Classic methods and techniques of closed needle insertion for distal radius fractures

Distal radius fracture is a common fracture after slipping on snow in winter, and closed reduction and Kirschner wire fixation are the most common treatment methods.

This article refers to K-Wiring Principles and Techniques to introduce the surgical techniques of closed pinning.

The three-wire fixation technique is the classic three-wire fixation technique

One through the lister tubercle.

One through the radial styloid process.

One through the lunate fossa bone block.

If: severe comminuted fractures and osteoporosis occur, additional Kirschner wires can be used.

1. Surgical method

First, closed reduction of the fracture is performed, with slow and continuous traction, and dorsal and radial displacement is corrected by palmar flexion and ulnar deviation. After reduction, the hand is placed on a rolled sheet, maintaining palmar flexion and ulnar deviation (Figure 2a, b), and fixed with at least three percutaneous Kirschner wires.

The first K-wire is inserted at Lister's tubercle, angled at 45°, and aimed at the palmar cortex of the proximal bone fragment on the long axis of the radius. If the insertion point is on the ulnar side of Lister's tubercle, the extensor pollicis tendon may be injured.

The second K-wire is inserted 0.5 cm distal to the radial styloid process, the K-wire is at a 60° angle to the radial axis, and penetrates the ulnar cortex proximal to the fracture.

The third K-wire is fixed to the lunate fossa bone fragment 0.5 cm distal to the wrist joint line, located between the fourth and fifth extensor compartments. The K-wire is fixed to the palmar side of the radius at a 45° angle, as shown in Figures a and b below.

Classic percutaneous Kirschner wire fixation of distal radius fractures is shown in Figures a-e below.

Finger movement after percutaneous Kirschner wire fixation is shown in Figures a-d below.

2. Precautions and techniques for surgery

1.If the K-wire slips into the medullary cavity without penetrating the contralateral cortex, it may be caused by too much tilt when the K-wire enters. In this case, people tend to raise their hands to reduce the tilt. But in fact, the opposite is true. The K-wire will be angled and bent in a concave manner, resulting in a failure of the K-wire puncture. Instead, it should be gently convex upward according to the contour of the K-wire, as shown in the figure below.

With the K-wire pointed convexly upward, an entry point is made in the distal cortex without axial pressure, and it can penetrate the distal cortex. Alternatively, the insertion point should be changed and started from the beginning (Figures a-e below).

2.In the Kapandji technique, two to three K-wires are inserted into the fracture site to reduce and correct the distal fracture fragments into the desired position. Once reduced, the K-wires are advanced into the proximal fragments (Figures a-f below).

3.If the Kirschner wire entry and exit points are very close to the fracture, fixation failure may occur. The two dorsal Kirschner wires should not pass through the palmar cortex at the same level, and the palmar exit point must be 2 cm away from the fracture site. See Figures a-c below.

4. When the dorsal cortex is extremely comminuted, try not to enter the fracture site of the distal bone fragment, as this may lead to fixation failure. Figures a-e below.

5. For severe osteoporosis, it is best to use four to five Kirschner wires to fix the fracture. Sometimes, in order to maintain the length of the radius, a transverse Kirschner wire is used to fix the distal radius bone block to the distal ulna.

6. In long segment fractures of the epiphyseal end, a large inclined Kirschner wire can be used for fixation. However, the Kirschner wire may slip into the medullary cavity and is difficult to fix (Figures a-d below).

7. The intra-articular bone fragment is opened and fixed with a transverse Kirschner wire under the cartilage first, and then fixed with three percutaneous Kirschner wires in the conventional way (Figures a-d below).

8. Severe comminuted fracture of the distal radius accompanied by shortening and collapse requires an additional transverse Kirschner wire to pass through the ulna to maintain the height of the radius. The Kirschner wire is best pointed from the palm side of the styloid process to the dorsal side of the ulna, as shown in Figures a and b below.

9. Radial styloid fracture with dorsal displacement. After reduction, fix with two radial styloid Kirschner wires: one on the dorsal side and the other on the palmar side to the tip of the styloid. (Figures a and b below)

10. A four-part fracture of the distal radius, with dorsal displacement and separation of the lunate fossa from the palmar side. The Kirschner wire can be fixed from the dorsal cortex in an oblique manner from the proximal to the distal metacarpal bone fragment. (Figures a and b below).

11. When using dorsal and palmar Kirschner wires to treat comminuted fractures of the distal radius, if the palmar fragment of the lunate fossa is not reduced during surgery, you can use a palmar approach, use a vascular clamp to separate the bone, and then insert the Kirschner wire from the palmar edge fragment into the dorsal cortex. (Figures a-h below)

12. For obviously displaced distal radius fractures that cannot be reduced by closed reduction, a 3 mm Kirschner wire can be used to lift the distal fracture fragment from the back to achieve reduction (Figures a-h below).

13. Use external fixators to treat comminuted fractures of the distal radius. External fixators are suitable for severe comminuted fractures of the distal radius accompanied by huge swelling, open fractures, or local skin conditions that do not allow internal fixation (such as plate fixation) (Figures a-d below).

3. Prevent complications

1.To prevent unstable fixation, pay attention to the following operations

Pay attention to bicortical fixation.

Avoid placing the distal needle exit point close to the fracture.

Avoid all Kirschner wires converging at the distal end to concentrate the force.

Be careful to avoid loose rotation when bending the Kirschner wire.

In case of osteoporosis, additional Kirschner wire fixation is required.

2. Measures to prevent needle tract infection

First cut the skin, separate the soft tissue to the bone with a vascular clamp, and then use a Kirschner wire.

Drill slowly to prevent thermal necrosis.

Avoid repeated operations too many times.

Reduce the pressure of the Kirschner wire on the skin.