, a distal radius malunion or nonunion is associated with an increased cost both to the health system as well as the patient, and then also malunion resulting in the sort of highest predictor of litigation. So it's just something to be aware of. Dan Franklin said, an ounce of prevention is worth a pound of cure. And that sort of, that remains a truism today. The best way to prevent a complication is to, the best way to treat a complication is to prevent a complication. And so as one sort of looks at the data as all comers, there are certain types of treatment that result in lower rates of malunion. And we've kind of progressed through history to the point now where almost everybody is sort of approaching these with a bowler locked plate. Not surprisingly, that correlates with a lower instance of malunion. This is a patient of mine on the screen right. She was a very fit 55 year old lady who unfortunately fell jogging around the reservoir. Her initial radiographs, you see the PA, she looks great at about five days post injury. Unfortunately, we did not follow her as closely as we should have. And you can see the six week images, she's lost a significant bit of radial height. So that's just a reminder that, you know, depending on how you're treating folks, one has to have a higher index of suspicion and monitor these patients closely, particularly if you're doing something like casting. However, now I'm going to surprise nobody and be the fourth person in a row to talk about the volar ulnar corner. This is one of the classic descriptions or classic issues that one encounters with treatment of dysarthritic fractures, particularly with the volar plate. It is not unfortunately a panacea. And so if you go back to that harness paper, which not surprisingly had Dr. Jupiter on it, what you see here is sort of three specific radiographic findings that predict instability here and just sort of help raise your suspicion or put things on your radar. The first of which is relatively obvious. It's the volar shear pattern. The second and third things though, I think are pretty interesting and useful is that if that little fragment is in fact little, if it's five millimeters or less, that predicts instability. And if at the initial injury, it was greatly displaced, i.e. that greater than five millimeters of displacement, those two kind of components predict a subsequent pattern of instability and should raise your suspicion in the OR. These are the radiographs that you've now already seen. Dr. Richard included these, as I believe Dr. Rosenthal did as well. This is the photographs or radiographs from the paper. And unfortunately, what I'm about to show you now is a case of mine. So this is a 57 year old lady who fell skiing. Her initial radiographs demonstrated what appeared to be a pretty non-displaced fracture. However, we remained vigilant, kept an eye on it. And then at two weeks, we see sort of loss of that central column. We got a CAT scan to confirm that we weren't sort of missing something. And in fact, she does have Vuller displacement of the central column. She was taken to the OR, and you'll have to take my word for it. She was perfectly reduced with the screws through the Vuller on her corner. However, these are her two week x-rays and we've completely lost it. So the one thing we don't see on this is Vuller translation of the corpus. I remember this very vividly because I called my boss, who's Dr. Rosenthal, who's in charge of this discussion. And we had a pretty long and frank discussion about what to do. Interestingly enough, this patient was vehemently against a repeat operation. And this is her at approximately two years post-op. Now the radiographs are certainly ugly, particularly the PA, but we don't see any Vuller translation of the corpus and she's remained extremely active with a dash score of six. So this is, I'm not advocating that everybody treat a loss of reduction with sort of benign neglect. However, it's something that one can be aware of. But yes, bear in mind that the Vuller on her corner will get you. If anybody familiar with the Fast and the Furious knows this quote pretty well. So I am Paul Walker in this case, and Paul Walker has just narrowly lost a race to Vin Diesel where he gets out of the car and says, dude, I almost had you. And then in this particular case, the distal radius fracture is Vin Diesel who said, dude, you never had me, you never had your car. So being aware of it and sort of proactively treating it is sort of the best course of action. Moving on to when to intervene with malunions. You know, it used to be that people would sort of let these things heal, see how they're doing functionally, and then go back in if there was a problem. But sort of the counter-argument to that was spearheaded by Jupiter with a pretty seminal article in the mid 90s, whereby they actually did a comparison between folks that they let sit for 40 weeks plus and folks that they went in relatively early, they defined as eight weeks. And this has been backed up by Lowe's Group out of the Cleveland Clinic and Wake Forest as well. And what we see is at worst, the early intervention is just as good as letting it wait and see. So what you get by going in early is less time off of work, and perhaps more importantly, or at least as importantly, much easier operation. So less soft tissue contracture and getting patients back moving much more quickly. So that tends to be what we favor in our clinic, or at least in our practice. Now, when you move to going from, all right, we're gonna fix it, we're gonna get after it, we're gonna go in early, how does one do that? Well, everybody likes a closing wedge osteotomy, and ideally, if you just have to correct volar tilt, that's what you're gonna do. But it's not always the case, and sometimes you have significant loss of radial length. So in that setting, the classic answer was a big tricortical crest graft from the hip. However, that has its own set of challenges. And what's been very interesting is that there's been a couple of groups, one out of Sapporo, Japan, Dr. Wada's group, and another group out of London, Dr. Opel's group, have championed this idea of doing a closing wedge osteotomy to correct your coronal plane, as well as your volar tilt. And then instead of trying to jack that whole thing back out to length, actually shortened the ulna. And I've had good success with this in my practice. I think it's a nice technique. Certainly not for everybody, but particularly, at least in Japan, it's been employed in the 55 to 65-year-old female population with excellent success. The other thing that Dr. Kakar has already alluded to is going in and correcting intraarticular problems through the scope. He is certainly a master of that. I actually favor going in through sort of a mini open dorsal approach, a lot of Dr. Jupiter, but certainly both are correct, and you can get good results with either of those techniques. This is just a case example of a 27-year-old gentleman who was actually on a mission trip and fractured his wrist in Puerto Rico, and then unfortunately was unable to return until six weeks post-injury. So you can see here, he's got both loss of radial length as well as a loss of volar tilt. So we basically treated him like an acute fracture with the exception of the fact that we had to perform an osteotomy, but again, going into a nice closing wedge osteotomy. If you're gonna be really critical, we probably could have gotten about a millimeter or two more of a radial length back, but he did great and healed up at basically around six to eight weeks and was back to working. This is a different case and a very different patient. This is a 57-year-old gentleman who presented to me. 11 months after sustaining this injury, he was initially treated by one of our affiliated hospitals non-operatively, secondary to pretty significant psychosocial issues in addition to his drinking and smoking problem. However, he presented to our clinic with significant discomfort and a pretty sizable deformity. I didn't think in this particular case that the closing wedge and ulnar shortening was in his best interest. So we treated him with a sort of tried and true osteotomy. Here's his CAT scan showing that we have a little bit of bone to play with this story, but not a whole lot. So he underwent the standard osteotomy, big tricortical iliac crest graft. And I think the important thing when you deal with these is to essentially over-distract with a laminar spreader in order to get your graft in and allow the soft tissue to contract back around it to compress it. Fortunately, he did pretty darn well. He healed at about four and a half months, which is pretty good given the amount that he smokes. And functionally, he's doing pretty well now. Moving on now to non-unions. And so anybody who goes to literature and expects to find sort of a treasure trove of data is in for a rude awakening. There's really not a lot out there on non-unions. It's a pretty rare event. No risk factors have been particularly proven. However, there's two kinds of schools of thought. One of which is that it's a metabolic condition or problem. And one of which is that it's secondary to over-distraction at the fracture site at the initial sort of time of ORAF, which I think both are probably true. And for me and my practice, one needs to A, figure out what was done, what the initial fracture looked like, what the other risk looks like, and C, if over-distraction was in fact the culprit. And I'll show you a case of that in a second. But the other issue is that if that's not the case, one really needs to figure out what's going on from a metabolic perspective. And I don't hesitate to consult our endocrinology colleagues at all in that regard. No real indications in terms of timing, no consensus really at all, but you have to understand that, if there is a true non-union present, that thing is hanging on by the plate and it's just one move away from fracturing. So we tend to be relatively aggressive with these once they're defined, particularly if there's any discomfort. Really any non-union with pain is a recipe for operative correction. Unfortunately, the union rates are sort of all over the board with these. Between 50 to 90%, depending on which paper you read. So they can be a challenge. And any type of augmentation one can do in order to improve the healing milieu is useful. And again, that is very helpful to have a good endocrinology colleague around. So this is the case that I was alluding to. This is a case from one of my partners. It's actually, it looks like it's a non-union. The initial treatment was a non-union, but it was just a straightforward extra-articular just a radius that I think got over distracted. She unfortunately never healed. So these are her one-year post-op x-rays whereby you can see a pretty clear line in the sagittal plane. Unfortunately, this past winter, she was on the fantail of her family's fishing boat in Florida doing yoga. Now it's a tough life. And when she felt a crack and she comes, she actually flew back like the next day on their family plane, presents with this, obviously this isn't good. So she got a CT scan for their characterization as well as a metabolic bone workup. That was all normal, believe it or not. And so we set about correcting her. And once we actually excised the fibrous junk, we actually found that there's a pretty sizable defect. So this was treated with a big tricortical piece of iliac crest. And unfortunately where the prior plate stopped was right about the mid aspect right here. And unfortunately we didn't have anything slightly longer. So she got the mega deluxe distal radius plate, but fortunately has gone on to heal well. I think we've got time for one additional case, which sort of gets into sort of more nuanced territory. And this is, I like to call this my magnum opus because she's got like three distal radius complications all in one. This is a 67 year old lady who was initially referred to me by one of my trauma colleagues. She sustained this distal radius fracture due to psychosocial issues, including her alcohol and tobacco consumption. She was treated non-op. So you can see a fracture pattern here that is both shortened as well as resulting in excessive volar tilt. She presented because she had an EPL rupture. So we did an EIP transfer. However, she no-showed her first three operative appointments, which kind of sets the stage. So on the fourth trial, we finally got her EIP transferred over. Despite only going to one OT appointment, she did great and had excellent function in that regard, but presented at about six months post EIP transfer, complaining of wrist pain. And you can see a complete subluxation slash dislocation of the carpus, which is another complication of excessive volar tilt. So given my initial experience with her, I was loath to try to do anything bony. That turned out to be a massive mistake. I'll show you why in a second. We decided to go in and actually try to do a volar and dorsal ligament reconstruction. And pinning the carpus. So initially our reduction looked pretty darn good. However, when those pins came out at around eight weeks, yeah, this happened. So now at this point in time, she's been presented at conference. Numerous colleagues have been contacted and we decided to address a bony problem with a bony solution. She gets brought back out to length with the distal radius osteotomy. We again pin the carpus, although we don't quite get it. Despite everybody's best efforts, we were unable to get the thing perfect. And then not surprisingly, when the pin came out, she healed the osteotomy, but continues to sublux. So now we're at a point where if and when it comes to it, she's gonna be getting a total wrist fusion. I think, well, I've got a couple more cases, but I think we need to move on to Dr. Tintle just from a timing perspective. Great. Thank you all. This has been great. I'm learning a lot. If someone would shake their head if they can hear me. All right, perfect. I'm gonna talk today about rehabilitation and bone health screening. I do not have any disclosures other than the work that I've done in the past. I've done a lot of work in the past. Any disclosures other than the work for the government, and these are my opinions. I'm having a little trouble moving the screen here though. Great. So we'll go back here. Okay. So I apologize that my talk's the last talk, and there's unfortunately not a lot of cases, but I'll try to keep it quick here. So this first case, or the only case, is a 42 year old female, and she had a fall from standing height. She really has no significant past medical history. Again, she's got this intra-articular accommodated fracture. There is a small volar on her corner, again, on this fracture. And I do frequently get CT scans. I find them to be pretty helpful for my planning, as well as teaching the residents about the various fracture fragments. And so this was treated with an open reduction internal fixation, a volar plate. And I do typically use this plate, and I do like it for all the reasons that we sort of discussed already, but I love having the hook that I can put on these fractures when it's needed. This one in particular, I think we had that fragment, but I'm always more cautious. And if I see it there, especially on the easier fractures, I will definitely put the hook on there so that when I really have to do it, I'm better at putting it on there, because you can struggle a little bit putting this on, especially if you don't have a good enough exposure. And so the question then becomes, well, should I move this patient? Is it safe to move the patient? And so going to the literature, this is a paper from Jesse Jupiter and David Ring and Lozano Calderon. It's quoted often in the literature. And what they looked at, these groups here, they looked at an early motion group that started at two weeks, came out of their post-op splint and started moving. They were, there were really no attempts to monitor the patients and see how much they were actually moving. And they compared these to a late motion group at about six weeks. What they noted at about three in six months, there were no difference in the flexion extension arc. There was no real difference in the grip strength male or dash scores. And so ultimately this is a paper that you can use for whichever way you want to go with this. There was really no real benefit, but there was also no real condemnation of early wrist motion. And so one of the conclusions of this paper was they called into question some of the other papers that were suggesting that patients with early motion were doing substantially better than patients that were immobilized for six weeks. Well, then we get to a paper in 2014 by Bremer and Husband, another one that's frequently quoted in the literature. And you gotta be really careful when you look at early motion papers or early accelerated rehabs. You really have to look in the details here because I was even surprised at looking at some of these papers. When they went and said accelerated rehab, they were looking at motion at day three to five. And so that was what I thought was accelerated rehab. But when you look at their standard rehab, it was also motion at day three to five. So the real difference in what they were doing in this paper was they began strengthening at two weeks. So they were actively strengthening these patients at two weeks, and they were starting passive range of motion at two weeks, which was really the variable. So moving on here, I seem to be frozen again. I'm gonna give it one second. Okay. So what they found was when you, and I'm sorry, it's going forward here, at two weeks, three weeks, four weeks, six, eight, and 12 weeks, there were some statistical differences in how these patients did with regards to their dash scores. What they found was it was really clinically significant at both the three and six week timeframes, but ultimately by 12 weeks and 26 weeks, I'm sorry, we're really struggling here with where I am on this PowerPoint. So what they found was, again, at those four and six week time points, the accelerated rehab, or really the group that was doing active strengthening and passive range of motion, they did a little bit better, but by 12 weeks, all those benefits were really gone. And so when, you know, if you're a little bit more worried about your fixation or you're a little bit worried about starting early range of motion, this is another paper that you can utilize that looked at patients at one weeks, three weeks, and six weeks, and started physical therapy shortly thereafter after their splints were removed. And they looked at patient rated risk scores, and then secondary, they looked at dash grip strength and range of motion. And again, they found that the risk scores were a little bit better in the early motion group at six weeks timeframe, but ultimately at 12 or 26 weeks, these were gone. So it's a familiar trend here that the benefits of these really seem to be gone by about three months. And so these authors concluded that there really were no significant differences in the adverse events with the shorter immobilization periods. And, you know, coming to a little more recent literature, this is a randomized control trial, where again, now we get to early, really early mobilization of these patients. So these patients were placed in a lace-up wrist brace that post-op day one, and they started with a finger and wrist range of motion nearly immediately. And then compared to a late mobilization group, which is in two weeks in a plaster cast, and then they started the same, the very same exercises. So again, the variable here was the first 14 days or so. And this, again, this is pretty rapid movement of these patients. They did start patients at physical therapy at around the four weeks timeframe, if they felt that there was low grip strength or low range of motion, and that was up to the treating physician's discretion. And they have very good follow-up rate. What they found here is the summary up above here shows that there really were no significant differences between the two groups at any of the time points. And it really did not lead to improved patient outcome scores. Ironically, the authors of the study found though, that it was safe. And in their opinion, the patients were very happy with their ability to shower and wash their hands. And so based on the results of their study, they have switched to going with very early mobilization of patients on post-op day one. This is another paper that's frequently quoted and is becoming, I think, a little more important as we started looking at the cost of physical therapy, because nobody really knows how quickly or how many physical therapy visits patients really need. And this was a systematic review of controlled trials. And this looked at both distal radius, proximal humerus fractures and therapy thereafter. And so what they found is that there were really 13 trials that were insufficient to refute home exercise program versus therapy supervised for distal radius or proximal humerus fractures. They found that there were three trials insufficient to support or refute the effectiveness of exercise therapy compared with advice or no exercise following distal radius. And then they found that there was one study that looked at distal radius that supported early and reduced immobilization. And so they concluded that there was increasing evidence that prescribed physical therapy may not actually reduce the impairment or improve the activity of our patients over that of just performing everyday activities. I think any discussion of the distal radius at this point wouldn't be complete without discussing Dr. Kevin Chong's and the risk group trial that I believe is continuing to go on. And a lot of the speakers here are part of that. And this trial looks at patients that are 60 years and older. They're randomized to one of three groups, open reduction, internal fixation, closed reduction and X fix plus or minus K wires, closed reduction and pinning, and then an observational group that does not want surgery. This is a very practical trial and referral to therapy is really at the surgeon's discretion. And they looked at 304 patients that were enrolled in the study. And they found that similar to what other literature suggests that hand surgeons that are a part of the hand society use therapy a little bit more than generalists or trauma surgeons likely. And so 80% of these patients received some sort of therapy. There was no real difference in the type of surgical treatment with who received therapy. They looked at the start of therapy, which was at a mean of 3.8 weeks. The voral locking plate started the earliest at 2.9 weeks. And then when we look at the number of sessions, about 9.2 was the average. The average duration of therapy was a little over three months. And their main primary outcome measure was the MHQ. So patient reported outcome. And what they found is there were really no differences in the values. Ironically, they found that those who did therapy recovered less grip strike. It was 79% compared to the other side. And the patients who did not do therapy had an 87% grip strike. So again, the authors concluded it's similar to the Bruder study, that the meta-analysis that I just talked about. Performing every day activities leads to as good or better outcomes potentially than formal rehabilitation. And Dr. Chung importantly points out that as we move more towards bundled type payments, this may become a real issue. So moving along here, what it appears as therapy moves on, it looks like there's more and more online therapy. This is a new trial that's gonna be starting soon. You'll be utilizing video games and iPhone in order to help our rehab our patients. And I think that this is really likely the future. So to kind of just very rapidly wrap this up with our bone health, this patient did pretty well with therapy. She did about 14 or 15 therapy visits similar to the mean was doing very well when she unfortunately went on the fun slide, broke her wrist at the proximal aspect of her plate and presented back. So she returned for another over-reduction internal fixation, fixed that. And when I went to review her DEXA, I found that unfortunately she did not get her DEXA despite the fact that I ordered it. And this highlights a problem with many of our systems that it's very difficult to get the bone health screening. So I'm gonna just flash forward very quickly and just say the one thing that Dr. Rosenthal has previously taught us. And that is that the most important thing that I think you can do as the treating doctor is order the patient's DEXA and then send those results to their primary care provider and start treatment. I think that if you're comfortable starting the treatment and there's lots of reasons why you should probably be comfortable starting the treatment, that's a great thing to do. But really the number one thing is to order the DEXA. And I think we're running very short on time. So I'm gonna just end it there. Thank you. Thanks, Scott. Sorry that I got cut short a little bit there, but obviously I'm a believer. So I think it's an important point to make. I just have, I think, one question on the chat so far. We have a few minutes left if anybody has anything else they'd like to ask. So I think this one was for Carl is on the case that you presented with the bone grafting that you did for the non-union, would you have considered also adding a dorsal spanning plate? I think the short answer is yeah. And just like Dr. Kakar talked about, if you feel like your fixation is inadequate, you shouldn't at all hesitate to go dorsal if you need to. I don't think you strip too much back there and I don't think it would impact the union rate. But what's interesting is when you use that laminar spreader to get it really out to length and then pop your graft in like a puzzle piece, once that laminar spreader comes out, it compresses really aggressively. The soft tissues are so contracted that I didn't think we needed, and I haven't augmented much or felt the need to augment much in that regard. I'm not sure if anybody else has different feelings on that. And then along that, Mark, why do you prefer the third metacarpal to the second? Sanj and I were just texting about that. It's the long axis or the central axis of the wrist which is third metacarpal capitate right through the intermediate column. So it is that central axis of the wrist. It's got the shortest bone-to-bar distance. If you notice, when you go to the second, you don't need to transpose the UPL because the plate's actually over it. The plate breakages in that early group of bridge plates that had the central cluster were all on the second, not on the third, because you've got a little bit more play there and that's where they go. It's not where that bone-to-bar distance is zero. It also, we had a biomechanical study just showing that when you go to the third, it's stronger than the second, probably for that reason. And when you add the middle screw, it's the strongest. So someone who's really gonna be weight-bearing on these is a polytrauma. It's the strongest construct that you can have. It's really hard. There's no real opportunity for that middle of the plate screw when you go to the second because it's off bone a little bit. And then lastly, it does allow you the ability to do some articular reduction through that intermediate column right there, which I like as well. You can make a separate incision if you go to the second, but I prefer the third for that reason. The study that looked at the EPL rupture, if you look at how they did it, they didn't make a middle incision. I do believe you have to make that third incision and protect EPL, but if you do that, you're fine. Interestingly, I tend to be about 50-50. I tend to put it in and then kind of decide where I think it sits better. Many good ways with the bridge, it's a good tool. I think, yeah. What do you do with it, Scott? Second or third? So I typically go to the second after the EPL paper. That's pretty much what I do. Great, well, that pretty much takes us to 9.30. So I know everybody has other things to get to, but I wanna thank my panelists again for a really great evening. Thanks for joining us. And I hope that some of the tips that were shared will be useful. Have a good night. Thanks, everybody. Thanks, Tamara. Thanks, everybody. Bye.

distal radius fractures

soft tissue injuries

triangular fibrocartilage complex

scapholunate ligament

open reduction internal fixation

closed reduction and casting

rehabilitation timing

early motion

immobilization

bone health screening

DEXA scans

osteoporosis treatment