Management of distal radial fractures

Comparison between cast immobilization versus volar locking plate fixation of distal radius fractures in active elderly patients, the Asian perspective

Displaced distal radius fractures in active elderly patients with high functional demand present a clinical dilemma because current evidence is equivocal in the recommendation of treatment. Internal fixation is an increasingly popular option with proposed superior results. Our study aims to evaluate the results among a population of active elderly patients with displaced fractures managed with either cast immobilization or internal fixation with volar locking plate. Seventy-five patients (35 cast immobilization and 40 internal fixation) with mean age of 74 ± 7.5 years with minimum of 12 months follow-up were studied. The radiological and clinical parameters were assessed at three, six, and 12 months. Functional outcomes (DASH, Green-O'Brien) were assessed at 12 months. Patients who underwent surgery regain wrist motion and grip strength earlier, but this was not statistically significant after six months.

Manipulation of displaced distal radial fractures in the superelderly: prediction of malunion and the degree of radiographic improvement

Superelderly patients (≥80 years old) account for 20% of all distal radial fractures and are at an increased risk of malunion. The primary aim of this study was to identify predictors of malunion and the degree of improvement in the fracture position offered by closed manipulation of displaced distal radial fractures in the superelderly. We retrospectively identified 228 displaced distal radial fractures in superelderly patients from a prospective database of 4024 distal radial fractures. The inclusion criterion was a patient that underwent closed manipulation as their primary intervention. The majority of patients (n = 196, 86%) were defined as having a malunion. A premanipulation dorsal angulation of greater than 25 degrees (P = 0.047) and an ulnar variance of 6 mm or more (P = 0.02) significantly increased the risk of malunion. The premanipulation dorsal angulation was a significant independent predictor of the degree of improvement in the final dorsal angulation (P < 0.001) and ulnar variance (P = 0.01). Patients with a high risk of malunion or poor improvement in the fracture position can be identified before manipulation and these patients may benefit from primary surgical intervention.

Outcomes and cost of care for patients with distal radius fractures

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997-2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial

OBJECTIVES

To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.

DESIGN

A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.

SETTING

18 trauma centres in the United Kingdom.

PARTICIPANTS

461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.

INTERVENTIONS

Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.

PRIMARY OUTCOME MEASURE

validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient's experience of pain and disability to give a score out of 100.

SECONDARY OUTCOMES

disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.

RESULTS

The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was -1.3, 95% confidence interval -4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.

CONCLUSIONS

Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN 31379280. UKCRN 8956.

Treatment of comminuted distal radius fractures by resurfacing prosthesis in elderly patients

In elderly patients, distal radius fractures are often associated with osteoporotic bone. Under these conditions, anatomic resurfacing implants may provide satisfactory results in terms of range of motion, pain and function. Between July 2009 and January 2012, eight elderly patients were treated with the SOPHIA™ implant at our hand surgery department. Inclusion criteria were isolated comminuted distal radius AO type C2 fractures in patients greater than 70 years of age. All patients were reviewed in February 2013 by an independent surgeon. Clinical, functional and radiographic assessments were performed. Mean follow-up was 25 months (range 17-36 months). Mean ROM was 45° (range 40-50°) in flexion and 44° (range 40-50°) in extension. Mean pronation-supination range was 160°. Mean grip strength was 18 kgf. Mean Quick DASH was 18.2/100 (range 6.82-29.55) and mean pain on VAS was 2.33 (range 0-4). X-rays did not reveal any implant loosening or ulnar translation of the carpus. Use of a wrist resurfacing implant led to rapid recovery of autonomy in elderly patients with comminuted distal radius fractures. It parallels the use of shoulder or elbow prostheses for complex joint fractures in the elderly.

The association of education level on outcome after distal radius fracture

BACKGROUND

Socioeconomic factors have been found to be predictors of outcome for other ailments. The purpose of this study was to evaluate the association of patient education level on pain and disability after distal radius fracture.

METHODS

A series of patients with distal radius fractures (n = 335) were enrolled into a prospective research registry. Standard demographic information was obtained from patients, including a five-value categorical education variable. After treatment with closed reduction, external fixation, or internal fixation patients were evaluated for pain, function (Disability of the Arm, Shoulder, and Hand score [DASH]), range of motion (ROM), and grip strength at standard intervals until 12 months post-injury. A series of linear mixed effects models were developed to evaluate the relationship between time from injury and education level with each of the outcomes measured.

RESULTS

Complete demographic and 12-month follow-up data were available on 227 patients (75 %). There were neither group differences in mode of injury, severity, nor treatment modality after stratification by education level. Mixed effects model analyses revealed a significant linear association between level of education and measured outcomes at each follow-up point. Overall, each increase in education level demonstrated a doubling of improvement in pain, ROM, grip strength, and DASH score.

CONCLUSIONS

Outcome of distal radius fracture depends on acute care and follow-up rehabilitation; however, patient-related factors indicative of socioeconomic status are becoming increasingly relevant as predictors of outcome and should be considered by the orthopaedist.

Traumatic disorders of forearm rotation: anatomy, biomechanics and treatment

The forearm is a complex structure which produces a wide range of movement. Forearm injuries are very common, but many injuries are missed or poorly treated. This article examines the anatomy and biomechanics of the forearm, and describes the important injuries to be recognized.

Comparative study of the closed reduction percutaneous cannulated screw fixation and open reduction palmar locking plate fixation in the treatment of AO type A2 distal radius fractures

INTRODUCTION

The present study was designed to demonstrate the efficacy of standard 4.0 mm cannulated screw fixation by comparing it with palmar locking plate fixation in the treatment of acute, unstable, simple extra-articular distal radius fractures.

MATERIALS AND METHODS

We prospectively collected and retrospectively analyzed outcomes data for 65 patients aged between 18 and 60 with AO type A2 fractures treated with closed reduction, percutaneous cannulated screw fixation (CRPCS n = 34) or open reduction palmar locking plate fixation (ORPLP n = 31). Range of motion, grip strength, Gartland-Werley and QuickDASH scores were compared at 2 months after surgery, and final follow-up (mean 32 months, range 12-90). Deterioration in radiographic parameters were measured and compared. Operative time and return to preinjury activity were evaluated.

RESULTS

Parameters did not differ significantly between the groups at either time point with respect to grip strength or range of motion, except pronation and supination; they were better in the CRPCS group (p = 0.005 and 0.025, respectively) at 2 month follow-up. The Gartland-Werley and QuickDASH scores obtained at final follow-up were similar for each group and lacked statistical significance. Group comparison for the deterioration of radiologic parameters showed no significant difference. CRPCS group had significantly shorter operative time (p = 0.001) and there was no significant differences between the groups regarding the return to preinjury activity (p = 0.129).

CONCLUSIONS

CRPCS group was found to be as successful as ORPLP group and it may be suitable in the case of young, active individuals with AO type A2 distal radius fractures.

Leveraging the plate: reliably restoring volar tilt of distal radius fractures

Restoration of volar tilt is critical when performing open reduction and internal fixation of distal radius fractures. A reproducible technique is required to consistently achieve this goal. A simple technique using the locking plate and an electrocautery scratch pad as reduction tools can reliably generate volar tilt. This technique can be performed with minimal aid from surgical assistants.

Clinical and biomechanical investigation of an increased articular cavity depth after distal radius fractures: effect on range of motion, osteoarthrosis and loading patterns

INTRODUCTION

After fracture, distal radius malunion with dissociation of the volar and dorsal ulnar fracture fragments can lead to an increased articular cavity.

PATIENTS AND METHODS

To investigate its clinical impact we retrospectively analyzed the outcome of 81 patients and simulated this form of malunion in a biomechanical experiment with six cadaver specimens in a dynamic loading set-up.

RESULTS

In clinics, a higher arthritis stage was significantly correlated with an increased articular cavity depth and an increased anterioposterior distance. In cadaver specimens, a significantly decreased range of motion and significantly altered intraarticular contact characteristics were recognized for an increased cavity.

CONCLUSION

Alterations in contact biomechanics could be one reason for the higher incidence of posttraumatic osteoarthritis when a deeper central impaction of the distal radius is present. From a clinical and experimental point of view, restoration of the normal shape of the distal radius is considered to minimize the risk for posttraumatic radiocarpal osteoarthritis.

Less invasive surgery with wrist arthroscopy for distal radius fracture

BACKGROUND

We developed a surgical procedure that can facilitate arthroscopic intervention for volar locking plate fixation for distal radius fracture (DRF) with a less invasive technique. This study is to investigate the effectiveness of our original procedure for the treatment of DRF.

METHODS

One hundred fifty-five wrists of 153 consecutive patients underwent our original procedure: the plate presetting arthroscopic reduction technique (PART) for DRF. The fractures consisted of 37 extra-articular and 118 intra-articular fractures. The fractures were reduced, anatomical alignment was regained with the aid of an image intensifier, and the volar locking plate was preset. Wrist arthroscopy was then performed and the intra-articular condition assessed. If there were any residual dislocations of the intra-articular fragments, these were reduced arthroscopically, and soft tissue injuries were subsequently treated. The traction was then removed, and the plate was securely fixed. One hundred forty-five patients were followed up from 12 to 48 months. The final outcome was evaluated with the Mayo modified wrist score and Disability of the Arm, Shoulder and Hand questionnaire (DASH). The effectiveness of arthroscopy was also investigated.

RESULT

On arthroscopic inspection, intra-articular dislocations were found to be residual in 35.2 %, even if reduction seemed to have been achieved when viewed with the image intensifier. Scapholunate interosseous ligament injury was recognized in 28.9 %, and triangular fibrocartilage complex injury was observed in 63.2 %. The final outcome was 112 excellent, 31 good, and 2 fair. The mean DASH score was 4.1.

CONCLUSION

We developed the PART to simplify the combination of volar locking plating and arthroscopy. This technique was less invasive and effective in the treatment of DRF.

[The significance of displacement in dorsally angled distal radial fractures]

BACKGROUND

Distal radial fractures occur very frequently. Most are dorsally displaced (Colles' fracture). In contrast to previously, approximately a quarter of these patients now undergo surgery. This is more than the number that is reduced and immobilised in a plaster cast. Volar plate osteosynthesis is now the most common type of surgery. There is great uncertainty regarding indications for surgery.

METHOD

The article is based on own research, a search in PubMed and a review of reference lists to identify articles that compare radiological and clinical outcomes after Colles' fractures.

RESULTS

A number of national orthopaedic associations have reviewed the literature in an attempt to draw up guidelines for indications for performing surgery on distal radial fractures, without being able to arrive at definite recommendations based on randomised studies. Our review of the literature indicates a very uncertain correlation between radiological displacement and the final clinical outcome. This applies particularly to elderly patients (over 55-65), where by far the majority of the studies do not find any such correlation. Complications and reoperation are common among patients who have undergone volar plate surgery.

INTERPRETATION

There is surprisingly little correlation between the radiological and clinical outcome after Colles' fractures. A practice where a large proportion of patients undergo surgery is probably not justified. Elderly patients will very seldom benefit from surgery in the longer term.

More is not necessarily better. A biomechanical study on distal screw numbers in volar locking distal radius plates

INTRODUCTION

Currently available volar locking plates for the treatment of distal radius fractures incorporate at least two distal screw rows for fixation of the metaphyseal fragment and have a variable-angle locking mechanism which allows placement of the screws in various directions There is, however no evidence that these plates translate into better outcomes or have superior biomechanical properties to first generation plates, which had a single distal screw row and fixed-angle locking. The aim of our biomechanical study was to compare fixed-angle single-row plates with variable-angle multi-row plates to clarify the optimal number of locking screws.

MATERIALS AND METHODS

Five different plate-screw combinations of three different manufacturers were tested, each group consisting of five synthetic fourth generation distal radius bones. An AO type C2 fracture was created and the fractures were plated according to each manufacturer's recommendations. The specimens then underwent cyclic and load-to-failure testing. An optical motion analysis system was used to detect displacement of fragments.

RESULTS

No significant differences were detected after cyclic loading as well as after load-to-failure testing, neither in regard to axial deformation, implant rigidity or maximum displacement. The fixed-angle single-row plate showed the highest pre-test rigidity, least increase in post-testing rigidity and highest load-to-failure rigidity and least radial shortening. The radial shortening of plates with two distal screw rows was 3.1 and 4.3 times higher, respectively, than that of the fixed-angle single-row plate.

CONCLUSION

The results of our study indicate that two distal screw rows do not add to construct rigidity and resistance against loss of reduction. Well conducted clinical studies based on the findings of biomechanical studies are necessary to determine the optimal number of screws necessary to achieve reproducibly good results in the treatment of distal radius fractures.

[Arthroscopy-assisted management of wrist fractures]

Distal radius fractures are the most common fractures in humans and early surgical intervention with modern plating systems is becoming increasingly more established to avoid secondary dislocation. Even fractures with slight dislocations are adequately stabilized and the affinity for surgical intervention and plating procedures is applied to secure these simple fractures. In this aspect the surgical indications are significantly dependent on X-ray examination results. Further diagnostics with respect to ligamentous and soft tissue injury are the exception although the impact energy which creates osseus fractures is sufficient by far to destroy functional soft tissue, cartilage and ligaments. The ongoing development of wrist arthroscopy enables new possibilities especially concerning concomitant articular involvement of distal radius fractures. Arthroscopy-assisted reduction and stabilization as well as minimally invasive soft tissue repair and loose body removal seem to be adequate methods to improve the surgical treatment of distal radius fractures.

Type C distal radial fractures treated with conventional AO plates: an easy and cost-saving solution in a locking plate era

PURPOSE

C-type distal radial fractures remain challenging fractures. Currently locking plates are very popular because of their length preserving, stability. A considerable drawback is the high cost. Since 2003 we have been using mini AO plates (2.7 mm) as an alternative. We analysed our results and performed a cost analysis.

METHODS

Retrospective analysis was performed of all patients operated upon between 2003 and 2008 for C type distal radius fractures. Reduction was achieved with mini AO plates, applied in a buttress fashion, with ligamentotaxis. Rehabilitation consisted of immediate mobilisation. Pre- and postoperative X-rays, operative results and patient charts were reviewed. Furthermore, we prospectively evaluated the functional results using VAS, DASH and Mayo wrist scores. Lastly, we assessed the implant costs and compared them to locking plates.

RESULTS

Thirty-four patients were treated with a mean age of 49 years. Mean radial shortening improved 2 mm; dorsal and radial angulation improved 23 and 4°, respectively. At consolidation (eight weeks) the average radial shortening was 0.75 mm, a volar angulation of 3°, and 21° of radial angulation. Functional results were excellent, demonstrated by a mean VAS score less than 1, a DASH score of 12 and a Mayo wrist score of 87. Compared to locking plates, there was an overall reduction in material costs of 15,300 Euro.

CONCLUSIONS

Our technique has excellent biomechanical stability, enabling immediate functional rehabilitation, good anatomical and functional outcome with significantly lower costs.

Radiographic outcomes of volar locked plating for distal radius fractures

PURPOSE

To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures.

METHODS

We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type.

RESULTS

At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome.

CONCLUSIONS

Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpal tunnel syndrome after distal radius fracture

Carpal tunnel syndrome is a common condition and is a well-recognized phenomenon following a distal radius fracture. The treating surgeon should be vigilant in noticing the signs and symptoms. If acute carpal tunnel syndrome is noted, then surgical release of the carpal tunnel and fracture fixation should be performed urgently. If early carpal tunnel syndrome findings are noted during distal radius fracture management, all potential causes should be evaluated. Delayed carpal tunnel syndrome presenting after a distal radius fracture has healed is best managed in standard fashion. There is no role for prophylactic carpal tunnel release at the time of distal radius fixation in a patient who is asymptomatic.

Incidence and clinical outcomes of tendon rupture following distal radius fracture

PURPOSE

To evaluate the incidence of tendon rupture after nonoperative and operative management of distal radius fractures, report clinical outcomes after tendon repair or transfer, and examine volar plate and dorsal screw prominence as a predictor of tendon rupture.

METHODS

We performed a retrospective chart review on patients treated for tendon rupture after distal radius fracture. We evaluated active range of motion, Disabilities of Arm, Shoulder, and Hand score, grip strength, and pain score, and performed radiographic evaluation of volar plate and dorsal screw prominence in both the study group and a matched control group.

RESULTS

There were 6 tendon ruptures in 1,359 patients (0.4%) treated nonoperatively and 8 tendon ruptures in 999 patients (0.8%) treated with volar plate fixation. At the time of final follow-up, regardless of treatment, we noted that patients had minimal pain and excellent motion and grip strength. Mean Disabilities of the Shoulder, Arm, and Hand scores were 6 for patients treated nonoperatively and 4 for those treated with volar plating.

CONCLUSIONS

We were unable to verify volar plate or dorsal screw prominence as independent risk factors for tendon rupture after distal radius fractures. However, we recommend continued follow-up and plate removal for symptomatic patients who have volar plate prominence or dorsal screw prominence. In the event of tendon rupture, we report excellent clinical outcomes after tendon repair or tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Percutaneous cannulated screw fixation in the treatment of distal radius fractures

PURPOSE

The aim of this study was to determine the results of closed reduction and percutaneous fixation of distal radial fractures with standard 4.0-mm cannulated screw.

METHODS

We collected prospective outcomes data for 20 patients between 18 and 60 years of age (mean 39) with acute, displaced, extraarticular and unstable fractures of the distal radius treated with closed reduction, percutaneous cannulated screw fixation and early mobilization. The visits at months 2, 6 and 12 were specified as index follow-up visits and assessments of motion, grip strength and standard radiographs were performed. The Gartland Werley functional scores and the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were recorded.

RESULTS

Mean values of flexion, extension, pronation and supination on the injured side were up to 70 % of those on the uninjured side at 2 months postoperatively. By 12 months, range of motion values on the injured side showed continuous and significant improvement and flexion, extension, pronation, supination and ulnar deviation reached up to 90 % of those on the uninjured side. A large and significant improvement was seen from 2 to 6 months in the QuickDASH score. A smaller improvement was seen from 6 to 12 months, which was judged not to be significant. Radiographic values were close to anatomic parameters, and the alignment was maintained at 12 months follow-up. No complications occurred.

CONCLUSIONS

Cannulated screw fixation appears to be an effective means of allowing immediate range of motion of the wrist, resulting in a rapid and comfortable functional recovery while maintaining alignment to bone healing.

The biomechanical effects of a deepened articular cavity during dynamic motion of the wrist joint

BACKGROUND

A deepened articular cavity of the distal radius due to a metaphyseal comminution zone is associated with early osteoarthritis and reduced joint motion. As this deformity has not been investigated biomechanically, the purpose of this study was to evaluate the effects of a deepened articular cavity on contact biomechanics and motion range in a dynamic biomechanical setting.

METHODS

Six fresh frozen cadaver forearms were tested in a force controlled test bench during dynamic flexion and extension and intact mean contact pressure and contact area as well as range of motion were evaluated. Malunion was then simulated and intraarticular as well as motion data were obtained. Intact and malunion data were compared for the scaphoid and lunate facet and the total radial joint surface.

FINDINGS

Due to malunion simulation, cavity depth increased significantly. Motion decreased significantly to 54-69% when compared to the intact state. Malunion simulation led to a significant decrease of contact area in maximum extension for all locations (by ~50%). In maximum flexion and neutral position, contact area decrease was significant for the scaphoid fossa (by 51-54%) and the total radial joint surface (by 47-50%). Contact pressure showed a significant increase in maximum extension in the scaphoid fossa (by 129%).

INTERPRETATION

Already a small cavity increase led to significant alterations in contact biomechanics of the radiocarpal joint and to a significant range of motion decrease. This could be the biomechanical cause for degenerative changes after the investigated type of malunion. We think that restoration of the normal distal radius shape can minimize osteoarthritis risk post trauma and improve radiocarpal motion.

Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients

PURPOSE

To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures.

METHODS

A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained.

RESULTS

We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32.

CONCLUSIONS

In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

DORSALLY DISPLACED FRACTURES OF THE DISTAL RADIUS — A STUDY OF PREFERRED TREATMENT OPTIONS AMONG UK TRAUMA AND ORTHOPAEDIC SURGEONS

Distal radius fractures are common, and surgeons have in their armament a variety of ways of treating them. In this study, 50 orthopaedic surgeons in the UK were shown five clinical scenarios and radiographs from patients with various fracture patterns of the distal radius, and were asked for their preferred management. There was a wide variation in the preferred treatment for each scenario presented. Across all of the cases, 52% of surgeons preferred to use a volar locking-plate compared with 21% who chose fixation with Kirschner wires. There was very little consensus among surgeons with regard to the optimal method of fixation for patients sustaining dorsally displaced fractures of the distal radius. This disagreement is not surprising as there is currently no high level evidence to guide surgeons as to the best management option for this common and potentially debilitating injury.

Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius

PURPOSE

To evaluate whether there was a difference in complication rates in our patients treated with external fixation versus volar plating of distal radius fractures. We also looked for a difference in radiographic results; in the clinical outcomes of flexion, extension, supination, pronation, and grip strength; and in scores on the visual analog scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

METHODS

We reviewed 115 patients with comminuted intrarticular distal radius fractures. Of those patients, 59 were treated with external fixation and 56 with volar plate fixation. Postoperative radiographs, range of motion, and grip strength were measured; DASH and VAS pain questionnaires were administered; and complications were documented.

RESULTS

The external fixation group had a significantly higher overall complication rate. In the volar plate group, there were more tendon and median nerve complications, but this difference was not significant. Radiographically, the external fixator group demonstrated radial shortening of 0.7 mm, whereas the volar plate group demonstrated 0.3 mm of radial shortening during the postoperative period. There were no significant differences between the groups in the measurement of scapholunate angle or palmar tilt. The mean DASH score at final follow-up was 32 in the external fixation group and 17 in the volar plate group, which was statistically significant. The final VAS scores were statistically different at 3.1 for the external fixation group and 1.1 for the volar plate group. On physical examination, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.

CONCLUSIONS

In the patients we studied, volar plate fixation has an overall decreased incidence of complications and significantly better motion in flexion-extension and supination-pronation compared to external fixation. Volar plate fixation also has less radial shortening than the external fixation group, yet the absolute difference in magnitude of ulnar variance was only 1.4 mm, calling into question the clinical significance of this difference. Patients with volar plating also have better pain and functional outcomes and better grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

External or internal fixation in the treatment of non-reducible distal radial fractures?

BACKGROUND AND PURPOSE

We have previously shown in a randomized study that in the first year after treatment, open reduction and internal fixation resulted in better grip strength and forearm rotation than closed reduction and bridging external fixation. In the present study, we investigated whether this difference persists over time.

PATIENTS AND METHODS

The 50 patients included in the original study (mean age 53 years, 36 women) were sent a QuickDASH questionnaire and an invitation to a radiographic and clinical examination after a mean of 5 (3-7) years.

RESULTS

All 50 patients returned the QuickDASH questionnaire and 45 participated in the clinical and radiographic examination. In the internal fixation group, the grip strength was 95% (SD 12) of the uninjured side and in the external fixation group it was 90% (SD 21) of the uninjured side (p = 0.3). QuickDASH score, range of motion, and radiographic parameters were similar between the groups.

INTERPRETATION

The difference originally found between internal and external fixation in distal radial fractures at 1 year regarding grip strength and range of motion was found to diminish with time. At 5 years, both groups had approached normal values.

UK DRAFFT - a randomised controlled trial of percutaneous fixation with kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius

Background

Fractures of the distal radius are extremely common injuries in adults. However, the optimal management remains controversial. In general, fractures of the distal radius are treated non-operatively if the bone fragments can be held in anatomical alignment by a plaster cast or orthotic. However, if this is not possible, then operative fixation is required. There are several operative options but the two most common in the UK, are Kirschner-wire fixation (K-wires) and volar plate fixation using fixed-angle screws (locking-plates). The primary aim of this trial is to determine if there is a difference in the Patient-Reported Wrist Evaluation one year following K-wire fixation versus locking-plate fixation for adult patients with a dorsally-displaced fracture of the distal radius.

Methods/design

All adult patients with an acute, dorsally-displaced fracture of the distal radius, requiring operative fixation are potentially eligible to take part in this study. A total of 390 consenting patients will be randomly allocated to either K-wire fixation or locking-plate fixation. The surgery will be performed in trauma units across the UK using the preferred technique of the treating surgeon. Data regarding wrist function, quality of life, complications and costs will be collected at six weeks and three, six and twelve months following the injury. The primary outcome measure will be wrist function with a parallel economic analysis.

Discussion

This pragmatic, multi-centre trial is due to deliver results in December 2013.

Trial registration

Current Controlled Trials ISRCTN31379280

UKCRN portfolio ID 8956

Dorsally displaced distal radius fractures treated by fixed-angle volar plating: Grip and pronosupination strength recovery. A prospective study

INTRODUCTION

Malunion following open reduction and internal fixation of distal radius fracture threatens wrist function. Fixed-angle palmar plates provide rigid fixation that is stable over time; however, the pronator quadratus sectioning required by the anterior approach entails a risk of pronation strength loss and of distal radioulnar joint destabilization. The present study assessed recovery of grip, pronation and supination strength following such internal fixation.

PATIENTS AND METHOD

A prospective study included 26 distal radial fractures with dorsal displacement, osteosynthesized using a fixed-angle palmar plate, in 25 patients (mean age: 47.5 years; range: 17-72 years). Assessment concerned the classical parameters, plus grip and pronosupination strength recovery.

RESULTS

At a mean 14 months follow-up (range: 6-30 months), patients had recovered 91% grip strength, 88% pronation strength and 85% supination strength with respect to the healthy side. Complications comprised three cases of malunion, two of reflex sympathetic dystrophy syndrome, and four of post-traumatic carpal tunnel syndrome.

DISCUSSION

A study of the literature found 75-95% grip strength recovery following osteosynthesis using fixed-angle plates. Few studies, however, have focused on pronosupination strength, and none reported its evolution following osteosynthesis.

CONCLUSION

The present study found no drawbacks associated with a technique which usually involves sectioning the pronator quadratus. Except in case of malunion or joint stiffness, fixed-angle palmar plate osteosynthesis was followed by recovery of grip and pronosupination strength.

LEVEL OF EVIDENCE

Level IV: prospective non-randomized, non-comparative observational study.

Anatomical and radiological study applied to distal radius surgery

PURPOSE

The purpose of this study was to determine, during anterior plating of the distal radius, the length of a screw above which there is a risk for the extensor tendons and the optimal shape of an anterior plate. It was also to determine the projection of the axis of the distal third of the radius on the distal articular surface in case of wrist arthroplasty in order to simplify the procedure.

METHODS

We studied 74 dry radii from adult cadavers. Each one underwent a CT scan. We measured the thickness of each radius at the dorsal tubercle level, at the second compartment level and at the third compartment level. We calculated the metaphyseal-epiphyseal angles of the lateral column and of the intermediate column (Rikli and Regazzoni in J Bone Joint Surg (Br) 78(4):588-592, 1996). We also calculated the projection of the longitudinal axis of the most distal 7 cm of the radius on the distal carpal surface of the radius.

RESULTS

Mean thickness at the dorsal tubercle level was 22.1 mm (18-26.1). The mean slope of the lateral column was 155° (143-167) while that of the intermediate column was 145° (134-153). We have found a statistically significant difference (p < 0.0001) between these two slopes. The axis of the distal radius was projected on the posterior-lateral quadrant of the distal articular surface.

CONCLUSIONS

The emergence of new implants needs a precise evaluation of a fractured, an arthritic or a reconstructed distal radius. The double slope of the distal radius complicates the manufacturing of an "anatomical" plate. The optimal shape is between these two slopes. Moreover, ancillaries for wrist replacement are still approximations, which means that it is important to know the projection of the radial axis on the articular surface of the distal radius.

Management of distal radius fractures: treatment protocol and functional results

Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment is controversial and still debated in the literature. For a correct management of these lesions many authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint mobilisation. We report our experience in the daily management of these lesions. The fractures are evaluated considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture stability. The best treatment option must be decided in accordance to the type of fracture, the extent of metaphyseal comminution, the quality of the bone and the medical condition of the patient.

Intramedullary nailing vs. palmar locked plating for unstable dorsally comminuted distal radius fractures: a biomechanical study

BACKGROUND

The purpose of this study was to compare the stability of a 2.4mm palmar locking compression plate and a new intramedullary nail-plate-hybrid Targon DR for dorsally comminuted distal radius fractures.

METHODS

An extraarticular 10mm dorsally open wedge osteotomy was created in 8 pairs of fresh frozen human radii to simulate an AO-A3-fracture. The fractures were stabilized using one of the fixation methods. The specimens were loaded axially with 200 N and dorsal-excentrically with 80 N. 2000cycles of dynamic loading and axial loading-to-failure were performed.

FINDINGS

Axial loading revealed that intramedullary osteosynthesis (Targon DR: 369 N/mm) was significantly (p=0.017) stiffer than plate osteosynthesis (Locking compression plate: 131 N/mm). With 214 N/mm the intramedullary nail also showed higher stability during dorsal excentric loading than the Locking compression plate with 51 N/mm (p=0.012). After 2000 cycles of axial loading with 80 N the Targon DR-group was significantly stiffer than the Locking compression plate-group under both loading patterns. Neither group showed significant changes in stiffness after 2000 cycles. Under dorsal excentric loading the Targon DR-group was still significantly stiffer with 212 N/mm than the Locking compression plate-group with 45 N/mm (p=0.012). The load to failure tests demonstrated higher stability of intramedullary nailing (625 N) when compared to plate osteosynthesis (403 N) (p<0.025).

INTERPRETATION

The study shows that intramedullary fixation of a distal AO-A3 radial fracture is biomechanically more stable than volar fixed-angle plating under axial and dorsal-excentric loading in an experimental setup.

Influence of screw diameter and number on reduction loss after plating of distal radius fractures

BACKGROUND

The current options for plate-screw combinations in volar locking distal radius plates used for the treatment of distal radius fractures are either plates with a single distal screw row or plates with multiple distal screw rows. Additionally, the screws themselves may have either fixed angle locking or polyaxial locking mechanisms. To date, there is no evidence or consensus regarding the optimal plate-screw combination. The aim of this study was to assess the biomechanical behaviour of different plate-screw combinations with respect to total distal screw number, number of distal screw rows and screw projection surface area of the most distal row.

METHODS

Biomechanical study to assess six different plating configurations in five different volar locking plate models in a Sawbone distal radius fracture model. The specimens were loaded with 800 Newton loads for 2.000 cycles at 1 Hz. After cyclic loading, load-to-failure testing was performed.

RESULTS

  With cyclical testing, there was a significant and positive correlation between rigidity and a greater projection area of the most distal screws. Dorsal tilting was significantly more pronounced in plate models with a lesser projection area of the most distal screws and a smaller number of distal screws. With load-to-failure testing, there was a significant increase in rigidity with increasing screw projection area of the most distal row and total number of distal screws.

CONCLUSIONS

Additional distal screw rows in volar locking distal radius plates might not add substantially to resistance against loss of reduction in the post-operative period.

Locked volar plating for complex distal radius fractures: Patient reported outcomes and satisfaction

Background

Distal radius fractures are common. The increasing prevalence of osteoporosis contributes to frequently complex articular injuries sustained even after low energy falls. The best method of treating complex type C distal radius fractures is debated. Locked volar plating and external fixation are both widely used with good reported results. Measures of success are traditionally based on technical measurements or the perception of the surgeon. Patient reported measures of outcome are increasingly recognised as important markers of surgical success. We report our experience using locked volar plating for complex type C distal radius fractures as well as patient reported measures of success and satisfaction.

Methods

Over a 12 month period we treated 21 patients with type C distal radius fractures using locked volar plating. These patients were followed up for at least 12 months and the outcome was assessed using clinical examination, grip strength measurements, radiographs and Patient Rated Wrist Evaluation (PRWE) scoring.

Results

The 21 patients studied had an average age of 48 years. There were 8 men and 13 women. All of the fractures had united by 3 months. There were no cases of wound infection or tendon injury/irritation. Patients reported low pain scores, good patient rated wrist evaluation scores and high levels of satisfaction.

Conclusions

Locked volar plating for complex distal radius fractures produces good results when assessed using patient reported measures of outcome. Further work should address whether locked volar plating offers superior outcomes and patient satisfaction compared to external fixation.

Intramedullary fixation of distal radius fractures

Intramedullary fixation is the latest in a variety of techniques that have been developed to manage distal radius fractures. Intramedullary nailing of these fractures combines the soft-tissue advantages of a less invasive surgical approach with the biomechanical advantages of locking screw technology. These features may enable an accelerated postoperative rehabilitation and quicker return to function. Disadvantages associated with the intramedullary technique include the necessity of a closed or percutaneous reduction and the inability of the implant to adequately stabilize intraarticular or highly comminuted fractures. Consequently, intramedullary implants are primarily indicated for fixation of extra-articular or simple intraarticular split patterns and should not be employed for management of volar or dorsal shear fractures. Preliminary clinical data is emerging in the form of short-term follow-up studies with limited numbers of study participants.

Operative treatment of distal radial fractures with locking plate system-a prospective study

The aim of this study was to determine the results of operative treatment of distal radial fractures with a 2.4-mm locking plate system in a single tertiary teaching hospital. Seventy-five patients were recruited into the study between May 2004 and November 2006. There were 41 males and 34 females, with a mean age of 51. Seventy-five percent of patients had AO type C fractures. All patients were allowed free active mobilisation of the wrist joint immediately after surgery. They were followed up at two weeks, three months, six months, one year and two years. Assessments of pain, motion, grip strength, and standard radiographs were performed. The Gartland and Werley functional scores, the modified Green and O'Brien score, and the disabilities of the arm, shoulder and hand (DASH) scores were recorded. The radiographic results at the final follow-up showed a mean of 18° of radial inclination, 5° of volar tilt, 1.3-mm radial shortening, and no articular incongruity. Twenty-nine percent of patients showed grade 1 osteoarthritic changes and 6% had grade 2 changes in their final follow-up radiographs. An excellent or good result was obtained in 98% and 96% of patients according to the Gartland and Werley, and modified Green and O'Brien scores, respectively. The mean DASH score was 11.6, indicating a high level of patient satisfaction. Internal fixation of distal radial fractures with a 2.4-mm locking plate system provided a stable fixation with good clinical outcomes and patient satisfaction.

A novel non-bridging external fixator construct versus volar angular stable plating for the fixation of intra-articular fractures of the distal radius--a biomechanical study

Non-bridging external fixation has recently been introduced as an alternative to volar angular stable plating for the fixation of unstable intra-articular distal radial fractures. The purpose of this study was to biomechanically compare a new non-bridging external fixator construct to volar angular stable plate fixation in a dorsally comminuted intra-articular fracture model of the distal radius.

MATERIALS AND METHODS

Five pairs of fresh frozen human cadaveric radii were randomly supplied with either a non-bridging external fixator or a stainless steel volar locking plate. A three-fragmental AO 23-C2.1 fracture was created by removing a 15 degrees dorsal wedge with remaining volar cortical contact and by an intra-articular osteotomy lateral to the lister-tubercle. Physiological load transfer via the wrist was simulated by means of a custom-made seesaw. For biomechanical testing, the bones were loaded in cyclic axial compression. Starting at 100N, the load was monotonically increased at 0.025 degrees N per cycle until failure of the construct. Motion of the lunate and scaphoid fragments with respect to the radial diaphysis was acquired by optical three-dimensional (3D) motion tracking. Plastic wedge deformation was determined after 2000, 4000 and 6000 cycles.

RESULTS

The amplitude of wedge motion at the beginning of the test as a measure for construct stiffness was significantly lower for the fixator group (P=0.003, power=0.99). Plastic wedge deformation after 2000, 4000 and 6000 cycles was found significantly lower for the external fixator (repeated measures analysis of variance (ANOVA), P=0.009, power=0.86). Displacement of the intra-articular gap was found below 0.6mm (mean) for both groups (P>0.05).

CONCLUSION

The study revealed superior biomechanical properties of the proposed non-bridging external fixation compared to volar locked plating in an unstable intra-articular fracture model with volar cortical support. However, both fixation techniques seem to apply sufficient stabilisation to restore and retain anatomy after fracture of the most distal part of the radius and should be individually chosen according to distinct criteria.

The role of locking technology in the upper extremity

The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.

A retrospective pilot study comparing the number of therapy visits required to regain functional wrist and forearm range of motion following volar plating of a distal radius fracture

PURPOSE

The purpose of this retrospective study was to compare the number of therapy visits and amount of time required to achieve functional motion in patients who underwent open reduction and internal fixation of the distal radius.

METHODS

Fourteen patients started early range of motion (ROM) and nine patients started ROM exercises after six weeks. Group comparisons were performed regarding age, Upper Limb Functional Index scores across time points, forearm and wrist ROM measurements across time points, grip strength, days until goal attainment, and number of visits attended.

RESULTS

A statistically significant difference (F=6.48, p<0.005) (95% confidence interval [CI] -14.52 to -6.34) was present between groups when comparing the number of therapy visits. A statistically significant difference (F= 2.35, p<0.005) (95% CI -49.72 to -24.49) was present between groups when comparing the number of days each group took to attain functional ROM of the wrist and forearm.

LEVEL OF EVIDENCE

3.

Distal radial fracture treatment: what you get may depend on your age and address

BACKGROUND

Distal radial fractures are common and confer a considerable financial burden on the health-care system; however, controversy surrounds the optimal treatment of these injuries. This study was performed to determine (1) the rate of distal radial fractures in the U.S. Medicare population stratified by hospital referral region and (2) whether the type of fracture treatment is affected by patient age, race, sex, comorbidity, or hospital referral region.

METHODS

A 20% sample of Medicare Part-B claims from the years 1998 through 2004 was analyzed. Procedural codes for nonoperative treatment, percutaneous fixation, and open reduction and internal fixation of distal radial fractures were identified. These codes were then used to determine the overall rate of distal radial fracture. The rates of distal radial fracture were then evaluated according to hospital referral region and patient age, sex, comorbidity, and race. The types of treatment were determined and were also analyzed on the basis of hospital referral region and patient age, sex, comorbidity, and race. Regression analysis was performed with use of the above variables.

RESULTS

We identified 107,190 patients. The rate of distal radial fracture was 125 per 10,000 Medicare beneficiaries. The rate of the fracture in white individuals (136 per 10,000) was more than twice that in non-white individuals (fifty-nine per 10,000), and the rate in women (189 per 10,000) was 4.8 times higher than that in men (thirty-nine per 10,000). The overall fracture rate varied widely across the United States, from forty-seven per 10,000 beneficiaries in New Orleans, Louisiana, to 220 per 10,000 in Spartanburg, South Carolina. Treatment rates were similar across race, with the rate of nonoperative treatment being 84% for white beneficiaries compared with 83% for non-white beneficiaries, the rate of percutaneous fixation being 11% for white beneficiaries compared with 10% for non-white beneficiaries, and the rate of open treatment being 6% for white beneficiaries compared with 7% for non-white beneficiaries. There was variation across the country, with the rate of nonoperative treatment ranging from 60% in San Luis Obispo, California, to 96% in Covington, Kentucky; the rate of percutaneous fixation ranging from 2% in Boulder, Colorado, to 39% in San Luis Obispo, California; and the rate of open treatment ranging from 0.4% in Wilkes-Barre, Pennsylvania, to 25% in Great Falls, Montana. While the rates of percutaneous fixation and nonoperative treatment remained relatively stable, the overall rate of operative fixation nearly doubled from 5% in 1998 to 8% in 2004.

CONCLUSIONS

There is wide variation in the rate of distal radial fractures across sex, age, race, and geographic region in the United States. There is also significant variation in the treatment of these fractures, driven mainly by age and region. Between 1998 and 2004, a strong trend toward more frequent operative fixation was apparent. While white individuals had more than twice as many fractures as did non-white individuals, there did not appear to be significant racial variation in the treatment of this injury.

Distal radius fractures in older patients: is anatomic reduction necessary?

The relationship between radiographic and functional outcomes in older patients with distal radius fractures is controversial. We explored this relationship by assessing the influence of radiographic displacement and fracture comminution on the functional outcomes of these fractures. We also asked whether operative intervention and demographic factors (age, gender, duration of followup) influenced outcome. We examined 53 patients older than 55 years with distal radius fractures with various functional assessments: range of motion (ROM) and strength measurements, three subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient-rated Wrist Evaluation; Modernized Activity Subjective Survey of 2007), a Gartland and Werley score, and an objective, standardized hand performance test (Jebsen-Taylor). We measured angulation, articular gap/stepoff, and radial shortening on final radiographs and fracture comminution of preoperative radiographs. We observed no effect of radiographic displacement on subjective or objective outcome assessments, including standardized hand performance timed testing. Surgically treated fractures were less likely to display residual dorsal angulation and radial shortening, but surgical intervention did not independently predict functional outcome. Fracture comminution, patient gender, and months of followup similarly had no effect on outcome. We found no relationship between anatomic reduction as evidenced by radiographic outcomes and subjective or objective functional outcomes in this older patient cohort.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Screw impingement on the extensor tendons in distal radius fractures treated by volar plating: sonographic appearance

OBJECTIVE

The objective of our study was to analyze the sonography examinations of nine consecutive patients with a history of distal radius fracture treated by open reduction and internal fixation of the volar plate who were referred by hand surgeons for sonography of the dorsal aspect of the wrist.

CONCLUSION

We postulate that impingement of the extensor tendons in patients with distal radius fracture treated by volar plating starts with local hyperemia and is followed by tenosynovitis and, finally, by partial and complete tendon tears. Sonography is an effective, dynamic, and noninvasive technique with which to diagnose and evaluate damage to the extensor tendons and their synovial sheaths.