05:02, 14/04/2017

Thank you very much, chairman.

I am deeply honored to be invited in this meeting and great pleasure to seeing you again in HCMC.


My working place, Kushiro is located on the eastern part of Hokkaido.

It’s blessed with the grandeur of nature, including the “Kushiro Wetland” and “Akan” national parks.

It functions as the social, economic and cultural center, and base city of eastern Hokkaido.

A cool and comfortable climate shows with the highest temperature in mid summer around 20 degrees but the lowest temperature in mid winter around -15 degrees.

Between Dec and Apr, the snow and ice covered on the land.

The river is usually frozen in mid winter season.


The road is always frozen in winter. Therefore, slipping accident is usually occurred.


I’ll show you the graph of total amount of distal radius fractures in our hospital last year.

There were 145 operated cases only one year.


Then, let’s get start on my topics.

Managements for the intra-articular distal radius fractures are challenging. Surgical treatment are required in most cases, however, there is a small number of paper  ‘how to make the anatomical reduction’.


Today’s topic is how to make a reduction for intra-articular displacement on my short case presentations.


Anatomical reduction has been reported to give better functional results by many investigators. Intra-articular incongruity of 1 mm or greater co-rrelated with the articular arthrosis by Fernandes.

On the other hand, Kevin Chung reported that patients with increased radiographic incongruity (step off and gap) showed low functional results at early stage after surgery, however, only increased age and decreased income were associated with lower functional results.



The Japanese guideline recommended that the incongruity in young adult should be reduction below -10 degrees in palmar tilt, greater than 2mm in ulnar variance, greater than 1mm in step off and gap.

However, there is no clearly criteria in the elderly because of depending on their activities.


Because I believe the anatomical reduction is much better, I’ll introduce my technique.


There are two types of fractures in the severe intra-articular fractures of distal radius such as C2 or C3 according to the AO classification.


Split type is frequently occurred in the elderly. The reduction is so easy by using some K-wires. If there is the fracture void, bone grafting or bone substitute is recommended.


At first, an intra focal K-wire is inserted through the dorsal fracture site. Using the lever technique, the dorsal displacement is reduced.

Secondly, radial displacement is reduced by the 2nd K-wire. All procedures are performed under fluoroscopy and percutaneus technique.


This case is 62 years old female slipping on the frozen road showed C3 split type of fracture with the fracture void.


A first K-wire is inserted from the dorsal fracture site under fluoroscopy. When the first K-wire is inserted deeply, the displaced fragment is often overcorrected. In these cases, the operator should support the fragment by his finger from the volar site.

Secondly, the second K-wire is inserted from the radial fracture site. In that time, it is important to check not to overcorrect. The anatomical reduction is usually achieved by two K-wires in most split fractures.

After reduction, a locking volar plate is fixed. Because this case is the split type, the additional fixation is recommended. This case is used radial external fixator.

The fracture void exists in most cases. I usually use bone substitute for fracture stabilization.


X-ray on just after surgery shows the anatomical reduction.


Just ten days after surgery, the range of motion is good.

Split and depression type is usually occurred by high energy injuries. It is not easy to make an anatomical reduction. It is usually required bone grafting or bone substitute for the fracture void. Arthroscopic reduction is sometimes required.


All cases are performed using the FCR approach. After opening bone window, intra-articular reduction was performed transmedurally to make pushing up to the articular surface. The reduced fragments were fixed using the K-wires or half pins of the radial external fixator. After plate fixation, bone substitute or bone graft was filled to the fracture void.


Case 2 is 68 years old female showed C2 fracture, split and depression type.


You can see the split is not so severe and slightly depression.

At first, a locking volar plate is put on the distal radius. Secondary, the bone window is opened to male reduction for the depression fragments.

The fragments in the articular surface are reduced transmedurally by pushing up toward articular surface using a bone impactor.

Subsequently, the half pins of the non-bridging external fixator are inserted through the radial styloid.

After fix of the locking pins, bone substitute is injected to the fracture void.

Intercrossed the half pins and locking pins support to the articular surface.


X-ray on just after surgery shows its anatomical reduction.


On fifth days after surgery, the range of motion is excellent.


This case is 72 years old female showed C3 split and depression fracture.


Anatomical reduction was achieved using a palmar locking plate, non-bridging external fixator and bone substitute.


Show the movie just 5 days after surgery. The range of motion was excellent.


An anatomical reduction was keeping on 4 weeks after surgery.


Since 2013, 88 cases with intra-articular displacement of step-off or gap in X-ray measurements over 2mm were studied.  The evaluation of type of fractures is performed in 4 directions X-ray and 3DCT.


There were 39 male and 49 female. The age at the time of injury ranged between 32 and 84 years old. Follow up term ranged from 6 to 12 month. Cause of injury included as follows.


The locking volar plate was used in all cases. Non-bridging radial external fixator was used in 84 cases. Bone substitute with local bone grafting was used in all cases


Clinical evaluations included Green & O’brien score, X-ray measurements, and complications.


After 6 month later, excellent rate was 73%.


Reduction loss was 0.5 degree in palmar tilt and 0.6mm in ulnar variance.


Reduction loss was 0.2mm in step off and 0.2mm in gap.


Complication included disorder in superficial branch of radial nerve in 9 cases, pin tract infection in 5 cases and CRPS in 2 cases.


First of all, the evaluations of the fracture type are very important. A CT image is better for the diagnosis of sigmoid notch fracture, step-off and articular gap. Pre-surgery evaluation using 3D CT is more useful.


The 30-degree oblique view is useful for the evaluation of lunate fossa. And, the 15-degree oblique view is better for the evaluation of radio-carpal joint, volar edge and dorsal edge of radius.


It is not established when we should operate for severe intra-articular fractures. In my experience, if the operation performs just after injury, injured tissue is usually swelling and too much bleeding.

1 week after injury will be better.


General principles for the treatment of severe intra-articular fractures are the reconstruction of the metaphysis, an adjustment for the intra-articular surface, the early excise of the wrist joint, the structure support for fracture void, and keeping the reduction.


To make a rigid and anatomical reduction, the intercrossed half pins and distal locking pins under the subchondral bone is useful. To keep the radial length and axially support the locking volar plate is recommended. Bone substitute or bone graft is useful for structure support.


The fracture void is often seen in most severe intra-articular fractures. I use an injectable bone substitute ‘BIOPEX’ with local auto bone graft.

As local auto bone graft, I usually use volar cortical bone and cancellous bone to prevent the leakage of injectable bone substitute. Make a closed space is very important procedure before bone substitute injection.



04_2017-TOBE /HCMC_2017ppt.ppt

Có vấn đề góp ý, xin gởi email về: bvctchtphcm@gmail.com.Trân trọng.

Nguồn: Phòng công nghệ thông tin (Topic: How to make reduction for severe intra-articular fractures of distal radius, Masahiro Tobe MD, Dept of Hand Surgery, Eastern Hokkaido Hospital)
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