Outcome after surgery of distal radius fractures: no differences between external fixation and ORIF

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Prospective Descriptive Study of Radiological and Functional Outcomes of Volar Barton’s Fracture Fixed by Volar Locked Plate

BACKGROUND: Volar Barton’s fracture is a shearing mechanism of injury that results in fracture and subluxation of distal end radius in which volar rim of the distal radius is displaced with hand and carpus. Open reduction and volar plate fixation ensure more stable change of displacement, preservation of reduction, and early mobilization. AIM: This study aims to assess the functional and radiological outcome results of volar Barton’s fracture treated by volar buttress plate using the demerit points system of Gartland and Werley. PATIENTS AND METHODS: This study is a prospective descriptive observational study on 32 patients who were treated with ORIF by volar buttress plate for isolated volar Barton’s fractures between February 2018 and June 2020 in Alkindy teaching hospital/Baghdad/Iraq. All volar Barton’s fracture cases satisfying the inclusion criteria which included patient over 18 years, isolated fracture, medically fit, and <5 days old injuries, while fractures extend to radius shaft, compound fractures, and associated with other injuries were excluded from the study. All fractures are fixed by volar locked plate followed up for 12 week’s duration for functional and radiological assessment using the Demerit points system of Gartland and Werley. RESULTS: Most cases were in the age group below 40 years, average age 38 years (range 19–64 years), male patient was 69%, side of involvement was right wrist in 75% of cases, falling on an outstretched hand account 50%, while roads traffic accidents in 37.5%, fall from a height in 6.25%, and direct trauma in 6.25%. The final sequel of the results was average volar tilt was 11.1°, the radial shortening average was 4 mm, the radial inclination average was 19.9°, and the ulnar variance was 0.3 mm. Functional outcomes depending on Gartland and Werley’s score were 50% as excellent results, 43.75% as good results, 6.25% as fair results, and no poor results in this study. CONCLUSIONS: Volar locking buttress plate provides fracture stability and early mobilization, therefore, recovery of daily live activity in a short time.

Effect of Metacarpal Fixation Configuration on Strength and Fracture Gap Displacements in a Cadaveric Model of Externally Fixed Distal Radius Fractures

Background: The purpose of the study was to determine the biomechanical effect of distal pin configuration in unilateral external fixation of distal radius fracture in a cadaveric model. Methods: A standardized 2-part extra-articular distal radius fracture model with dorsal comminution was created in 6 matched pairs of cadaveric upper extremities. Specimens within each matched pair were randomly assigned to either 4 or 6 cortices of distal pin metacarpal fixation. Cyclic, compressive loads were applied to the palmar hand. Results: No significant differences were detected in maximum forces. Six-cortex metacarpal fixation showed significantly lower magnitude of actuator displacement at 100 N cyclic loading. The difference in construct stiffness did not translate to disparities in angular and translational interfragmentary displacement at the fracture gap. Conclusions: Utilizing only 4 cortices and sparing the middle finger metacarpal avoids the need for a more transverse orientation required with 6-cortex fixation, which may otherwise impede thumb motion.

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Purpose:

Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database.

Methods:

Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses.

Results:

Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery.

Conclusion:

This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Epidemiology and treatment of distal radius fractures: current concept based on fracture severity and not on age

PURPOSE

A shift towards surgical treatment of distal radius fractures seems to be apparent. The purpose of the present study was to assess current epidemiological data, the fracture severity according to the AO classification and the changing trend in the treatment.

METHODS

This study presents a retrospective review of 268 patients ≥ 18 years of age admitted to our level I trauma center with distal radius fractures between 2013 and 2015. The data were obtained from the hospital inpatient enquiry system and review of the radiological examinations.

RESULTS

The ratio between males and females was 87:181. The average age of the patients was 56.9 (18-99) years. A fall from standing position was the most common mechanism of injury. According to the AO classification, 43.3% were type A fractures, 13.1% type B, and 43.7% type C. As the intensity of the injury mechanism increased, the percentage of type C fractures also increased. A total of 61.9% of patients underwent surgery with open reduction and internal fixation with volar locking plates used as the preferred surgical treatment. Fracture severity correlated well with surgical decision. Elderly patients were just as likely to get surgical treatment as adult patients.

CONCLUSIONS

Our findings confirmed the increasing popularity of surgical intervention with open reduction and internal fixation. Contrary to previous studies, the fracture type profile showed an equal proportion of type A and C fractures and the indication for surgical treatment correlated with fracture severity and not age.

Is volar locking plate superior to external fixation for distal radius fractures? A comprehensive meta-analysis

Objective

The aim of this meta-analysis of randomized controlled trials (RCT) and retrospective cohort studies (CS) regarding the use of volar locking plate (VLP) and external fixation (EF) in distal radius fractures was to determine whether there was any evidence that one treatment was superior to the other.

Methods

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electrical databases (PubMed, EMBASE and the Cochrane library) were retrieved to find RCTs and CSs met the eligibility criteria. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis with RevMan 5.1. The publication bias was test by Stata 14.0. The Begg's and Egger's test were performed by Stata 14.0. The quality of evidence was graded according to the criteria of GRADE. We ultimately included ten RCTs and eleven CSs.

Results

A total of 1590 subjects were reported. Publication bias was detected by funnel plot in RCTs. VLP could provide better results such as DASH scores (RCT: MD = −6.12, 95%CI = −12.07–0.17; CS: MD = −6.43, 95%CI = −12.53–0.3), ulnar variance (RCT: MD = −0.81, 95%CI = −1.25–0.37) and infection rate (RCT: RR = 0.25, 95%CI = 0.10–0.65; CS: RR = 0.15, 95%CI = 0.06–0.40). There were no significant differences for G-W scores, VAS and grip strength between the VLP group and EF group. There was significantly greater loss of volar tilt (P = 0.01) and radial inclination (P = 0.02) in patients receiving EF, basing on the CSs.

Conclusions

VLP could provide better results, such as DASH scores, ulnar variance, volar tilt, radial inclination and infection rate. The use of VLP appear to be associated with better results of ROM (flexion, pronation, supination and radial deviation), radiographic parameters (volar tilt and radial inclination) and lower total complication rate and CRPS rate in CSs.

Level of evidence

Level 1, Therapeutic study.

Epidemiology of distal radius fracture in Akershus, Norway, in 2010-2011

BACKGROUND

Several studies published over the last decade indicate an increased incidence of distal radius fractures (DRF). With Norway having one of the highest reported incidence of DRFs, we conducted a study to assess the epidemiology of DRFs and its treatment in the catchment area of Akershus University Hospital (AHUS).

METHODS

Patients 16 years or older who presented to AHUS with an acute DRF during the years 2010 and 2011 were prospectively recorded and classified according to the AO fracture classification system. The mechanism of injury and treatment modality were noted.

RESULTS

Overall, 1565 patients with an acute DRF presented to the institution in 2010-2011, of which 1134 (72%) were women. The overall annual incidence was 19.7 per 10,000 inhabitants 16 years or older. Women had an exponential increase in incidence after the age of 50, though the incidence for both genders peaked after the age of 80 years. There was an even distribution between extra- and intra-articular fractures. Falling while walking outside was the most common mechanism of injury. Of the 1565 registered, 418 (26.7%) patients underwent surgery, with a volar locking plate being the preferred surgical option in 77% of the cases.

CONCLUSION

The overall incidence of distal radius fractures was lower in our study than earlier reports from Norway. Postmenopausal women had a higher risk of fracture than the other groups, and low-energy injuries were most dominant. 26.7% were treated operatively, which is higher than earlier reports, and might reflect an increasing preference for surgical treatment.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation

PURPOSE

To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model.

METHODS

We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique.

RESULTS

Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation.

CONCLUSIONS

A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction.

CLINICAL RELEVANCE

External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

INTRODUCTION

Using network meta-analysis, we evaluated the adverse effects of the seven most common treatment methods, i.e., bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating, by their associated risk of developing complex regional pain syndrome (CRPS) in distal radius fracture (DRF) patients.

MATERIAL AND METHODS

Following an exhaustive search of scientific literature databases for high quality studies, randomized controlled trials (RCTs) related to our study topic were screened and selected based on stringent predefined inclusion and exclusion criteria. Data extracted from the selected studies were used for statistical analyses using Stata 12.0 software.

RESULTS

A total of 17 RCTs, including 1658 DRF patients, were enrolled in this network meta-analysis. Among the 1658 DRF patients, 452 received bridging external fixation, 525 received non-bridging external fixation, 154 received K-wire fixation, 84 received plaster fixation, 132 received dorsal plating, 123 received volar plating, and 188 received dorsal and volar plating. When compared to bridging external fixation patients, there was no marked difference in the CRPS risk in DRF patients receiving different treatments (all p > 0.05). However, the surface under the cumulative ranking curves (SUCRA) for plaster fixation (77.0%) and non-bridging external fixation (71.3%) were significantly higher compared with the other five methods.

CONCLUSIONS

Our findings suggest that compared with bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation might be the better treatment methods to reduce the risk of CRPS in DRF patients.

The comparative risk of developing postoperative complications in patients with distal radius fractures following different treatment modalities

In this study, we performed a network meta-analysis to compare the outcomes of seven most common surgical procedures to fix DRF, including bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. Published studies were retrieved through PubMed, Embase and Cochrane Library databases. The database search terms used were the following keywords and MeSH terms: DRF, bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. The network meta-analysis was performed to rank the probabilities of postoperative complication risks for the seven surgical modalities in DRF patients. This network meta-analysis included data obtained from a total of 19 RCTs. Our results revealed that compared to DRF patients treated with bridging external fixation, marked differences in pin-track infection (PTI) rate were found in patients treated with plaster fixation, volar plating, and dorsal and volar plating. Cluster analysis showed that plaster fixation is associated with the lowest probability of postoperative complication in DRF patients. Plaster fixation is associated with the lowest risk for postoperative complications in DRF patients, when compared to six other common DRF surgical methods examined.

Comparison of Risk of Carpal Tunnel Syndrome in Patients with Distal Radius Fractures After 7 Treatments

Background

To compare risk of carpal tunnel syndrome (CTS) in distal radius fracture (DRF) patients after 7 treatments using bridging external fixation (BrEF), non-bridging external fixation (non-BrEF), plaster fixation, K-wire fixation, dorsal plating fixation, volar plating fixation, and dorsal and volar plating by performing a network meta-analysis.

Material/Methods

An exhaustive search of electronic databases identified randomized controlled trails (RCTs) closely related to our study topic. The published articles were screened, based on predefined inclusion and exclusion criteria, to select high-quality studies for the present network meta-analysis. Data extracted from the selected studies were analyzed using STATA version 12.0 software.

Results

The literature search and selection process identified 12 eligible RCTs that contained a total of 1370 DRF patients (394 patients with BrEF, 377 patients with non-BrEF, 89 patients with K-wire fixation, 192 patients with plaster fixation, 42 patients with dorsal plating fixation, 152 patients with volar plating fixation, and 124 patients with dorsal and volar plating fixation). Our network meta-analysis results demonstrated no significant differences in CTS risk among the 7 treatments (P>0.05). The value of surface under the cumulative ranking curve (SUCRA), however, suggested that dorsal plating fixation is the optimal treatment, with the lowest risk of CTS in DRF patients (dorsal plating fixation: 89.2%; dorsal and volar plating: 57.8%; plaster fixation: 50.9%; non-BrEF: 50.6%; volar plating fixation: 39.6%; BrEF: 38.4%; K-wire fixation: 23.6%).

Conclusions

Our network meta-analysis provides evidence that dorsal plating fixation significantly decreases the risk of CTS and could be the method of choice in DRF patients.

External fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes

Background

The objective of the study was to compare the efficacy of external fixation and volar plating on the functional parameter of displaced intra-articular (Cooney’s type IV) distal end radius fractures using the Green and O’Brien scoring system.

Materials and methods

This prospective randomized study comprised 68 patients treated with external fixation and 42 patients treated with volar locking plates. The patients were followed up at 6 months and 1 year after surgery. The assessment of pain, range of motion, grip strength and activity were assessed at each follow-up visit and scored according to the Green and O’Brien scoring system.

Results

At 1 year after surgery, we observed that external fixation showed significantly better results than volar locking plates using the Green and O’Brien scores for range of motion (22.0 ± 4.77 vs 19.89 ± 5.05), grip strength (19.91 ± 5.4 vs 16.89 ± 4.4) and final outcome (87.36 ± 11.62 vs 81.55 ± 11.32). No difference was found in pain and activity between these two groups of patients. Patients aged <50 years treated with external fixation showed excellent results (final score (91.57 ± 9.01) at 1 year follow-up.

Conclusion

External fixation showed superiority over volar locked plating after 1 year of surgery.

Level of evidence

IV.

Minimally invasive plate osteosynthesis for distal radius fractures

BACKGROUND

Fractures of distal radius are common injury in all age groups. Cast treatment with or without close reduction is a viable option. However, the results are often unsatisfactory with restricted function. The open reduction and internal fixation often results in extensive soft tissue dissection and associated high rates of infect and delayed/nonunion. The distractor/external fixator have reported good functional and anatomical results but the incidence of pin traction infection nerve injury and cosmedic deformity are high. We introduced a modified operative technique for minimally invasive plate osteosynthesis (MIPO) for distal radial fracture and evaluated the functional outcomes and complications.

MATERIALS AND METHODS

22 distal radial fractures (10 left, 12 right) were treated using the MIPO technique and two small incisions with a palmar locking plate from August 2009 to August 2010. The wrist function was assessed according to Dienst wrist rating system, and postoperative complications were recorded.

RESULTS

According to Dienst wrist rating system, 13 patients showed excellent results, 6 cases showed good results and 3 patients had moderate results. No patient had poor results. Thus, the excellent and good rate was 86.4%. One patient had anesthesia in the thenar eminence and this symptom disappeared after 3 months. One patient had delayed healing in the proximal wrist crease. Two patients had mild pain on the ulnar side of the wrist and two patients had limited wrist joint function.

CONCLUSION

The MIPO technique by using two small palmar incisions is safe and effective for treatment of distal radial fractures.

Functional outcome in patients with unstable distal radius fractures, volar locking plate versus external fixation: a meta-analysis

The aim of this study was to compare bridging external fixation with volar locked plating in patients with unstable distal radial fractures regarding functional outcome. A systematic search was performed in the Cochrane Central Register of Controlled Trials, Medline and EMBASE. All randomized controlled trials that compared bridging external fixation directly with volar locked plating in patients with distal radial fractures were considered. Three reviewers extracted data independently from eligible studies using a data collection form. Studies in which the primary endpoint was measured on the disabilities of the arm shoulder and hand (DASH) score at 3, 6 and 12 months were included in the analysis. To this end, mean scores and standard deviations were extracted. The software package Revman 5 provided by the Cochrane Collaboration was used for data analysis. Three studies involving 174 patients were analyzed. Ninety patients were treated with an (augmented) bridging external fixator and 84 with a volar locking plate. Data were analyzed with the random effects model. The robustness of the results was explored using a sensitivity analysis. Patients treated with a volar locking plate showed significantly lower DASH scores at all times. A difference of 16 (p = 0.006), six (p = 0.008) and eight points (p = 0.06) was found at 3, 6 and 12 months follow-up, respectively. Patients treated with a volar locking plate showed significantly better functional outcome throughout the entire follow-up. However, this difference was only clinically relevant during the early postoperative period (3 months).

Locking versus nonlocking palmar plate fixation of distal radius fractures

This study compared functional and radiological outcomes after treatment of extension-type distal radius fractures with conventional titanium nonlocking T-plates or titanium 1.5-mm locking plates. A total of 60 patients were included and followed for 4 to 7 years after receiving nonlocking T-plates (group A; n=30) or locking plates (group B; n=30) with and without dorsal bone grafting. Bone grafting was significantly more often performed in the nonlocking group to increase dorsal fracture fixation and stability (P<.003). Pre- and postoperative and follow-up values for palmar tilt, radial inclination, radial shortening, and ulnar variance were recorded. Age, sex, and fracture type were similarly distributed between the 2 groups. Postoperative and follow-up evaluation revealed equal allocation of intra-articular step formation and osteoarthritic changes to both groups. The overall complication rate was 25%. Compared with the nonlocking system, patients undergoing locking plate fixation presented with statistically significantly better values for postoperative palmar tilt (5.53° vs 8.15°; P<.02) and radial inclination (22.13° vs 25.03°; P<.02). However, forearm pronation was significantly better in group A (P<.005). At follow-up, radial inclination tended to approach a statistically significant difference in favor of group B. All clinical assessment, including Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand score, Green and O'Brien score, Gartland and Werley score, visual analog scale score, and grip strength, yielded no statistically significant difference between the 2 groups. Locking plates seem to provide benefits regarding surgical technique and comfort, improvement in implant anchorage (especially in osteoporotic bone), and reduce the necessity of additional bone grafting.

External fixation versus internal fixation for unstable distal radius fractures: a systematic review and meta-analysis of comparative clinical trials

OBJECTIVES

There is no consensus on the surgical management of unstable distal radius fractures. In this systematic review and meta-analysis, we pool data from trials comparing external fixation and open reduction and internal fixation (ORIF) for this injury.

DATA SOURCES

We searched electronic databases (including MEDLINE, EMBASE, and SCOPUS) and conference proceedings from 1950 to 2009 in the English literature.

STUDY SELECTION

We pooled data from 12 trials totaling 1011 patients (491 fractures treated with external fixation and 520 with ORIF). All randomized studies of external fixation to ORIF for unstable distal radius fractures were considered, and nonrandomized trials were included if and only if they directly compared external fixation with ORIF.

DATA EXTRACTION

Two authors independently extracted data from all eligible studies, including patient characteristics, sample size, fracture type, length of follow-up, intervention, and outcomes.

DATA SYNTHESIS

Continuous variables were pooled across studies using the method of standard mean differences (SMD) or effect size. ORIF demonstrated significantly better Disabilities of the Arm, Shoulder, and Hand scores (SMD, 0.28; 95% confidence interval, 0.03-0.53; P = 0.03), recovery of forearm supination (SMD, 0.23; 95% CI, 0.08-0.38; P = 0.003), and restoration of volar tilt (SMD, 0.53; 95% CI, 0.34-0.72; P < 0.00001). However, external fixation resulted in significantly better grip strength (SMD, -10.32; 95% CI, -16.36 to -4.28; P = 0.0008), and subgroup analyses of randomized studies showed external fixation yielded better wrist flexion (SMD, -0.38; 95% CI, -0.58 to -0.17; P = 0.0004).

CONCLUSIONS

For surgical fixation of unstable distal radius fractures, ORIF yields significantly better functional outcomes, forearm supination, and restoration of anatomic volar tilt. However, external fixation results in better grip strength, wrist flexion, and remains a viable surgical alternative.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

[Unrepaired fracture of the styloid process of the ulna: not a bad treatment result at distal radius fracture]

BACKGROUND

There are well-defined criteria for the treatment of distal radius fractures but the impact of an unrepaired fracture of the styloid process of the ulnar on recovery after operative treatment is uncertain. This study evaluated radiological and functional results after different operative treatment procedures of distal radius fractures in patients with an untreated fracture of the styloid process of the ulna and those without such a fracture.

METHODS

Out of 480 patients with operatively treated distal radius fractures 238 were examined at least 1 year after injury. The fracture of the styloid process of the ulna was not repaired. Three groups (patients without a fracture of the styloid process of the ulna, patients with a tip fracture and those with a basal fracture) were evaluated by multivariate analysis (MANOVA) in order to detect influences of the fracture of the styloid process of the ulna on the radiological and functional results.

RESULTS

Neither the existence nor the location of the fracture of the styloid process of the ulna had a significant effect on the radiological and functional results (p(function)=0,849, p(radiology)=0,330, p(scores)=0,426, MANOVA).

CONCLUSIONS

The repair of a fracture of the styloid process of the ulna is not necessary if reduction and fixation of the distal radius fracture is anatomical and stable.

Significant change in the surgical treatment of distal radius fractures: a nationwide study between 1998 and 2008 in Finland

BACKGROUND

Studies from the United States report a large increase in the surgical treatment of distal radius fractures with open reduction and internal fixation using locked plates. The aim of the present study was to determine whether the same trend has occurred in a Scandinavian country by assessing the number, incidence, and surgical methods of all surgically treated distal radius fractures in Finland over a recent 11-year period.

METHODS

The study covered the whole adult population (aged >19 years) in Finland during the 11-year period from January 1, 1998, to December 31, 2008. Data on surgically treated distal radius fractures were obtained from the nationwide National Hospital Discharge Registry.

RESULTS

During the 11-year study period, a total of 14,514 surgical operations (external fixation, percutaneous pinning, or plating) for adult distal radius fractures were performed in Finland. There was a dramatic shift toward internal fixation with plating; the incidence and number of platings more than doubled between 2006 and 2008. The incidence and number of external fixations decreased correspondingly. Percutaneous pinning was used in 13% of the surgical procedures during the study period.

CONCLUSIONS

A striking shift from external fixation to plating in the treatment of distal radius fractures has occurred in Finland over the past few years, despite the fact that the scientific literature does not support plating over external fixation. In addition, the incidence and number of surgeries for distal radius fractures doubled between 1998 and 2008. The reasons for these changes are not known.

Accurate radiographic measurement of the distal radial tilt

Both wrists in 189 patients who had been treated for dorsally displaced distal radius fracture were X-rayed with both right angle and 15° tilted lateral views. Two investigators measured the radial tilt. The mean difference in the angles recorded by the two investigators was 2.5° for the tilted and 3.7° for the right angle projections (p = 4.7 × 10(-8)). The precision of the method was 2.6° for the tilted and 3.5° for right angle projection. The mean angle measured on the tilted views was 3° more dorsal than on the right angle views for wrists with a volar tilt between 10° and 15°, and 0° to 2° for wrists with less volar tilt or dorsal displacement. Lateral projections tilted 15° allow more precise measurements than right angle views. Correction is not necessary when comparing to right angle views, as long as there is displacement in a dorsal direction of the distal fragment.

Repositioning and stabilization of the radial styloid process in comminuted fractures of the distal radius using a single approach: the radio-volar double plating technique

Background

A possible difficulty in intra-articular fracture of the distal radius is the displacement tendency of the radial styloid process due to the tension of the brachioradialis tendon.

Methods

Ten patients treated within one year for complex distal radius fractures by double-plating technique with a radial buttress plate and volar locking plate, through a single volar approach, were followed prospectively during 24 months. Outcome measures included radiographic follow-up, range of motion, grip strength and score follow-up (VAS, Gartland-Werley score and patient-rated wrist evaluation).

Results

Ten patients with intraarticular distal radius fractures with dislocation of the radial styloid process were treated with this technique. This resulted after 24 months in good clinical outcome (mean visual analog scale 0.9; almost symmetric range of motion; mean Gartland-Werley score 2 ± 3; mean patient-rated wrist evaluation 3.2 ± 2.4). Radiologic evaluation according to the Dresdner Score revealed anatomic reduction without secondary dislocation during the follow-up and uneventful consolidation.

Conclusions

The described technique strongly facilitates anatomic reduction and stable fixation of intra-articular distal radius fractures with dislocation of the radial styloid process and leads to satisfactory clinical and radiographic outcome.

Trends in the United States in the treatment of distal radial fractures in the elderly

BACKGROUND

Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting. However, since the introduction of the volar locking plating system in 2000, there has been an interest in the use of more aggressive treatment methods. The purpose of the present study was to assess changing trends in the treatment of distal radial fractures in elderly patients in the United States.

METHODS

We evaluated a 5% sample of Medicare data from 1996 to 1997 and a 20% sample from 1998 to 2005. Information on four treatment methods (closed treatment, percutaneous pin fixation, internal fixation, and external fixation) was extracted from the dataset. Other available data were diagnosis, physician specialty, and patient age, sex, and race. We calculated frequencies and rates to compare the utilization of different treatments over time.

RESULTS

Over the ten-year time period examined, the rate of internal fixation of distal radial fractures in the elderly increased fivefold, from 3% in 1996 to 16% in 2005. Closed treatment, however, remained the predominant method (used for 82% of the fractures in 1996 and 70% in 2005). Fractures in patients with an age of eighty-five years or more were significantly more likely to be treated in a closed fashion (p < 0.0001). There was a large variation among physician specialties with regard to the fixation methods that were used. Orthopaedic surgeons were significantly more likely to use closed treatment than hand surgeons were, whereas hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were.

CONCLUSIONS

Since 2000, although the majority of distal radial fractures are still treated nonoperatively, there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States.

Prospective Randomised Study of Intra-Articular Fractures of the Distal Radius: Comparison Between External Fixation and Plate Fixation

Introduction: Intra-articular fractures of the distal radius represent high energy, complex, unstable injuries and the optimal method of treatment remains controversial. Materials and Methods: The aim of the paper is to compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Thirty-five patients were enlisted from December 2003 to September 2005 after a failure of initial conservative treatment. The patients were randomised into EF or ORIF groups. The patients were followed-up at 1 week, 3, 6, 12 and 24 months. Clinical and radiological outcomes were measured. They were scored using the Green and O’Brien or the Gartland and Wertley score. Results: Of the 35 patients, 5 defaulted the 6-month follow-up and were excluded. We found that the clinical and radiological outcomes for the 2 groups were not significantly different. Complication rates were also similar. Conclusion: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF. Introduction: Intra-articular fractures of the distal radius represent high energy, complex, unstable injuries and the optimal method of treatment remains controversial. Materials and Methods: The aim of the paper is to compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Thirty-five patients were enlisted from December 2003 to September 2005 after a failure of initial conservative treatment. The patients were randomised into EF or ORIF groups. The patients were followed-up at 1 week, 3, 6, 12 and 24 months. Clinical and radiological outcomes were measured. They were scored using the Green and O’Brien or the Gartland and Wertley score. Results: Of the 35 patients, 5 defaulted the 6-month follow-up and were excluded. We found that the clinical and radiological outcomes for the 2 groups were not significantly different. Complication rates were also similar. Conclusion: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF.

Retrospective comparison of percutaneous fixation and volar internal fixation of distal radius fractures

A change in the practice of a single surgeon provided an opportunity for retrospective comparison of comparable cohorts treated with percutaneous fixation (17 patients) or a volar plate and screws (23 patients) an average of 30 months after surgery. The final evaluation was performed according to the Gartland and Werley and Mayo rating systems and the DASH questionnaire. There were no significant differences on the average scores for the percutaneous and volar plating groups, respectively: Gartland and Werley, 4 vs 5; Mayo, 82 vs 83; and DASH score 13 for both cohorts. Motion, grip, and radiographical parameters were likewise comparable. Volar internal plate and screw fixation can achieve results comparable to percutaneous fixation techniques in the treatment of fractures of the distal radius.

Evaluation of a treatment protocol in distal radius fractures: a prospective study in 581 patients using DASH as outcome

BACKGROUND AND PURPOSE

Distal radius fractures are most often treated nonoperatively, but sometimes they are treated surgically when deemed unstable. Based on the literature, a consensus protocol for treatment has been developed in southern Sweden to aid clinicians in their decision making. We evaluated the results of this protocol prospectively using a validated outcome instrument (DASH) in a large consecutive and population based series of unselected patients.

METHODS

581 patients were treated according the protocol. Age, sex, fracture side, and type of treatment were registered. The subjective outcome was measured by DASH. 133 patients were operated.

RESULTS

75% of the patients returned the questionnaire. The median DASH score at 3 months was 18.3 and at 12 months it was 7.5. All treatment groups had low DASH scores at the final follow-up. Reduced, nonoperated fractures had a worse score (11.6) than undisplaced (4.2) or operated fractures (6.0). Age was the only other predictor, with older patients having a worse score. A correlation was found between the short-version 11-item QuickDASH questionnaire and the full 30-item DASH, both at 3 months (r = 0.98) and at 1 year (r = 0.97) (p< 0.001 for both).

INTERPRETATION

Most patients have residual symptoms at 3 months after the fracture but are normalized at 1 year. Good final subjective result was achieved with the proposed protocol regardless of initial severity and treatment of the fracture, as indicated by a low median DASH score in all groups. There was correlation between QuickDASH and the full DASH, and the former could be used in future studies.

Comparison of external fixation, locking and non-locking palmar plating for unstable distal radius fractures in the elderly

This study compares the effectiveness of locking and non-locking palmar plating and external fixation for unstable distal radius fractures in the elderly. In a retrospective match-paired study, 45 patients aged 50 to 70 years who underwent surgery for C1/C2 distal radius fractures were evaluated. The surgical procedures were external fixation or plating with locking or non-locking palmar plates. Radiological and functional outcomes were assessed. Outcomes according to Gartland and Werley, Martini and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were compared. The locking palmar plate fixation method demonstrated significantly better radiological and functional results in comparison to external fixation and the non-locking palmar plating methods. The subjective assessment of plate fixation proved to be better than that of external fixation. Complications and reoperations were fewer for both plate fixation groups. Our data indicates that most displaced intra-articular distal radius fractures can be treated successfully with the locking palmar plate.

External fixation of distal radius fractures

External fixation has been used for the treatment of distal radius fractures for more than 50 years. Although the fixator configurations have undergone considerable modification over time, the type of fixator itself is not as important as the underlying principles that provide the foundation for external fixation. Although volar plate fixation is currently in vogue, the indications for external fixation remain largely unchanged. Newer fixator designs have also expanded the traditional usage to include nonbridging applications that allow early wrist motion. The following discussion focuses on the myriad uses for external fixation as well as the shortcomings and potential pitfalls.

Ist die Behandlung der instabilen distalen Radiusfraktur beim älteren Menschen mittels Fixateur externe nicht mehr indiziert?

BACKGROUND

In recent years there has been an increasingly marked shift in the operative treatment of unstable fractures of the distal radius. The introduction of locking compression plates has made it possible to extend the indications for palmar stabilisation according to the principles of internal fixation to extension fractures even in osteoporotic bone, and since then the new design has been used more and more widely. First clinical results show very good and good clinical and radiological outcomes in over 80% of cases after locking compression plate osteosynthesis. All this raises the question of whether external fixation is no longer indicated for distal radius fractures in the elderly, or is now no more than a second-line treatment.

PATIENTS AND METHODS

Within a 5-year period, 67 patients over 65 years of age were identified among 220 who had had unstable fractures of the distal radius in our hospital with external fixation. The average follow-up period (clinical and radiological examinations) was 37 months. We devoted particular attention to the analysis of complications and problems during the treatment.

RESULTS

Complete bone healing was observed in all patients treated with external fixation. In most cases, complications were minor pin-track infections (10%). The radiological follow-up examination revealed radial shortening by an average of 2 mm and an average radial shift of 0.2 mm. The joint angle was 2.5 degrees with lateral irradiation and 18 degrees with dorso-palmar irradiation. According to the Gartland and Werley score, the functional, radiological and subjective outcome was excellent or good in 87% of these patients.

CONCLUSIONS

Overall, internal fixation with angular fixed plates has definite benefits. The medium- and long-term follow-up and functional outcome still show no benefits over external fixation, however. External fixation is a genuine option, even if as second-line treatment.