Salvage procedure after malunited distal radius fractures and management of pain and stiffness

A proposed paradigm shift in the management of distal radius fractures

Background and objective

Distal radius fractures represent a remarkable orthopaedic entity. Most distal radius fractures can be treated conservatively with closed reduction and immobilisation with satisfactory results, while open reduction and internal fixation is reserved for displaced fractures. Our objective was to propose a paradigm shift in the management of distal radius fractures.

Methods

A literature search of management of distal radius fractures was conducted. PubMed and Cochrane databases were used for the search. English articles with open access or institutional subscription availability were included.

Key content and finding

Current literature supports operative management for younger active patients with defined radiographic inclusion parameters, but among the elderly there is little evidence of benefit. Most orthopaedic literature defines "elderly" as patients above 65 years of age. Non-surgical treatment for fractures of the distal radius tends to yield satisfactory functional results, and these favourable outcomes do not necessarily align with normal radiological parameters. For the minority of patients that have symptomatic malunion, corrective osteotomy is a good option to improve the function provided the symptoms can be clearly attributed to the malalignment.

Conclusion

The vast majority of distal radius fractures can be managed conservatively. Further studies are recommended to explore the feasibility of advocating for universal conservative treatment for patients with less functional demands while still having the option of staged surgery in the form of corrective osteotomy where there is symptomatic malunion amenable to anatomical correction. Future research should also aim to identify patients who would benefit most from surgical intervention by considering the type of functional recovery needed, rather than relying predominantly on the patient's chronological age as the determining factor in the decision-making process.

The Use of Montage Bone Putty in Assisting in the Maintenance of Reduction in Comminuted Distal Radius Fractures

Background  The distal radius fracture is the most common fracture in the United States. Achieving stable reduction and fixation of complex fracture patterns can be challenging. In order to help maintain reduction of comminuted fracture to simplify plating, the calcium phosphate-based bone putty Montage has been developed. Questions/Purposes  Does Montage assist in achieving stable reduction and fixation of complex distal radius fractures with an acceptable complication profile? Patient and Methods  We retrospectively analyzed all patients who were treated intraoperatively with Montage bone putty along with volar plate fixation at a large-volume urban county hospital. Preoperative, intraoperative, and postoperative measurements of radiographic features were recorded at 2 and 6 months, as were any complications. Statistical analysis was then performed on these values. Results  Preoperative and postoperative radiographs demonstrated significant improvement in standard distal radius fracture measurements, reflecting adequate reduction with the use of Montage intraoperatively. Critically, radiographs demonstrated maintenance of reduction compared to intraoperative fluoroscopy images at 2 months, showing short-term stability of the use of Montage in these fracture patterns as well as long-term stability at 6 months in a subset of patients. There were no major complications in this study. Conclusion  In this study, we demonstrate the utility of Montage bone putty for complex distal radius fractures with short-term follow-up and limited long-term follow-up. This initial study underlines its efficacy in maintaining reduction without major complications. Level of Evidence  IV, Therapeutic.

Treatment of post-operative infected nonunion distal radius fracture using the Darrach procedure and radioscapholunate fusion with volar locking plate

There is no established standard treatment for post-operative infected nonunion distal radius fracture with severe damage to the joint surface. Herein, we report a case of post-operative infected nonunion distal radius fracture with severe articular damage, which was treated using a combination of the Darrach procedure and radioscapholunate fusion with a volar locking plate after implant removal and antibiotic treatment. A 61-year-old man underwent internal fixation with a volar locking plate for a distal radius fracture. Repeated post-operative infections caused distal radius nonunion, a bone defect in the lunate fossa of the radius, subluxation of the carpal bones on the palmar and ulnar sides, and significant limitation of rotation. Implant removal and wound debridement were performed to control infection. After oral antibiotic treatment, the Darrach procedure and radioscapholunate fusion with a volar locking plate combined with ulnar head bone grafting were performed. The patient was able to perform his activities of daily living without any problems after the two-stage surgery. This is the first report describing the treatment of post-operative infected nonunion distal radius fracture with severe damage to the radiocarpal and distal radioulnar joints.

Computed Tomography and Pathobiomechanical-Based Treatment of Volar Distal Radius Fractures

Today, there are various classifications for distal radius fractures (DRF). However, they are primarily based on plain radiographs and do not provide sufficient information on the best treatment option. There are newer classifications that simultaneously consider the pathobiomechanical basis of the fracture mechanism and analysis of computed tomography images. Main determinants of which type of DRFs occurs are the strength/direction of the applied forces on the carpus and radius, and the position of the wrist relative to the radius during the fall. Reconstruction of the mechanism of injury provides information about which anatomic structures are involved, such as torn ligaments, bone fragments, and the dislocated osteoligamentous units. This article attempts to combine and modify current pathobiomechanically oriented classifications with an improved understanding of the "key fragments" to subsequently offer a treatment approach to stabilize these critical fragments through specific types of internal fixation.

Wrist arthroscopy for diagnosis and treatment of acute and chronic conditions

Wrist arthroscopy is a constantly evolving procedure. Allowing direct visualization and dynamic testing of intra-articular structures led to a novel approach toward traumatic and degenerative lesions based on most of the classifications routinely used in wrist surgery. The development of specific instrumentation, combined with a novel understanding of the local anatomy, progressively allowed wrist surgeons to describe more ambitious and complex surgeries. Wrist arthroscopy has become an increasingly useful tool in hand and wrist surgeons' panoply and seems promised to have further development in the future. This paper discusses the surgical technique and the various pathologies that can be treated by arthroscopy of the wrist.

The role of VFG in wrist arthrodesis: Long term results in a series of 11 patients and literature review

BACKGROUND

Total wrist fusion (TWF) is indicated for longstanding degenerative, posttraumatic and/or post-oncological conditions to provide pain relief and wrist stability at partial expense of wrist motion.

PATIENTS AND METHODS

A total of 11 consecutive patients who had completed TWF with Vascularized Fibula Graft (VFG) for massive distal radius defects were identified retrospectively from our center using inpatient records. We evaluated bone fusion times and long term functional outcomes following the procedure. Post-operative grip strength (GS) and prono-supination were objectively measured. The new Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to rate disability and symptoms; pre- and post- operative pain with the Visual Analog Scale (VAS) was assessed. A literature review of the present studies about TWF with VFG was performed, with the aim of comparing long-term functional results of the surgical techniques so far reported in the English literature.

RESULTS

Our experience with TWF using VFG appeared slightly better than that found in the literature. The procedure was successful in all the cases, achieving bone union in 4,8 months on average. Complication rate was 27,2%, no flap loss was recorded. There were no wrist instability, deformation or dislocation; mean pronation/supination (P/S) was 57,5°/61,2° Average grip strength resulted 59% of the contralateral side. Mean recorded levels of visual analog scale (VAS) for pain postoperatively were 2,32 ± 0,792, which improved significantly from the pre-operatively value of 7,90 ± 0,79. Mean overall satisfaction was good and all the patients comfortably returned to normal activities.

CONCLUSIONS

Wrist arthrodesis by means of VFG resulted to be an effective and reliable option in dealing with massive defects of distal radius with involvement of radio-carpal joint. Although the cohort analyzed is relatively small and definitive conclusions cannot be drawn, the long term radiographs and the overall functional outcomes encourage to use the described surgical option over other techniques, such as prosthetic replacement and non-vascularized bone grafts.

Inevitable nonunion after ulnar shortening osteotomy in patients with ulnar impaction syndrome and breast cancer under bisphosphonate treatment

BACKGROUND

Nonunion after ulnar shortening osteotomy (USO) was observed at a high rate in patients undergoing long-term bisphosphonate (BP) maintenance treatment after breast cancer surgery. Here, we report the unique features of these nonunions.

METHODS

In total, 485 patients who had undergone USO between March 2008 and September 2017 were screened for inclusion based on the following criteria: (1) definitive nonunion after USO; (2) prior history of or ongoing BP therapy after the diagnosis of breast cancer; and (3) no evidence of metastasis in the ulna treated with USO, as determined based on the radiological evaluation.

RESULTS

Five patients with histories of breast cancer and subsequent BP treatment were identified; all (100%) of these patients showed definitive nonunion after USO. The mean age was 56.2 years, and all ulnae were on the contralateral side to that of the original breast cancer. Intravenous Ibandronate^® and Zolendronate^® were administrated to one and four patients, respectively. The mean period of administration was 67.8 months. Three patients exhibited suspicious lesions impending atypical fracture on their femurs, and the other two patients were treated by intramedullary nailing after the occurrence of atypical fractures. Radiological evaluation revealed no evidence of a metastatic lesion, including in the musculoskeletal system, in any patient. Osteosynthesis was performed with cancellous iliac bone graft and mean of 4.3 months after osteosynthesis, union in all cases was achieved.

CONCLUSIONS

Problems associated with BP treatment are well known. Even in cases in which the agent is essential for preventing bony metastasis of breast cancer, the normal bony physiology, including bone turnover and healing, is likely to be compromised. In addition to atypical fractures of the femur and ulna, procedures such as USO are likely to be affected by BP. Furthermore, not only a primary iliac bone graft but also other method (oblique osteotomy) should be needed to avoid nonunion during plating in USO.

LEVEL OF EVIDENCE

IV, Retrospective case series.

Radiocarpal joint stiffness following surgical treatment for distal radius fractures: the incidence and associated factors

Background

Postoperative radiocarpal joint stiffness (RJS) is common in patients with distal radius fractures (DRFs). The purpose of this study was to record the incidence of RJS and to determine potential risk factors that may be associated with it.

Methods

We retrospectively included a series of patients who suffered from DRFs and underwent volar plate fixation. Patients’ basic data, radiographic data, and postoperative data were collected. The incidence of RJS during follow-up was recorded, and both univariate analyses and multivariate logistic regression were used to determine factors associated with it.

Results

A total of 119 patients were included in this study. After surgical procedures, there were 42 (35.3%) patients with RJS and 77 (64.7%) patients without. The incidence of RJS after surgical treatment is 35.3%. Multivariate analysis showed that intra-articular fracture (OR, 1.43; 95% CI, 1.13–1.81), pre-operative severe swelling (OR, 1.35; 95% CI, 1.05–1.74), post-operative unsatisfied volar tile (OR, 1.38; 95% CI, 1.01–1.89), and improper rehabilitation exercise (OR, 1.72; 95% CI, 1.18–2.51) were correlated with the incidence of RJS during follow-up.

Conclusions

Patients with intra-articular fracture, pre-operative severe swelling, post-operative unsatisfied volar tile, and improper rehabilitation exercise were factors associated with the incidence of wrist stiffness. Preoperative risk notification and postoperative precautions are necessary for relevant patients.

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year

INTRODUCTION

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year.

METHODS

A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.

RESULTS

Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = - 0.18, p = 0.04) and Mayo Score (r = - 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (< 2 mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65 years of age.

CONCLUSIONS

Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2 mm) was not associated with a worse clinical important outcome. Age (< 65/> 65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

Radioscapholunate fusion for posttraumatic osteoarthritis with consecutive excision of the distal scaphoid and the triquetrum: A comparative study

The aim of this study was to assess the clinical and radiographic outcomes after radioscapholunate (RSL) fusion for posttraumatic osteoarthritis. This was a retrospective, dual-center study of all patients who underwent RSL fusion between 1995 and 2015 for posttraumatic radiocarpal osteoarthritis. Patients were assessed at the final review to determine clinical (pain, wrist range of motion and strength), self-reported (QuickDASH, PRWE and MWS scores) and radiological (degenerative osteoarthritis in the scaphotrapeziotrapezoid (STT) or midcarpal joint and radiocarpal fusion) outcomes. We analyzed three groups: RSL fusion alone, RSL fusion with distal scaphoid excision (DSE) and RSL fusion with DSE and triquetrum excision (TE). Eighty-five patients were included; 10 were lost to follow-up and 11 required conversion to total wrist fusion before the final review. Finally, 64 patients had both clinical and radiographic evaluations. The mean follow-up was 9.1 years (range 1-21.4). RSL fusion alone was performed in 29 patients, RSL fusion with DSE in 23 and RSL fusion with DSE and TE in 12. At the final follow-up, the three groups did not differ in their pain or wrist motion. Overall, 47 (73%) patients were satisfied or very satisfied with the procedure. DSE significantly decreased STT osteoarthritis and radiocarpal non-union. The total wrist osteoarthritis rate after RSL fusion was 55%. RSL fusion is an effective procedure to preserve some motion in wrists with posttraumatic radiocarpal osteoarthritis. DSE prevents STT osteoarthritis by removing bony impingement and increases the fusion rate. LEVEL OF EVIDENCE: Level IV, Case series, Therapeutic studies.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Corrective osteotomy after malunited distal radius fractures

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Arthroscopic assisted treatment of distal radius fractures and concomitant injuries

Wrist arthroscopy is mainly used to assist fracture reduction and fixation and to diagnose and treat concomitant injuries mainly to the scapholunate (SL), lunotriquetral (LT) ligament and the triangular fibrocartilage complex (TFCC). Arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures (DRFs). Yet, the literature that the functional outcome correlates with the use of arthroscopy, is limited. Non-surgical treatment and immobilization is recommended for Geissler grade I-III Sl-ligament injuries, while open reduction, ligament suture and/or K-wire pinning is mandatory for complete ligament tears according to Geissler grade IV. This manuscript describes the current literature and gives insight into the authors' opinions and practice.