Gambar 1a. Sudut normal sendi radiokarpal di bagian ventral (tampak lateral)

Gambar 1b. Sudut normal yang dibentuk oleh ulna terhadap sendi radiokarpal

Terapi fraktur diperlukan konsep ”empat R” yaitu : rekognisi, reduksi/reposisi, terensi/fiksasi, dan rehabilitasi.

• Recognized : look, feel, move, X- ray

• Reposition : Menyesuaikan fragment distal terhadap fragment proximal sehingga mencapai posisi acceptable

• Retain : Imobilisasi atau fiksasi luar,fiksasi dalam

• Rehabilitation : mengembalikan fungsi secepat mungkin dan menghindari kecacatan

The 3-column concept.

• Fraktur tak bergeser (atau hanya sedikit sekali bergeser), fraktur dibebat dalam slab gips yang dibalutkan sekitar dorsum lengan bawah dan pergelangan tangan dan dibalut kuat dalam posisinya.

• Fraktur yang bergeser harus direduksi di bawah anestesi. Tangan dipegang dengan erat dan traksi diterapkan di sepanjang tulang itu (kadang-kadang dengan ekstensi pergelangan tangan untuk melepaskan fragmen; fragmen distal kemudian didorong ke tempatnya dengan menekan kuat-kuat pada dorsum sambil memanipulasi pergelangan tangan ke dalam fleksi, deviasi ulnar dan pronasi.

• Posisi kemudian diperiksa dengan sinar X. Kalau posisi memuaskan, dipasang slab gips dorsal, membentang dari tepat di bawah siku sampai leher metakarpal dan 2/3 keliling dari pergelangan tangan itu.

• Slab ini dipertahankan pada posisinya dengan pembalut kain krep. Posisi deviasi ulnar yang ekstrim harus dihindari; cukup 20 derajat saja pada tiap arah.

• Lengan tetap ditinggikan selama satu atau dua hari lagi; latihan bahu dan jari segera dimulai setelah pasien sadar.

• Kalau jari-jari membengkak, mengalami sianosis atau nyeri, harus tidak ada keragu-raguan untuk membuka pembalut.

Reduksi : (a) pelepasan impaksi, (b) pronasi dan pergeseran ke depan, (c) deviasi ulnar.

Pembebatan : (d) penggunaan sarung tangan, (e) slab gips yang basah, (f) slab yang dibalutkan dan reduksi dipertahankan hingga gips mengeras

Metode Plaster/brace

Kelebihan Easy to apply

Tidak perlu operasi

KerugianGerak pada tangan mengakibatkan dislokasi fraktur

Digunakan selama 6 minggu sehingga tangan kaku

Metode "K" wires

Kelebihan Operasi simple

Kerugian Dapat terjadi infeksi

Masih membutuhkan plester

Dapat merusak tendo di sekitar pergelangan

Metode Fiksasi External

Kelebihan Reduksi tidak membuka fraktur (ligamentotaxis). Fiksator

mengijinkan pergerakan

kerugian Fiksator kaku , jika terlalu kencang dapat mengakibatkan tangan

kaku.Pin yang menempelkan tulang dan fiksator dapat mengalami

infeksi

Metode Bone Grafting

Kelebihan Dapat menyangga fraktur dan mencegah kominutif

dorsal.Kombinasi dengan tulang spons mempercepat

penyembuhan

Kerugian Butuh K wires untuk menahan transplant di tempat.Pengambilan

transplant dari pelvis sangat sakitdan mengakibatkan kesulitan

berjalan untuk beberapa minggu

MetodeInternal fixation (use of plates and screws)

Kelebihan

Sangat kuat dan mengijinkan untuk mobilisasi lebih cepat dan

tidak butuh plester

Kemungkinan terjadi dislokasi sangat kecil

Kerugian

Operasi sulit bila terdapat scar.

Dapat mengiritasi tendo di sekitarnya, tidak nyaman

Surgical Therapy

Dorsal plating• Dorsal plating had its greatest popularity in the 1990s, with the

development of plates specifically for the distal radius. The technique has lost most of its appeal for most fractures because of tendon irritation problems.

Fragment-specific fixation• Fragment-specific fixation uses very small, low-profile plates that are

specifically designed for the radial column, the central column, or the ulnar column of the radius. They lend themselves to many types of fractures, but the technique is difficult to learn and, many times, the plates must be removed.

Nonspanning external fixation• Nonspanning external fixation was popularized by McQueen and

capitalized on the strength of the subchondral bone and the volar cortex. While the proponents touted the possibility of early motion, others found that the range of motion was poor.

• External fixation• The key to external fixation is placing the pins

through small, open incisions.• Proximally, the plane of dissection should be

dorsolateral, not straight lateral, through the extensor carpi radialis longus and brevis or through the extensor carpi radialis brevis and the extensor digitorum communis.

• This avoids placing the pins near the radial sensory nerve and injuring it upon pin insertion or removal or subjecting it to the minor cellulitis of the pin tract.

Nonbridging external fixation using the Howmedica Mini-Hoffman external fixator.

Standard (bridging) external fixation using an Orthofix RadioLucent external fixator.

Volar plating• Volar plating, especially for dorsally unstable

fractures, was independently developed by Orbay, Jennings, and Drobetz, but its complications, particularly the incidence of tendon rupture, are now becoming recognized.

Volar anatomic landmarks important for the volar approach. The region marked pronator fossa is covered by the pronator quadratus (PQ) muscle. It extends distally to the PQ line, marked in blue. The watershed line marks the highest crest (most volarly projecting) surface of the radius. The red X marks the volar radial tuberosity, which lies just off the pronator quadratus. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR marks the volar radial ridge.

Volar fixed-angle plate using the Orthofix Contours VPS plate, posteroanterior view. This is a facet posteroanterior view, which is tilted at the same angle as the tilt of the distal articular surface, which allows assessment of the intra-articular versus extra-articular placement of the screws. Note that the distal screws engage both the radial styloid fragment and the dorsal ulnar fragment.

Volar fixed-angle plate using the Orthofix Contours VPS, lateral view. This is not a facet lateral view, and the distal articular surface is not seen tangentially, which makes some of the screws appear to be intra-articular. However, the posteroanterior view demonstrates that they are not. Note also that the distal screws do not past-point the dorsal cortex, but instead, they stop a few millimeters short of the dorsal cortex. Due to the difficulty of evaluating screw length, even with fluoroscopy, the screws should stop 2-4 mm short of the dorsal cortex.

Percutaneous pinning (Clancey technique)• After adequate anesthesia is established, prepare the skin.

Many surgeons find that placing the fingers in finger-trap traction assists with reduction. Reduce the fracture, and place a 0.062-inch Kirschner wire into the radial styloid.

• Using image intensification, drive the Kirschner wire across the fracture site and into (but not through) the opposite cortex. Pin migration can be limited by not going through the opposite cortex, but the pin must be securely in the cortex to maintain the reduction.

• The second pin is placed into the dorsal ulnar corner of the radius. Under image intensification, drive the pin across the fracture site and into the opposite cortex. Additional pins can be placed if needed for stability.

Percutaneous pinning with the Clancey technique, lateral view.

Percutaneous pinning with the Clancey technique, posteroanterior view.

• Percutaneous pinning (Kapandji technique)• Prepare as above, but place the pins into the

fracture site dorsally. Lever the distal fragment into place with the pin, observing the reduction with image intensification, and then drive it into the volar cortex.

• Usually, more than one pin is used. Kapandji has developed special pins called arum pins for this purpose.

PA view of fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware to the radial side is a radial pin plate. The pins hold the fragment in place, and the pin plate gives greater stabilization to the pins. The hardware to the ulnar side is a dorsal pin plate (also see image below), which holds the dorsal ulnar corner in place.

Lateral view of a fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware on the volar side is called a wireform and is supporting the subchondral bone. The hardware in the center of the image is a pin plate along the radial border of the radial styloid and serves to hold the large radial styloid fragment in place. There is a small pin plate along the dorsal surface.

Dorsal plate fixation using the Synthes Pi plate, lateral view.

Dorsal plate fixation using the Synthes Pi plate, posteroanterior view.

Postoperative management• Most casts are kept on for 6 weeks, but some

compressed fractures require only a splint.• Most external fixators are kept in place for 6

weeks, but 8 weeks is also common; and some fractures that are not bone grafted still collapse at 3 months.

• Volar fixed-angle plates are moved anywhere from 3 days to 3 weeks. Spanning internal fixation plates are usually removed at 3 months.

Program Rehabilitasi terapi fisik pergelangan tangan

Program ini dilakukan tergantung dari kebutuhanpasien• Fase 1 : mengontrol inflamasi dan edema dengan

Rest, Ice, Compression, dan Elevation.(RICE)• Fase 2 : pemulihan jaringan dengan scar massage,

whirlpool therapy, dan elastomer.• Fase 3 : meningkatkan range of motion (ROM)• Fase 4 : meningkatkan kekuatan.• Fase 5 : work-hardening untuk menyempurnakan

terapi sebelumnya, pengembalian kondisi normal.

Gambar 6. (a) Film pasca reduksi, (b) gerakan-gerakan yang perlu dipraktekkan oleh pasien secara teratur

Follow-up• The general rule for fractures that were

reduced is to obtain a radiograph at weekly intervals for the first 3 weeks

• Fractures stabilized operatively should be followed at 7-10 days, as the surgeon prefers. Subsidence should not be an issue.