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

Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.

Comparative clinical and radiographic outcomes between early and delayed wrist mobilization after volar fixed-angle plate fixation of distal radius fracture

Postoperative immobilization protocols after volar fixed-angle plate fixation of distal radius fractures (DRF) vary among surgeons. This study aimed to compare functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate fixation of DRF. This study is a randomized controlled trial. The early group was allowed to perform wrist motion exercise immediately after surgery and the delayed group was allowed to perform it after 2 weeks of external immobilization. Postoperative patient-rated wrist evaluation (PRWE), disabilities of arm, shoulder, and hand (DASH), wrist range of motion, visual analog scale (VAS) pain score, and grip strength were evaluated. Forty-eight patients with DRF were enrolled and randomly allocated to the early or delayed mobilization groups. The PRWE, DASH, VAS pain score, grip strength, and wrist motion of both groups significantly improved over time. However, there were no significant differences between groups at any timepoint. Radiographic parameters were not different between groups. There were no significant differences in functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate of DRF. Immediate postoperative wrist range-of-motion exercise can be safely initiated after volar fixed-angle plate fixation of DRF without external immobilization.Clinical trial registration: Thaiclinicaltrials.org identifier: TCTR20180927005. Registered 27/09/2018-retrospectively registered. https://www.thaiclinicaltrials.org/show/TCTR20180927005 .

Rehabilitation Following Surgically Treated Distal Radius Fractures: Do Immobilization and Physiotherapy Affect the Outcome?

Distal radius fractures (DRF) are one of the most common fractures treated by orthopaedic surgeons around the globe. It has been estimated that the National Health Services (NHS) spends an average of £1375.34 per patient for surgical fixation of DRF with a volar locking plate as a day case. This figure climbs to £1983.39 if the same patient stays at the hospital overnight. Inpatient physiotherapy costs the NHS a staggering £82.03 per day, while each outpatient session with physiotherapy is £40.70 for the NHS. This means that a substantial amount is spent by the NHS on rehabilitation and physiotherapy for each DRF, whether fixed surgically or non-surgically. Post-operative rehabilitation involving initial immobilization followed by physiotherapy/hand therapy is an indispensable part of the total management concept of DRF. Most of the conservative management protocols also advocate a five-week immobilization followed by physiotherapy/hand therapy. Due to the fact that more than 50% of the patients with DRF are still employed, the impairment caused by a restriction of range of motion, duration of the sick leave and the effects of DRF on quality of life play a very important socio-economical role in the broadest sense. Patients are routinely referred to physiotherapists/hand therapists following DRF to improve the range of motion (ROM), manage pain, strengthen the wrist and develop full functionality to pre-injury levels. However, the real impact of supervised exercises and active physiotherapy in restoring mobility and strength to the fractured wrist is still not well understood. This article aims to review the existing literature and evidence base regarding the efficacy of immobilization and physiotherapy in improving the functional outcome of surgically treated DRFs.

Early Mobilization After Volar Locking Plate Osteosynthesis of Distal Radial Fractures in Older Patients-A Randomized Controlled Trial

PURPOSE

To investigate if early mobilization after open reduction internal fixation of distal radius fractures improved the functional outcome. We hypothesized that early mobilization would lead to improved patient-reported outcome. Second, we aimed to assess whether early mobilization increased the risk of postoperative implant loosening or breakage.

METHODS

All included patients were treated with a volar locking plate. After surgery, patients were randomized to either early mobilization (E-MOB) with a removable orthosis (wrist lacer) and daily wrist exercises or to late mobilization (L-MOB) with a standard dorsal plaster cast for 2 weeks and, after that, a removable orthosis and exercises. We measured all patients at 4 weeks and at 3, 6, and 12 months after surgery. At each postoperative visit, we measured range of motion and grip strength and patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographic implant loosening or breakage was assessed 14 days after surgery.

RESULTS

A total of 47 patients were allocated to E-MOB and 48 to L-MOB. The DASH score improved substantially throughout the follow-up period with no significant differences between the 2 groups at any time point. Implant loosening and fracture redisplacement was observed in 1 patient in the E-MOB group. Range of motion and grip strength were similar between the 2 groups at all time points.

CONCLUSIONS

Early mobilization after surgical treatment of distal radius fractures does not lead to improved patient-reported outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Functional Outcome of Intraarticular Fracture of Distal Radius Managed by Volar Locking Plate

Objective

This study's main purpose is to determine the functional outcome of volar locking plates in the management of intraarticular fracture of the distal radius.

Methodology

This cross-sectional study was conducted from August 2016 to August 2019. Forty-nine patients with the intraarticular distal radius fractures managed by the volar locking plate were included in the study. Patients with open fractures, ipsilateral other limb injuries, polytrauma patients, pathological fractures, and patients having neurovascular injuries were excluded from the study. AO Classification was used to classify fractures. The fracture was approached through the volar approach and fixed by the volar locking plate. A modified mayo wrist score evaluated the functional outcome. All the data were recorded on predesigned performa, and Statistical Package for the Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY) was used to analyze the data.

Results

A total of 49 patients with intraarticular fractures of the distal radius were included in the study. The mean age of the patient was 37.20 ± 10.05 years. Out of 49 patients, 29 (59.2%) were males, and 20 (40.8%) were females. Union was achieved in almost all fractures except one case, which went into non-union despite the adequate initial reduction, and the mean time of union was 11.98 ± 1.64 weeks. With respect to the stratification of functional outcome very good and good functional outcome was achieved in 46 patients (93.8%) in both the groups, the satisfactory outcome was achieved in two (4.1%) cases and one patient had a bad outcome in which union was not achieved and went into non-union.

Conclusion

Open reduction and internal fixation of intraarticular fracture of the distal radius using a volar locking plate is a good option for managing these fractures as it provides stable fixation, and good to excellent outcomes can be achieved by using these plates.

A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation

Introduction

Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks).

Methods

The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted.

Results

Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later.

Discussion

Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Complications of Volar Plating of Distal Radius Fractures: A Systematic Review

Background  In recent years, there has been an increased utilization of volar locking plate fixation of distal radius fractures (DRFs). However, reported long-term complication rates with this technique remain unclear. Purpose  The purpose of this systematic review was to investigate the pooled incidence of complications associated with volar locking plating of DRF. Methods  A search of the Scopus database was performed from 2006 through 2016. Studies were considered eligible if they had a diagnosis of a DRF and were treated with a volar locking plate with an average of 12 months or longer follow-up. Results  The literature search yielded 633 citations, with 55 eligible for inclusion in the review (total n  = 3,911). An overall complication rate of 15% was identified, with 5% representing major complications requiring reoperation. The most common complication types identified included nerve dysfunction (5.7%), tendon injury (3.5%), and hardware-related issues (1.6%). Conclusion  Nerve complications were reportedly higher than tendon and hardware-related complications combined. However, despite varying complication rates in the literature, this systematic review reveals an overall low complication rate associated with volar locking plating of DRF.

Radiological Outcomes of Distal Radius Fractures Managed with 2.7mm Volar Locking Plate Fixation-A Retrospective Analysis

INTRODUCTION

Distal radius fractures accounts for around 15% of all fractures diagnosed and treated in the emergency rooms. These fractures usually result secondary to high velocity injury such as a motor vehicle accident or fall on an out stretched hand. In the elderly, it is a common fragility fracture. Volar Locking Compression Plates (LCP) is effective devices for fixation of the distal radius fractures. There is a lacuna with regard to literature on the 2.7 mm volar LCP and the current study retrospectively assesses the postoperative radiological outcomes.

AIM

To measure the radiological outcomes in patients with displaced distal radius fractures managed with 2.7 mm volar LCP fixation using Sarmiento's Modification of Lindstorm Criteria.

MATERIALS AND METHODS

A retrospective study was conducted in the Department of Orthopaedic Surgery at Kasturba Medical College Allied Hospitals, Mangalore from May 2014 to July 2016. All displaced distal radius fractures of skeletally mature patients who underwent volar locking plate fixation between May 2014 to July 2016 and follow up with X-rays at six weeks and three months were included as part of the study. The study comprised of 20 patients and fractures were classified using the AO and Melone's classification systems. The radiological outcome was scored based on Sarmiento's Modification of Lindstorm Criteria.

RESULTS

Post operative check X-rays were analysed at immediate post operative, six weeks and three months. The mean immediate post operative radial shortening, decrease in radial deviation and loss of palmar tilt were 4.08±2.23, 5.91±4.01and 4.11±3.29 respectively. The corresponding values at last follow up were 4.71±2.31, 7.9±5.13 and 4.91±3.32 respectively. No statistically significant difference (p=0.930;874;716) in radial shortening, decrease in palmar angulation and loss of radial deviation was seen till the final follow up. Sarmiento's Modification of Lindstorm Criteria showed a good radiological outcome in 60% followed by fair in 25% and excellent in 15%.

CONCLUSION

Use of 2.7 mm volar LCP showed good to excellent post operative radiological outcomes in majority of the cases. The fracture reduction achieved in the immediate post operative period is maintained throughout the follow up duration.

Fracture severity of distal radius fractures treated with locking plating correlates with limitations in ulnar abduction and inferior health-related quality of life

Introduction/background: The operative treatment of distal radius fractures has significantly increased after the introduction of locking plates. The aim of the present study was the evaluation of health-related quality of life, functional and radiological outcome of patients with distal radius fractures treated with the locking compression plate (LCP).

Materials and methods: In the present study 128 patients (130 fractures) that were operatively treated with the LCP (2.4 mm/3.5 mm, Synthes^®) were retrospectively evaluated. Mean follow-up was 22.7 months (SD 10.6). The fractures were radiographically evaluated (radial inclination, palmar tilt, ulnar variance) pre-, postoperatively and at the last follow-up visit. Range of motion (ROM) was documented. Grip strength was assessed with the use of a JAMAR dynamometer. The score for disabilities of the arm, shoulder and hand (DASH) and the Gartland-Werley score (GWS) were evaluated. Health-associated quality of life was assessed with use of SF-36 Health Survey.

Results: Postoperative reduction was excellent; at the last follow-up visit only minimal reduction loss was observed. Except for pronation, a statistically significant decrease of ROM was present; in most cases that was not disturbing for the patients. The injured side achieved 83.9% of grip strength of the intact side. Mean DASH was 18.9 and mean GWS was 3.5. Health-associated quality of life was generally not compromised. However, limitations in ulnar abduction correlated with inferior quality of life. Fracture severity correlated with inferior quality of life, despite the absence of correlation with the functional and radiological outcome. Complication rate was low.

Conclusions: Fracture severity seems to affect ulnar abduction and therefore patient quality of life, despite almost anatomical reduction; the objective and subjective scores were in most cases excellent. Modern everyday activities, such as keyboard typing, could be associated with the present results.

Volar locking plate osteosynthesis for distal radial fractures

PURPOSE

To review the one-year outcome after volar locking plate fixation for distal radial fractures.

METHODS

Records of 22 men and 40 women aged 17 to 86 (mean, 52.5) years who underwent volar locking plate fixation for distal radial fractures were reviewed. According to the Fernandez classification, the distal radial fractures were classified as type 1 (n=20), type 2 (n=24), type 3 (n=6), type 4 (n=6), or type 5 (n=6). Three types of plate were used: Stryker Variax (n=33), Synthes LCP (n=20), and Smith & Nephew Peri-Loc (n=9). Wrist function was assessed at one year using the validated patient-rated wrist evaluation (PRWE) questionnaire.

RESULTS

14 (23%) of the 62 patients had 24 complications: stiffness (n=13), median nerve symptoms (n=4), malunion (n=2), implant removal for persistent pain and stiffness but no improvement shown (n=2), complex regional pain syndrome (n=2), and carpal arthritis (n=1). The complication rates for types 1, 2, 3, 4, and 5 fractures were 20%, 17%, 67%, 0%, and 33%, respectively (p=0.052). The complication rates for low-risk (types 1 and 2) and high-risk (types 3, 4, and 5) fractures were 18% and 33%, respectively (p=0.315). The complication rates for Stryker Variax, Synthes LCP, and Smith & Nephew Peri-Loc were 26%, 20%, and 14%, respectively (p=0.75). At one year, the mean PRWE score was comparable in patients with low-risk or high-risk fractures (14 vs. 19, p=0.5). 79%, 13%, and 8% of the patients recovered >50%, 20-50%, and <20% of range of movement of the contralateral side, respectively.

CONCLUSION

Volar locking plate fixation followed by early rehabilitation for distal radial fractures achieved good outcome, with a low rate of implant-related complications.

Screw length in volar locking plate fixation for distal radial fractures

PURPOSE

To develop a reference for the distal screw length in volar locking plate fixation for distal radial fractures in an East Asian population.

METHODS

12 pairs of forearm specimens from 11 male and one female East Asian cadavers were scanned using computed tomography. On sagittal images of the distal radius, the mean cortex-to-cortex distance of 8 quadrants was measured as a reference for the distal screw length. In addition, intra-operative 3-dimensional fluoroscopy of 10 male and 10 female patients who underwent volar locking plate fixation for distal radial fractures was used to validate the distal screw length in the cadaveric reference. 76 distal locking screws were applied in the 8 quadrants; their cortex-to-cortex distances were measured.

RESULTS

The mean cortex-to-cortex distances at quadrants A, B, C, D, E, F, G, and H were 15.4 mm, 19.6 mm, 20.8 mm, 20.0 mm, 13.3 mm, 18.0 mm, 18.8 mm, and 17.4 mm, respectively. In 45% of the specimens, the 2 screws inserted at quadrants C and D were longest. Distal screws (quadrants A to D) were significantly longer than proximal screws (quadrants E to H) [p=0.02]. In intra-operative 3-dimensional fluoroscopic images, 2 of the 76 distal locking screws penetrated the dorsal cortex (one in quadrant A and one in quadrant F). The mean screw length was 88.0% of the cortex-to-cortex distance. Referenced to the cadaveric data, 88.2% of the screws could be safely inserted without penetrating the dorsal cortex, and the remaining 11.8% of screws (5 at quadrant D, one at quadrant B, and 3 at quadrant C; all in female patients) could potentially cause dorsal cortex penetration of 2 to 4 mm. In male patients, the mean screw length was 76.1% of the cortex-to-cortex distance based on the cadaveric reference. In female patients, when the screw length was 4 mm less than the cadaveric reference, the mean screw length would be 72.0% of the referenced cortex-to-cortex distance, with no dorsal cortex penetration.

CONCLUSION

In female patients, the screw length should be 4 mm less than the cadaveric reference to avoid dorsal cortex penetration.

Complications following volar locking plate fixation for distal radial fractures: a systematic review

The purpose of this systematic review is to assess the prevalence of complications following volar locking plate fixation of distal radial fractures. A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Only prospective comparative and prospective cohort studies that presented data concerning complications after treatment of distal radial fractures with a volar locking plate in human adults with a minimal follow-up of 6 months were included. Two quality assessment tools were used to assess the methodological quality of the studies (level of evidence rating according to the Oxford Centre of Evidence Based Medicine and the modified version of the Cochrane Bone, Joint and Muscle Trauma Group's former quality assessment tool). Thirty three studies were eligible for final assessment. Most complications were problems with nerve and tendon function as well as complex regional pain syndrome. With an overall complication rate of 16.5%, most of which were 'minor' complications and low rates of nonunion and malunion, volar locking plate fixation can be considered a reasonably safe treatment option for patients with distal radial fractures.

Complication rates and reduction potential of palmar versus dorsal locking plate osteosynthesis for the treatment of distal radius fractures

Background

The aim of this study was to evaluate the complication rates of volar versus dorsal locking plates and postoperative reduction potential after distal radius fractures.

Materials and methods

For this study 285 distal radius fractures (280 patients/59.4 % female) treated with locked plating were retrospectively evaluated. The mean age of the patients was 54.6 years (SD 17.4) and the mean follow-up was 33.2 months (SD 17.2). The palmar approach was used in 225 cases and the dorsal approach in 60 cases (95 % type C fractures).

Results

Adequate reduction was achieved with both approaches, regardless of fracture severity. In the dorsal group, the complications and implant removal rates were significantly higher and the operative time was also longer.

Conclusions

Based on these facts, we advocate the palmar locking plate for the vast majority of fractures. In cases of complex multifragmentary articular fractures where no compromise in reduction is acceptable, and with the biomechanical equality of palmar and dorsal plating remaining unproven, dorsal plating may still be considered.

Level of evidence

Therapeutic level IV.

Validade preditiva de equações de referência para força de preensão manual em homens brasileiros de meia idade e idosos

O objetivo deste estudo foi verificar a validade preditiva das equações de referência para predição da força de preensão manual (FPM) em homens brasileiros de meia idade e idosos. Foram avaliados 60 homens com idade de 58,7±8,6 anos (50-84 anos), estatura 168,7±8,0 cm, massa corporal 67,9±13,0 kg e índice de massa corporal 23,7±4,0 kg/m², utilizando equipamento 'padrão-ouro' na avaliação da FPM e seguindo todas as recomendações metodológicas preconizadas pela American Society of Hand Therapists (ASHT). Os resultados do diagrama de Bland-Altman para mão dominante (MD) apresentam um erro médio (viés) de -8,4% (IC95% -51,6-34,7). Já o diagrama de Bland-Altman para mão não dominante (MND) apresenta um erro médio (viés) de 1,4% (IC95% -47,1-49,8). O cálculo de Cronbach's alpha para a MD foi de 0,69 e 0,59 para MND. O coeficiente de correlação intraclasse para MD foi 0,52 (IC95% 31-68) e de 0,42 (IC95% 20-60) para a MND. Concluímos que as equações para predição analisadas neste estudo, para uma população de homens brasileiros de meia idade e idosos, apresentou baixa validade preditiva, o que pode gerar erros de interpretação dos resultados.

Therapeutic effects of volar anatomical plates versus locking plates for volar Barton's fractures

Volar Barton's fractures are uncommon and extremely unstable. Various surgical techniques have been reported in the literature, but open reduction and internal fixation using a volar plate system is currently advocated for the treatment of volar Barton's fractures. The purpose of this study was to compare the therapeutic effects of volar anatomical plates and volar locking plates in the treatment of volar Barton's fractures. A retrospective comparative study was performed of 33 patients with volar Barton's fractures treated between October 2005 and November 2010. One group was treated with a volar anatomical plate (n=16) and the other with volar locking plates (n=17). Radiological and functional results were compared between groups. All patients' fractures healed. Mean union time in the anatomical plate group was 12.93 weeks and in the locking plate group was 11.76 weeks (P>.05). No significant difference was noted between the 2 groups in terms of radial inclination, volar tilt, and ulnar variance. No significant differences were noted between the 2 groups in Disabilities of the Arm, Shoulder and Hand scores; however, according to Sarmiento's modification of the Gartland and Werley score, the excellent and good rate was 75% in the anatomic plate group and 94.1% in the locking plate group, which was statistically significant (P<.05). Anatomical and locking plates give satisfactory results in the treatment of volar Barton's fractures, but locking plates may provide better wrist function recovery.

A comparative study of Colles' fractures in patients between fifty and seventy years of age: percutaneous K-wiring versus volar locking plating

PURPOSE

This retrospective study was to compare the clinical outcomes of volar locking plating (VLP) and percutaneous Kirschner wiring (PKW) for the management of displaced Colles type distal radius fractures in patients between 50 and 70 years old.

METHODS

There were 31 elderly patients with displaced Colles' fractures treated by VLP. We compared them to 31 match-paired patients treated by PKW. The patients were matched according to age (within five years) and sex. All patients were followed up retrospectively for at least 12 months. The functional outcomes and radiological results were compared between the two groups.

RESULTS

All fractures healed within three months. There were two complications (6.5%) in the PKW group and one complication (3.2%) in the VLP group. At final follow-up, wrist flexion, extension, and ulnar deviation were significantly better in the VLP group compared with the PKW group (all p values<0.05). According to modified Green and O'Brien criteria, the VLP group showed a trend towards increased rate of satisfactory outcome compared with the PKW group (p = 0.09).

CONCLUSION

For the treatment of displaced Colles' fractures in patients between 50 and 70 years old, both groups had high union rate and low complication rate. However, better functional results can be expected in association with open reduction and volar locking plating.