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Intrafocal Pin Plate Fixation of Distal Ulna Fractures Associated With Distal Radius Fractures
SURGICAL TECHNIQUE
Intrafocal Pin Plate Fixation of Distal Ulna Fractures Associated With Distal Radius Fractures Brian J. Foster, MD, Randy R. Bindra, MD
Surgical Technique
Subcapital ulnar fractures in association with distal radius fractures in elderly patients increase instability and pose a treatment challenge. Fixation of the ulnar fracture with traditional implants is difficult due to the subcutaneous location, comminution, and osteoporosis. We describe an intrafocal pin plate that provides fixation by a locking plate on the distal ulna and intramedullary fixation within the shaft. The low profile and percutaneous technique make this device a useful alternative for treatment of subcapital ulna fractures in the elderly. (J Hand Surg 2012;37A:356–359. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius fracture, distal ulna fracture, intrafocal pin plate.
ISTAL ULNA FRACTURES OFTEN occur in association with fractures of the distal radius.1 The ulna fractures range from minimally displaced ulnar styloid fractures to the less-common ulnar head and neck fractures. The association of Colles’ fractures with an unstable ulnar head and neck fracture can lead to decreased forearm rotation, bridging callus between the ulna and radius, distal radioulnar joint instability, difficulty in distal radius fracture reduction, and distal radius nonunion.1,2 Several fixation options have been described including condylar blade plate, locked 2.0-mm plates, and percutaneous pinning.3,4 Difficulties with these techniques include prominence of hardware requiring removal, difficulty achieving fixation in osteoporotic bone, and morbidity associated with percutaneous pins.3–5 Intrafocal pin plates are commercially available for minimally invasive fixation of distal radius fractures. These devices combine a locking plate for fixation of the metaphysis distally with an intramedullary pin for proximal fixation within the shaft (Fig.
D
From the Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL. Received for publication December 3, 2010; accepted in revised form November 12, 2011. R.R.B. is a consultant for Tornier and receives royalties from the company. Corresponding author: Brian J. Foster, MD, Loyola University Medical Center, Department of OrthopaedicSurgery,MaguireCenterSuite1700,2160South1stAve,Maywood,IL60153;e-mail: [email protected]. 0363-5023/12/37A02-0028$36.00/0 doi:10.1016/j.jhsa.2011.11.013
356 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
1). This provides stable fixation in osteoporotic bone with a small incision and minimal implant prominence. The aim of this article is to describe a new method using an intrafocal pin plate device (Tornier Inc, Medina, MN) for fixation of subcapital distal ulna fractures in conjunction with traditional fixation of the associated distal radius fractures. This method offers a simpler alternative to open plating of the distal ulna by minimizing soft tissue dissection and total operative time. INDICATIONS AND CONTRAINDICATIONS The intrafocal pin plate is designed for fixation of distal radius fractures and is based on the principles of intrafocal pinning. The device consists of a long, S-shaped stem with a locking 1-hole or 2-hole plate at one end. The pin is introduced into the fracture site and inserted into the medullary cavity, bringing the plate to rest alongside the metaphysis to provide a buttress (Fig. 2). The curved stem creates 3-point fixation within the shaft. Additional fixation to prevent subsidence of the distal fragment is achieved by stabilizing the locking plate to the metaphysis with locking screws. We used this device for fixation of unstable subcapital ulnar fractures in elderly patients with associated distal radius fractures. These patients often have osteoporosis and thin soft tissue, a setting in which the intrafocal pin plate is indicated due to its low profile, minimal dissection, and fixed angle mechanism. Not all distal ulnar fractures need surgical fixation, as many will reduce
357
FIGURE 2: Schematic drawing of fixation of a distal ulna fracture with the intrafocal pin plate. The intramedullary portion is inserted through the fracture site into the proximal fracture fragment, the plate is turned 180° to afford reduction, and the distal plate is positioned on the ulnar border of the distal ulna. The metaphyseal fragment is fixed to the plate with locking screws placed into the ulnar head.
FIGURE 1: Intrafocal pin plate. The distal plate acts as a buttress and provides locked angle stability with a locking screw. The proximal intramedullary portion allows for a lowprofile design.
after the distal radius fracture is reduced and stabilized; however, this method is indicated in displaced distal ulna fractures that are unstable after fixation of the distal radius. Ulnar fractures that were felt to be unstable intraoperatively after stabilization of the distal radius were managed with this technique. This technique can also be used in the setting of unstable distal radius fractures that do not initially reduce; stabilization of the distal ulna fracture can improve the surgeon’s ability to reduce the distal radius fracture. Intrafocal pin plate fixation is also indicated in unstable distal ulna fractures with comminution at the neck. Fixation of the ulna with this technique can be performed, independent of the technique used for the distal radius. The latter fracture can be stabilized by internal fixation with volar or dorsal plate or external fixation, as determined by the treating physician. Contraindications to fixation with the intrafocal pin plate include open fractures with gross contamination, active infections, segmental fractures, or fractures that split or comminute the ulnar head.
SURGICAL ANATOMY The distal ulna is approached through the interval between the extensor carpi ulnaris and the flexor carpi ulnaris tendons. The incision for placement of the intrafocal pin plate is relatively small (1–2 cm); however, the dorsal cutaneous sensory branch of the ulnar nerve must be protected. The nerve arises from the ulnar aspect of the ulnar nerve at an average of 6.4 cm proximal to the distal aspect of the ulnar head.6 The nerve passes dorsal to the flexor carpi ulnaris and then becomes subcutaneous on the ulnar side of the forearm, 5 cm proximal to the pisiform.6 SURGICAL TECHNIQUE The associated distal radius fractures are first stabilized, by either internal or external fixation. Stability of the distal ulnar fracture is determined clinically and radiographically. Fixation of the ulna is performed if the ulnar fracture is felt to be unstable. The distal ulna fracture is then exposed through a dorsal approach. A 2-cm longitudinal skin incision is made over the subcutaneous border of the ulna, centered over the fracture site. The dorsal cutaneous sensory branch of the ulnar nerve is identified and protected. Soft tissue dissection is carried down to the level of the fascia overlying the flexor carpi ulnaris and the extensor carpi ulnaris. The ulnar fracture is exposed in the plane between flexor carpi ulnaris and extensor carpi ulnaris. A 1-hole or 2-hole pin plate device is selected, based on the length of the distal fragment. The pin plate is held in the
JHS 䉬 Vol A, February
Surgical Technique
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
358
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
Surgical Technique FIGURE 3: A Posteroanterior and B lateral left wrist radiographs of a 75-year-old woman who fell and sustained a displaced distal radius fracture and a comminuted displaced distal ulna fracture. The distal radius fracture was an open injury. The distal radius fracture was fixed with external fixation, and the distal ulna fracture was fixed with the intrafocal pin plate.
inserter and introduced into the fracture site (Fig. 2). The pin is then gently maneuvered into the medullary cavity of the ulna to its maximum depth. Reduction is achieved by manipulating the distal fragment to align with the proximal fragment, and the plate at the end of the device is aligned along the ulnar border of the distal fragment. As soon as the insertion device is detached, the plate is tensioned against the distal fragment due to the curvature of the pin. After the reduction is determined to be satisfactory with intraoperative fluoroscopy, the metaphyseal fragment is fixed to the plate with locking screws placed into the ulnar head from ulnar to radial. Final radiographs are then obtained. The surgical wounds are closed in typical fashion, and the patient is placed in a sugar tong splint. POSTOPERATIVE CARE AND REHABILITATION The patient is seen in clinic within 10 to 14 days after surgery, and the surgical dressings and splint are removed. Further splinting and therapy are determined by fixation of the associated distal radius fracture. Although the patient is allowed to rotate the forearm for daily activities, formal forearm rotation exercises are initiated no sooner than 6 weeks after surgery, when
there is clinical and radiographic evidence of healing of the distal ulnar fracture. CLINICAL CASE A 75-year-old right-handed woman fell onto her outstretched left hand from atop a stool and sustained an open distal radius fracture (Gustilo grade 1) and a distal ulna fracture of the left wrist. Radiographs demonstrated a comminuted distal radius fracture with dorsal translation and a comminuted displaced subcapital distal ulnar fracture with extension into the ulnar styloid (Fig. 3). She had irrigation and debridement, closed reduction, and external fixation of her left distal radius with a supplementary K-wire. The distal ulna fracture was stabilized with an intrafocal pin plate. Her K-wires and external fixator were removed 5 weeks after surgery, and she was casted for 1 additional week. Immobilization was discontinued 6 weeks after surgery, and range of motion with physical therapy was begun. Radiographs showed acceptable fracture alignment and healing at this time, and she was progressed to activity as tolerated (Fig. 4). At 6-month follow-up, she achieved range of motion equal to the uninjured extremity and returned to her preoperative activity levels.
JHS 䉬 Vol A, February
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
359
FIGURE 4: Left wrist A posteroanterior and B lateral radiographs of the patient presented in Figure 3 after removal of distal radius external fixation. The distal radius and ulna fractures have healed in acceptable alignment. The patient returned to preoperative activity levels.
PEARLS AND PITFALLS Pearls
COMPLICATIONS We have used this technique in 5 consecutive patients who are more than 55 years old over a period of 2 years. The clinical case presented in this article developed a pin track infection at the site of distal radius K-wire. This was treated successfully with oral antibiotics and early pin removal. One patient developed abundant callus formation around the distal ulna. She developed no symptoms and achieved full forearm range of motion. At a minimum of 1 year after surgery, all fractures united, and no patient developed any symptoms related to the implant or required additional surgery. REFERENCES
1. Indicated for unstable subcapital ulnar fractures
associated with distal radius fractures in elderly patients. 2. First perform reduction and fixation of the distal radius, then evaluate the ulna fracture intraoperatively and determine the need for ulnar fixation. 3. Ensure that the extensor carpi ulnaris tendon does not get entrapped beneath the plate, as visibility is limited due to the percutaneous technique. Pitfalls 1. The device can fail to stabilize the fracture if there
is excessive comminution of the ulna shaft. 2. These injuries are prone to developing cross-union
between the forearm bones. If abundant callus is
1. Biyani A, Simison AJM, Klenerman L. Fractures of the distal radius and ulna. J Hand Surg 1995;20B:357–364. 2. McKee MD, Waddell JP, Yoo D, Richards RR. Nonunion of distal radius fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma 1997;11:49 –53. 3. Ring D, McCarty LP, Campbell D, Jupiter JB. Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. J Hand Surg 2004;29A:103–109. 4. Dennison DG. Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg 2007;32A:801– 805. 5. Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clinic Orthop Relat Res 1996;327:135–146. 6. Botte MJ, Cohen MS, Lavernia CJ, von Schroeder HP, Gellman H, Zinberg EM. The dorsal branch of the ulnar nerve: an anatomic study. J Hand Surg 1990;15A:603– 607.
JHS 䉬 Vol A, February
Surgical Technique
noted in the interosseous space, consider immobilization of the forearm and temporary cessation of any passive exercises or therapy. 3. Avoid bicortical placement of the distal locking screw to prevent penetration into the distal radioulnar joint. 4. Evaluate the stability of the distal ulna fracture intraoperatively, as not all distal ulna fractures will require fixation.
Intrafocal Pin Plate Fixation of Distal Ulna Fractures Associated With Distal Radius Fractures Brian J. Foster, MD, Randy R. Bindra, MD
Surgical Technique
Subcapital ulnar fractures in association with distal radius fractures in elderly patients increase instability and pose a treatment challenge. Fixation of the ulnar fracture with traditional implants is difficult due to the subcutaneous location, comminution, and osteoporosis. We describe an intrafocal pin plate that provides fixation by a locking plate on the distal ulna and intramedullary fixation within the shaft. The low profile and percutaneous technique make this device a useful alternative for treatment of subcapital ulna fractures in the elderly. (J Hand Surg 2012;37A:356–359. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius fracture, distal ulna fracture, intrafocal pin plate.
ISTAL ULNA FRACTURES OFTEN occur in association with fractures of the distal radius.1 The ulna fractures range from minimally displaced ulnar styloid fractures to the less-common ulnar head and neck fractures. The association of Colles’ fractures with an unstable ulnar head and neck fracture can lead to decreased forearm rotation, bridging callus between the ulna and radius, distal radioulnar joint instability, difficulty in distal radius fracture reduction, and distal radius nonunion.1,2 Several fixation options have been described including condylar blade plate, locked 2.0-mm plates, and percutaneous pinning.3,4 Difficulties with these techniques include prominence of hardware requiring removal, difficulty achieving fixation in osteoporotic bone, and morbidity associated with percutaneous pins.3–5 Intrafocal pin plates are commercially available for minimally invasive fixation of distal radius fractures. These devices combine a locking plate for fixation of the metaphysis distally with an intramedullary pin for proximal fixation within the shaft (Fig.
D
From the Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL. Received for publication December 3, 2010; accepted in revised form November 12, 2011. R.R.B. is a consultant for Tornier and receives royalties from the company. Corresponding author: Brian J. Foster, MD, Loyola University Medical Center, Department of OrthopaedicSurgery,MaguireCenterSuite1700,2160South1stAve,Maywood,IL60153;e-mail: [email protected]. 0363-5023/12/37A02-0028$36.00/0 doi:10.1016/j.jhsa.2011.11.013
356 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
1). This provides stable fixation in osteoporotic bone with a small incision and minimal implant prominence. The aim of this article is to describe a new method using an intrafocal pin plate device (Tornier Inc, Medina, MN) for fixation of subcapital distal ulna fractures in conjunction with traditional fixation of the associated distal radius fractures. This method offers a simpler alternative to open plating of the distal ulna by minimizing soft tissue dissection and total operative time. INDICATIONS AND CONTRAINDICATIONS The intrafocal pin plate is designed for fixation of distal radius fractures and is based on the principles of intrafocal pinning. The device consists of a long, S-shaped stem with a locking 1-hole or 2-hole plate at one end. The pin is introduced into the fracture site and inserted into the medullary cavity, bringing the plate to rest alongside the metaphysis to provide a buttress (Fig. 2). The curved stem creates 3-point fixation within the shaft. Additional fixation to prevent subsidence of the distal fragment is achieved by stabilizing the locking plate to the metaphysis with locking screws. We used this device for fixation of unstable subcapital ulnar fractures in elderly patients with associated distal radius fractures. These patients often have osteoporosis and thin soft tissue, a setting in which the intrafocal pin plate is indicated due to its low profile, minimal dissection, and fixed angle mechanism. Not all distal ulnar fractures need surgical fixation, as many will reduce
357
FIGURE 2: Schematic drawing of fixation of a distal ulna fracture with the intrafocal pin plate. The intramedullary portion is inserted through the fracture site into the proximal fracture fragment, the plate is turned 180° to afford reduction, and the distal plate is positioned on the ulnar border of the distal ulna. The metaphyseal fragment is fixed to the plate with locking screws placed into the ulnar head.
FIGURE 1: Intrafocal pin plate. The distal plate acts as a buttress and provides locked angle stability with a locking screw. The proximal intramedullary portion allows for a lowprofile design.
after the distal radius fracture is reduced and stabilized; however, this method is indicated in displaced distal ulna fractures that are unstable after fixation of the distal radius. Ulnar fractures that were felt to be unstable intraoperatively after stabilization of the distal radius were managed with this technique. This technique can also be used in the setting of unstable distal radius fractures that do not initially reduce; stabilization of the distal ulna fracture can improve the surgeon’s ability to reduce the distal radius fracture. Intrafocal pin plate fixation is also indicated in unstable distal ulna fractures with comminution at the neck. Fixation of the ulna with this technique can be performed, independent of the technique used for the distal radius. The latter fracture can be stabilized by internal fixation with volar or dorsal plate or external fixation, as determined by the treating physician. Contraindications to fixation with the intrafocal pin plate include open fractures with gross contamination, active infections, segmental fractures, or fractures that split or comminute the ulnar head.
SURGICAL ANATOMY The distal ulna is approached through the interval between the extensor carpi ulnaris and the flexor carpi ulnaris tendons. The incision for placement of the intrafocal pin plate is relatively small (1–2 cm); however, the dorsal cutaneous sensory branch of the ulnar nerve must be protected. The nerve arises from the ulnar aspect of the ulnar nerve at an average of 6.4 cm proximal to the distal aspect of the ulnar head.6 The nerve passes dorsal to the flexor carpi ulnaris and then becomes subcutaneous on the ulnar side of the forearm, 5 cm proximal to the pisiform.6 SURGICAL TECHNIQUE The associated distal radius fractures are first stabilized, by either internal or external fixation. Stability of the distal ulnar fracture is determined clinically and radiographically. Fixation of the ulna is performed if the ulnar fracture is felt to be unstable. The distal ulna fracture is then exposed through a dorsal approach. A 2-cm longitudinal skin incision is made over the subcutaneous border of the ulna, centered over the fracture site. The dorsal cutaneous sensory branch of the ulnar nerve is identified and protected. Soft tissue dissection is carried down to the level of the fascia overlying the flexor carpi ulnaris and the extensor carpi ulnaris. The ulnar fracture is exposed in the plane between flexor carpi ulnaris and extensor carpi ulnaris. A 1-hole or 2-hole pin plate device is selected, based on the length of the distal fragment. The pin plate is held in the
JHS 䉬 Vol A, February
Surgical Technique
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
358
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
Surgical Technique FIGURE 3: A Posteroanterior and B lateral left wrist radiographs of a 75-year-old woman who fell and sustained a displaced distal radius fracture and a comminuted displaced distal ulna fracture. The distal radius fracture was an open injury. The distal radius fracture was fixed with external fixation, and the distal ulna fracture was fixed with the intrafocal pin plate.
inserter and introduced into the fracture site (Fig. 2). The pin is then gently maneuvered into the medullary cavity of the ulna to its maximum depth. Reduction is achieved by manipulating the distal fragment to align with the proximal fragment, and the plate at the end of the device is aligned along the ulnar border of the distal fragment. As soon as the insertion device is detached, the plate is tensioned against the distal fragment due to the curvature of the pin. After the reduction is determined to be satisfactory with intraoperative fluoroscopy, the metaphyseal fragment is fixed to the plate with locking screws placed into the ulnar head from ulnar to radial. Final radiographs are then obtained. The surgical wounds are closed in typical fashion, and the patient is placed in a sugar tong splint. POSTOPERATIVE CARE AND REHABILITATION The patient is seen in clinic within 10 to 14 days after surgery, and the surgical dressings and splint are removed. Further splinting and therapy are determined by fixation of the associated distal radius fracture. Although the patient is allowed to rotate the forearm for daily activities, formal forearm rotation exercises are initiated no sooner than 6 weeks after surgery, when
there is clinical and radiographic evidence of healing of the distal ulnar fracture. CLINICAL CASE A 75-year-old right-handed woman fell onto her outstretched left hand from atop a stool and sustained an open distal radius fracture (Gustilo grade 1) and a distal ulna fracture of the left wrist. Radiographs demonstrated a comminuted distal radius fracture with dorsal translation and a comminuted displaced subcapital distal ulnar fracture with extension into the ulnar styloid (Fig. 3). She had irrigation and debridement, closed reduction, and external fixation of her left distal radius with a supplementary K-wire. The distal ulna fracture was stabilized with an intrafocal pin plate. Her K-wires and external fixator were removed 5 weeks after surgery, and she was casted for 1 additional week. Immobilization was discontinued 6 weeks after surgery, and range of motion with physical therapy was begun. Radiographs showed acceptable fracture alignment and healing at this time, and she was progressed to activity as tolerated (Fig. 4). At 6-month follow-up, she achieved range of motion equal to the uninjured extremity and returned to her preoperative activity levels.
JHS 䉬 Vol A, February
INTRAFOCAL PIN PLATE FIXATION OF DISTAL ULNA FRACTURES
359
FIGURE 4: Left wrist A posteroanterior and B lateral radiographs of the patient presented in Figure 3 after removal of distal radius external fixation. The distal radius and ulna fractures have healed in acceptable alignment. The patient returned to preoperative activity levels.
PEARLS AND PITFALLS Pearls
COMPLICATIONS We have used this technique in 5 consecutive patients who are more than 55 years old over a period of 2 years. The clinical case presented in this article developed a pin track infection at the site of distal radius K-wire. This was treated successfully with oral antibiotics and early pin removal. One patient developed abundant callus formation around the distal ulna. She developed no symptoms and achieved full forearm range of motion. At a minimum of 1 year after surgery, all fractures united, and no patient developed any symptoms related to the implant or required additional surgery. REFERENCES
1. Indicated for unstable subcapital ulnar fractures
associated with distal radius fractures in elderly patients. 2. First perform reduction and fixation of the distal radius, then evaluate the ulna fracture intraoperatively and determine the need for ulnar fixation. 3. Ensure that the extensor carpi ulnaris tendon does not get entrapped beneath the plate, as visibility is limited due to the percutaneous technique. Pitfalls 1. The device can fail to stabilize the fracture if there
is excessive comminution of the ulna shaft. 2. These injuries are prone to developing cross-union
between the forearm bones. If abundant callus is
1. Biyani A, Simison AJM, Klenerman L. Fractures of the distal radius and ulna. J Hand Surg 1995;20B:357–364. 2. McKee MD, Waddell JP, Yoo D, Richards RR. Nonunion of distal radius fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma 1997;11:49 –53. 3. Ring D, McCarty LP, Campbell D, Jupiter JB. Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. J Hand Surg 2004;29A:103–109. 4. Dennison DG. Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg 2007;32A:801– 805. 5. Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clinic Orthop Relat Res 1996;327:135–146. 6. Botte MJ, Cohen MS, Lavernia CJ, von Schroeder HP, Gellman H, Zinberg EM. The dorsal branch of the ulnar nerve: an anatomic study. J Hand Surg 1990;15A:603– 607.
JHS 䉬 Vol A, February
Surgical Technique
noted in the interosseous space, consider immobilization of the forearm and temporary cessation of any passive exercises or therapy. 3. Avoid bicortical placement of the distal locking screw to prevent penetration into the distal radioulnar joint. 4. Evaluate the stability of the distal ulna fracture intraoperatively, as not all distal ulna fractures will require fixation.