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Chirurgie en cas de fracture du radius distal multifragmentée

29 mai, 2020

Fractura de radio distal multifragmentada_20200525_01

Ci-dessous vous pouvez lire une traduction de traducteur humain en anglais. Vous avez également accès à l’original espagnol en cliquant sur le drapeau dans le coin supérieur droit. Ce lien vous donne accès à une version de traduction automatique de Google en français: https://bit.ly/3eLZtMU

The patient, a 42 firefighter, suffers a right distal radius volar shearing fracture (that is, a break that occurs in a bone when subjected to two forces in parallel and opposite direction) in a motorcycle accident. Trauma affects both the metaphysis, which supports the articular surface, and the joint itself. distal radius fracture

Fracture view
This 42-year-old firefighter suffered his fracture in a motorcycle accident. Apparently it is a typical distal radius shearing fracture, but it has characteristics that make it especially complex (‘Atlas of distal radius fractures‘, Dr Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.4).

The problem

The violence of the fracture produces comminution, that is, multiple fragments. A fragment of the scaphoid fossa sinks deep into the metaphysis. In turn, an extraarticular comminution is generated combined with marginal fractures.

The goals

The main objective is to ensure that the patient recovers normal function as soon as possible.

The plan

First, a plate is placed on the anterior face of the radius. The plate acts as a pillar between the diaphysis fragments and the articular surface, and allows the length of the radius to be restored. This support system facilitates the placement of the limb in traction to perform a dry arthroscopy procedure, which now allows the reduction of joint fragments. To avoid fragmentation, the fragments are pushed from down to up after the surgeon accesses through a small hole in the metaphysis.

Surgical fixation
The most proximal screw (arrow) was also inserted to prevent displacement before the hand was placed in traction for the arthroscopy (‘Atlas of distal radius fractures’, Dr Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.9).

Dry arthroscopy – technique developed by Dr Piñal himself (‘Dry Arthroscopy of the Wrist: Surgical Technique‘, Journal of Hand Surgery American Edition Vol. 32A, Issue 1, January 2007, Pages 119-123) allows to act without extravasation of fluids around the joint, bone landmarks can be easily palpated during the procedure, and visibility is far superior to that of the classical technique.

 

‘Atlas of distal radius fractures’ chapter 6 video 6, Management of small fragments (Spanish subtitles). 

Final radiographs
Final case radiographs (‘Atlas of distal radius fractures’, Dr Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.22).

The development of this technique of arthroscopic reduction and rigid fixation combination by Dr Piñal allows the use of arthroscopy in complex wrist fractures, avoiding shortening and bone collapse (‘Arthroscopic Reduction of Comminuted Intra-Articular Distal Radius Fractures With Diaphyseal -Metaphyseal Comminution‘, Journal of Hand Surgery American Edition Vol. 39, Issue 5, May 2014, Pages 835-843).

PProcedure developed by Dr Piñal
Example of the procedure developed by Dr Piñal. A: Restoration of lenght and anatomy of the least comminuted fragments (in the example, radial styloid). B: Creation of a stable platform by inserting two locking pegs or screws. C: Arthroscopic fine-tuning of the ulnar aspect of the articular surface. D: Final result after insertion of the locking pegs or screws and fixation of diaphyseal fragments (‘Arthroscopic Reduction of Comminuted Intra-Articular Distal Radius Fractures With Diaphyseal-Metaphyseal Comminution‘, Journal of Hand Surgery American Edition Vol. 39, Issue 5, Fig 2).

The results

The rigidity, obtained by the rigid synthesis, and the restoration of the anatomy, derived from the reduction by arthroscopy, allow mobilization in the first 24 hours. One week after the procedure, the patient achieves complete pronation and supination, and in a few weeks, fully recovers mobility.

Pronation and supination
The patient achieved total pronation and supination just one week after the intervention (‘Atlas of distal radius fractures’, Dr Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.19).
Evolution of flexion-extension movement
Evolution of flexion-extension movement during the first twelve weeks (‘Atlas of distal radius fractures’, Dr Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.20).
Result at one year
Result one year after Dr. Piñal’s procedure (‘Atlas of distal radius fractures’, Dr. Francisco del Piñal © 2018 Thieme Medical Publishers, Inc. Fig. 6.21).