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Distal radius fracture – Manipulation Under Anaesthetic (MUA) and K-wire fixation

    Overview

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    Learn the Distal radius fracture : Manipulation Under Anaesthetic (MUA) and K-wire fixation surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Distal radius fracture : Manipulation Under Anaesthetic (MUA) and K-wire fixation surgical procedure.
    Distal radial fractures are a common injury that have a bimodal age distribution. Younger patients with the injury can be further split into two groups, the paediatric low energy physeal type injuries or young adults with high energy injuries. The most common group by number however, are older osteoporotic adults in the over 60 age group, who are typically female patients.
    Abraham Colles (1814) first described the dinner fork deformity of the dorsally displaced fracture of the distal radius and this eponym is regularly used. It should however be noted, that this is a clinical deformity diagnosis, as radiographs weren’t discovered until 1895 by Wilhelm Rontgen.
    In terms of how to manage these injuries, my own surgical practice is informed by the results of the DRAFFT study and subsequent critical appraisal.
    (Costa M et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of the distal radius: randomised controlled trial. BMJ. 2014; Aug 5: 349.
    Fullilove S, Gozzard C. Dorsally displaced fractures of the distal radius: a critical appraisal of the DRAFFT study. Bone Joint J. 2016: 98-B(3); 298-300).
    In short, if a closed reduction can adequately restore the anatomy and K-wires can control that fracture pattern, then I offer an MUA & K-wiring. If this is not the case, then I use internal fixation or on occasion external fixation, depending upon the fracture, soft tissue and patient specific factors.
    In addition there are particular groups of patients for whom I may offer a primary open reduction and internal fixation rather than considering manipulation and K-wiring. These are:
    Those who require early hand function, to aid with weightbearing or return to work.
    Those who cannot tolerate a cast such as the cognitively impaired.
    Those who will not be able to return for removal of wires at 4 weeks.
    Readers will find the following OrthOracle instructional techniques also of interest:
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    Compound distal radius fracture: stabilised with Hoffman II External Fixator
    Dorsal plating of distal radial fracture with Depuy/Synthes 2.4mm VA locking radial column plate assisted by wrist arthroscopy using Acumed ARC tower
    Distal ulna fracture fixation using the Synthes 2mm LCP Distal Ulna Plate

    Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
    In the USA contact: https://www.fda.gov/medical-devices/products-and-medical-procedures
    In the UK contact: https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency
    In the EU contact: https://www.ema.europa.eu/en/human-regulatory/overview/medical-devices

    Indications

    INDICATIONS
    The most common mechanism of injury is a Fall On Out Stretched Hand (FOOSH). This gives a classic dorsally displaced fracture pattern which can be either intra- or extra-articular.
    Indications for surgery are:
    Open fracture
    Intra-articular fractures with an articular step of more than 2mm
    Dorsal angulation greater than 20 degrees
    Shortening greater than 5mm
    Loss of radial inclination
    Articular steps will predispose to post-traumatic osteoarthritis. However a lot of patients don’t go on to develop symptoms that warrant further surgical treatment (e.g. wrist fusion / replacement etc…). Commonly patients lose wrist movement and if there is any shortening, then they develop ulna sided wrist pain (ulna impaction syndrome) which is evident on ulnar deviation or pronation (as the radius shortens relative to the ulna).
    In the over 65 age group, the criteria can be less strictly applied (BOA / BSSH guidelines) and a lot of patients with distal radius fractures and mild deformity do very well.
    SYMPTOMS & EXAMINATION
    The common symptoms associated with a distal radius fracture are: pain, swelling and deformity. Usually most patients are quite clear when presenting to the emergency department that they have broken their wrist and the x-ray is purely for confirmation (or to rule out a fracture). On inspection there will be generalised swelling and possibly bruising affecting the wrist. If there is an intra-articular fracture, a keen-eyed examiner would spot that there is fullness in the anatomical snuff box (due to the intra-articular haematoma). Palpation will reveal bony tenderness to the distal radius and possibly also to the distal ulna, indicating an associated ulna-sided injury as well e.g. ulna styloid or TFCC injury. A neurological examination is mandatory, as the median nerve can be compressed (either by fracture displacement or a carpal tunnel haematoma) causing an acute carpal tunnel syndrome.
    Abraham Colles (1814) first described the dinner fork deformity of the dorsally displaced fracture of the distal radius and this eponym is regularly used. It should however be noted, that this is a clinical deformity diagnosis, as radiographs weren’t discovered until 1895 by Wilhelm Rontgen.
    Robert William Smith (1847) first described the reverse Colles fracture. They are less common than a Colles fracture and the distal fracture fragment is displaced volarly. It can be either intra- or extra-articular but the volar and dorsal cortices are both involved.
    A Barton fracture is an intra-articular fracture that starts at the joint surface and then exits either volarly or dorsally. The opposite cortex is always intact. For example, in a volar Barton fracture, the fracture line starts at the articular surface and exits volarly, the dorsal cortex is undisturbed. They were first described by John Rhea Barton (1838) an American surgeon.
    IMAGING
    Plain Postero-Anterior (PA) and lateral radiographs are usually sufficient to make the diagnosis. For complex intra-articular fractures requiring surgical reconstruction, then a CT scan is very helpful for pre-operative planning.
    ALTERNATIVE OPERATIVE TREATMENT
    There are a myriad of surgical options for distal radius fractures and there are advocates for each technique. These include but are not limited to:
    Manipulation and K-wire fixation
    Open reduction internal fixation (volar / dorsal)
    Fragment specific fixation
    External fixation
    Bridge / distraction / spanning plate fixation
    Intramedullary devices
    There is no Cochrane review of the surgical treatments options in adults, as this was withdrawn by the authors in 2018.
    NON-OPERATIVE MANAGEMENT
    Non-operative treatment is by far the commonest treatment modality and is usually with a plaster cast. Wrist flexion should be minimised to prevent undue pressure on the median nerve however, a little bit is helpful to correct the sagittal plane joint surface angulation. Ulnar deviation of the wrist is used to maintain the radial inclination and occasionally an above elbow cast is used to restrict supination / pronation. Thumb immobilisation is not necessary. Distal radius fractures are normally immobilised for 5-6 weeks and in undisplaced / stable fractures a splint could be used instead or supplemented early for the cast.
    CONTRAINDICATIONS
    Complex Regional Pain Syndrome (CRPS) is a serious complication and has been reported with an incidence of up to 25% in distal radius fractures. It can be encountered with either operative or non-operative treatment. It presents however, after the treatment has been instituted and can significantly impede the rehabilitation.
    Cowell F, Gillespie S, Cheung G, Brown D. Complex regional pain syndrome in distal radius fractures: How to implement changes to reduce incidence and facilitate early management. J Hand Ther 2018; 31: 201-205.

    Setup

    The procedure can be performed under either a regional or general anaesthetic. I like the patients to receive a single dose of antibiotics.
    The patient is in the supine position with their arm placed on to an arm table.
    I do not use a tourniquet.

    Operation – 1

    The system I use for interpreting an extremity radiograph is:
    Trace around the cortex of each bone
    Check each bone to ensure that the bone density is homogenous
    Inspect each joint to ensure that the joint space is congruent and there are no peri-articular pathologies (e.g. fracture, cyst, peri-articular erosions, osteophytes etc…)
    Inspect the soft tissues looking for abnormal shadows or increased soft tissue swelling.
    This radiograph demonstrates an extra-articular fracture of the distal radius. There is no bony injury to the distal ulna.

    On the lateral view, the articular surface is dorsally angulated.
    The normal angles of the distal radius can be easily remembered with the rule of 11’s.
    11 degrees of volar tilt of the articular surface (seen on the lateral radiograph)
    22 degrees of radial inclination (seen on the PA radiograph)
    11 millimetres of radial height from the flat surface of the ulna head to the tip of the radial styloid (seen on the PA radiograph)

    The fracture has been manipulated and a dorsal backslab applied. Routinely distal radius fractures were manipulated using either a haematoma block (local anaesthetic injected into the fracture site) or Entonox or both.
    Recent guidance from both the British Orthopaedic Association (BOA) and the British Society for Surgery of the Hand (BSSH) are now advocating using a regional anaesthetic technique such as an axillary nerve block or intravenous regional anaesthesia (IVRA) e.g. a Bier’s block.

    The lateral radiograph demonstrates that the articular surface angulation has improved but is not normal. However, the volar cortex has not been adequately reduced and with dorsal comminution, this fracture is likely to re-displace.
    Lafontaine et al. in 1989 identified 5 factors on the initial radiographs that indicated the level of fracture instability.
    Dorsal angulation more than 20 degrees from the normal position (i.e. greater than 10 degrees of dorsal tilt)
    Dorsal comminution
    Intra-articular radiocarpal fracture
    Associated ulnar fracture
    Age over 60 years
    They found that 3 or more factors was indicative that closed cast treatment would be unlikely to adequately control the fracture and prevent re-displacement.
    Lafontaine M, Hardy D, Delince Ph. Stability assessment of distal radius fractures. Injury. 1989; 20: 208-210.

    The hand and wrist are washed with soap and water to remove any grease / oil that would prevent the antiseptic from adequately preparing the skin.

    Once socially clean, the fracture is manipulated to see if it is possible to achieve a closed reduction. If not, then the procedure can be changed to an open reduction and doing it this way, allows time for the theatre team to open the required surgical instrumentation sets.
    The forearm should be held in preference to the elbow, as it is possible to inadvertently dislocate the elbow. The assistant holds the patient’s thumb in one hand and the radial 2-3 fingers (index, middle +/- ring finger) in their other hand. When traction is applied, this causes ulnar deviation of the wrist and restores the radial inclination. Traction should be applied for 2-3 minutes to allow the fracture to disimpact and the periosteum to lengthen and undergo ‘creep’.

    The deformity is exacerbated to hinge open the fracture fragments. Using a thumb placed dorsally over the fracture, it is possible to manipulate the distal fragment, so that the fragment is volarly translated and the dorsal cortex aligns with the diaphysis.

    Traction is reapplied and the fracture is manipulated volarly and ulnar-wards.

    Criteria for an acceptable reduction were proposed by Jupiter et al (1986):
    Volar tilt (normal = 11 degrees): less than 20 degrees from normal
    Radial inclination (normal = 22 degrees): less than 5 degree change
    Radial height (normal = 11mm): less than 5mm of shortening
    Articular step off: less than 2mm
    Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68A(5):647-59.

    This reduction has met the criteria specified by Jupiter et al and now requires stabilisation.

    I routinely do a double prep using a dark pink and light pink chlorhexidine solution. The dark pink allows me to see that everywhere has been painted, and then the light pink washes off the dark pink solution.

    Before making any skin incisions, I plan and mark out where the wires should be inserted.
    I do not use a tourniquet, as it is very easy to damage a superficial vein and with an inflated tourniquet it won’t bleed until the end of the operation. If you do accidentally catch a vein, then the wire can be removed to permit access to ensure thorough haemostasis.

    The radial wire should pass through the styloid and not the articular surface. It should pass across the fracture site and get a second point of fixation in the intact ulnar side of the radius.

    The photo shows the proposed path of the wire marked on the skin surface.

    The ulna sided wire can either go through the interval between the 3rd and 4th dorsal compartments and enter the distal radius at Lister’s tubercle or the interval between the 4th and 5th dorsal compartments and enter the distal radius at the dorsal ulnar corner (DUC).
    The DUC wire is essential when there is an intra-articular fracture that splits the lunate and scaphoid fossa.

    The skin incision site is identified, taking into account the proposed wire trajectory and thickness of the wrist soft tissues.

    The skin marking process is repeated on the lateral view and the skin incision site for the radial styloid wire is identified.

    A small (approximately 5mm) skin incision is made. Do not do a ‘stab’ incision, as this is likely to damage the superficial radial sensory nerve branches or possibly injure the underlying tendons. More commonly however, it causes significant bleeding from one of the superficial veins. Only incise the deep dermis and then use a haemostat to bluntly dissect down to the bone.
    The haemostat is passed closed down to the bone surface and then opened and pulled back. It is then re-closed and carefully re-inserted through the same tract. It is turned through 90 degrees and re-opened and withdrawn in one smooth movement.
    Markings:
    A – dorsal ulna wire (from a PA view)
    B – radial styloid wire (from a PA view)
    C – radial styloid wire (from a Lateral view)

    A 10cm roll of crepe bandage is kept in its’ paper packet and the wrist is held palm down, using the bandage as a fulcrum at the fracture site. This helps to maintain the volar tilt to the distal fragment.
    A fresh 1.6mm wire is carefully inserted on power. I like to take lots of x-rays, as multiple passes of the wire will blunt the trochar tip and also burn the bone as the wire gets hotter.
    The wire is gradually advanced on oscillate so that none of the sensory nerves are inadvertently damaged. By pausing every centimetre to take an x-ray, the wire tip cools and also the wire angle can be changed to obtain the perfect path.

    The pre-operative markings are useful to guide the wire angle when you can only view it in one radiographic plane at a time.
    A – this is where the crepe bandage (in the paper packet) would act as a fulcrum.

    When in the lateral view, the crepe bandage is used as a fulcrum and is now placed under the ulna and the wrist is ulnar deviated and flexed. This helps to restore the distal radius inclination and maintain the volar tilt.
    The entry point here is too dorsal but has satisfactorily stabilised the fracture.

    The dorsal ulnar corner (DUC) wire is inserted through the 4/5 space and catches the crest of the distal radius. Often there is lots of comminution, so having the entry point any further proximal usually means that the wire falls through a fracture line and becomes intra-focal.
    Intra-focal wires (Kapandji technique) can be used. However, they only control one plane of movement i.e. they resist dorsal tilt (sagittal plane movement) but do not control coronal plane movement. They can also ‘over correct’ the reduction.

    The wire is slowly advanced.

    Again multiple x-rays are taken to watch the wire pass through the bone and fine adjustments are made as necessary.

    The ulnar wire has good hold in the distal fragment and has exited the radius on the volar radial side.
    A third wire (to replace the dorsal radial styloid wire) is inserted. I like the radial styloid wire to be volar and skirt along the inner cortex of the fragment. If the bone is osteopaenic, I feel this wire provides support to the fragment by not only having captured the fragment at the entry site but also providing an internal buttress to the volar cortex.

    Operation – 2

    The first wire has been removed and the radial styloid wire is slowly advanced.

    The trajectory of the wire was too shallow and it has not been able to lodge on the ulnar cortex of the radius.

    The wire is backed up and the trajectory changed.

    The wire is re-advanced but a constant bending force is applied to the wire. This bending bias resists the tendency for the wire to skim along the inner cortex.

    The fracture reduction and wire position is re-checked.

    The wires are pulled back a little so that only the tips are just through the bone.

    The wrist has been flexed and extended and then a final image is taken. This confirms that the fracture has been adequately stabilised using just 2 wires.
    For fractures involving the lunate fossa or dorsal ulnar corner, a lunate fossa view can be obtained by first taking a true lateral image and then elevating the forearm by 20 degrees away from the C-arm detector plate.

    The wires are bent. I prefer to use the wire bending pliers, that allow the wire to be bent by squeezing the plier handles together. This I feel prevents the wire from moving in the bone and possibly displacing the fracture. They can also be used with one hand, allowing the other hand to stabilise the wrist.

    At least 10-15 millimetres of wire must be left sticking out of the skin, so that if the wrist swells, the wire doesn’t disappear below the skin surface.
    If the wires are going to be in situ for longer than 4 weeks, then I would bury them.

    The wire is cut.

    Some surgeons use sutures to oppose the edges of the skin incision, I prefer to use a steristrip. I also pass the wire through the non-adherent dressing.

    A piece of folded gauze is placed under the shoulder of the wire to keep pressure on the skin and prevent a haematoma forming.

    A second piece of folded gauze is placed under the tip of the wire, to protect the skin in case it swells or the wrist moves. I’ve also used a wire cap (yellow).

    A backslab is applied to cover the ends of the wires, so that they don’t catch on anything. It also provides some pain relief and prevents wrist movement which could irritate the skin around the wires and lead to a wire tract infection.
    The wool is deliberately long and covers the proximal phalanges.
    The plaster is cut with a deep space for the thumb, so that the plaster can sit on the dorso-radial side of the wrist.

    When the plaster is applied, the wool is cut in line with the index and little finger phalanges. It is then reflected, so that the plaster is covered and the metacarpophalangeal joints (MCPJs) are free to move through their full range of motion.

    A crepe bandage is applied and the thumb is left free, so that the patient can use the hand.

    Post Operative

    Elevation – the wrist is elevated to reduce any swelling of the hand and fingers. I discourage the use of slings, as this places the hand and wrist in a dependent position. I recommend that the arm is placed on cushions / pillows to maintain the elevation when sat in a chair or sleeping in bed.
    Movement – I encourage patients to fully flex and extend their fingers and thumb through a full range. I also allow them to use the hand (e.g. using cutlery) but to avoid lifting anything heavy.
    2 weeks after the operation the patient is seen in clinic to check the wire sites and fresh dressings are applied. A check x-ray is also performed to ensure that the reduction has been maintained.
    4 weeks after the operation (2 weeks since the last clinic appointment) the wires are removed in clinic. At this point, they are placed into a lightweight cast or futura splint for 2 weeks.
    6 weeks after the operation the cast / splint is removed. A check x-ray confirms that the fracture has united and wrist range of motion exercises are commenced and the patient is referred to physiotherapy.
    12 weeks after the operation (6 weeks since the last clinic appointment), a clinical examination is performed to check that the pin sites are well healed with no signs of infection and no neuromas. The wrist range of motion is assessed and the patient is discharged if making satisfactory progress.

    Recommended Reading

    Distal Radius Acute Fracture Fixation Trial (DRAFFT)
    The DRAFFT trial was a pragmatic multi-centre randomised controlled clinical trial involving 18 hospitals comparing K-wire stabilisation vs open reduction and internal fixation using a volar locking plate (VLP).
    Method
    Inclusion criteria were:
    Dorsally displaced distal radius fracture within 3cm of the radio-carpal joint
    Patient would benefit from fixation
    Age 18 years or over
    Injury is less than 2 weeks old
    Exclusion criteria were:
    Fracture extends more than 3cm from the radio-carpal joint
    Open fracture with a Gustilo grading greater than 1
    The articular surface cannot be reduced by indirect techniques
    Contraindications to anaesthetic
    Patient would be unable to adhere to the trial protocol
    Primary outcomes were:
    Patient Rated Wrist Evaluation (PRWE).
    Secondary outcomes were:
    Disabilities of the Arm, Shoulder and Hand score (DASH)
    Euroqol (EQ5D)
    Complication rates (superficial / deep infection, nerve / vessel / tendon injury, re-fracture)
    Comparative cost effectiveness
    Results
    461 patients recruited (target 390). Outcomes were assessed at 3, 6, 12 months. No significant difference was found between the treatment groups.
    Conclusion
    “This trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with K-wires or volar locking plates. K-wires are however, cheaper and quicker to perform.”
    Dorsally displaced fractures of the distal radius – a critical appraisal of the DRAFFT study
    12,162 patients were assessed for eligibility and inclusion / exclusion criteria were applied (4,760 eligible patients)
    4,121 patients not recruited as surgeons felt:
    The fracture could not be reduced indirectly
    The fracture pattern was highly unstable
    178 patients declined to participate
    Leaving only 461 patients for the study, which is 4% of the population of distal radius fractures.
    Skill of the surgeon:
    2/3 of operations by non-Consultants
    13% of surgeons done less than 10 VLP
    13% of surgeons done less than 20 VLP
    X-rays better for VLP but no long term follow up
    DASH better for VLP (not a Minimal Clinically Important Difference)
    75% over 50 years (vs 60% national)
    Did not measure early improvement < 3 months e.g. return to work
    No cases of CRPS (which would have been expected)
    My practice and interpretation of the DRAFFT trial:
    If a closed reduction can adequately restore the anatomy AND K-wires can control that fracture pattern; then I offer an MUA & K-wires.
    However, if patients:
    Need early hand function (weightbearing / return to work)
    Cannot tolerate a cast / back slab (cognitively impaired)
    Will not be able to return for removal of wires at 4 weeks (out of area / holiday)
    I offer open reduction internal fixation
    Costa M et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of the distal radius: randomised controlled trial. BMJ. 2014; Aug 5: 349.
    Fullilove S, Gozzard C. Dorsally displaced fractures of the distal radius: a critical appraisal of the DRAFFT study. Bone Joint J. 2016: 98-B(3); 298-300

    Reference

    • orthoracle.com

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