Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review

Pronator quadratus preserving versus pronator quadratus dissecting approaches in volar plate fixation of distal radius fractures: a systematic review of comparative studies

PURPOSE

To compare pronator quadratus preserving (PQ-P) approaches with PQ dissecting (PQ-D) approaches in volar plate fixation of distal radius fractures (DRFs).

METHODS

Three databases were searched on March 10th, 2024. The authors adhered to the PRISMA and R-AMSTAR guidelines and Cochrane Handbook for Systematic Reviews. Data on demographics, fracture classifications, patient reported outcome measures (PROMs), range of motion, radiographic parameters, and complications were extracted.

RESULTS

Thirteen studies with a total of 1007 fractures were included. Two of three studies reported lower DASH scores in the PQ-P group between 6 weeks and 3 months postoperative, however no studies reported lower scores in the PQ-P group after 3 months. Three of three studies reported significantly lower VAS scores at 6 weeks postoperative, however no studies reported significant differences after 6 months. Only one of six studies reported significantly greater flexion, extension, and pronation in the PQ-P group. One of four studies reported greater radial deviation in the PQ-P group, while there were no differences in supination or ulnar deviation. One of ten and one of six studies reported greater volar tilt and ulnar variance or radial length, respectively, in the PQ-P group.

CONCLUSION

There is not sufficient evidence supporting the utility of PQ-P approaches over conventional PQ-D approaches for volar plate fixation of DRFs, especially at long-term follow-ups (3+ months). There may be short term benefits with PQ-P approaches, specifically with regards to PROMs in the short-term (< 6 weeks), however there is limited high-quality evidence supporting these findings.

LEVEL OF EVIDENCE

Level III.

[Basic principles of surgical treatment of distal radius fractures]

Distal radius fractures are one of the most frequent fractures of the upper extremities. The decision for conservative or surgical treatment is made after appropriate diagnostics using conventional radiographic and usually computed tomography imaging examinations. If the indications for surgical treatment are present, various options for reduction and fixation are available. The spectrum ranges from closed to open procedures up to accompanying arthroscopic support. Appropriate preoperative patient education about the procedure and the planned postinterventional treatment is essential. The goal of treatment is to restore wrist function while maintaining mobility and strength with a low risk of complications. All surgical procedures share the principle of reduction to restore anatomical relationship followed by fixation. Closed procedures include fixation with Kirschner wires and the construction of an external fixator. Volar locking plate osteosynthesis has become established in recent years as the method of choice for the majority of the fractures to be treated. For special fracture patterns and the treatment of accompanying injuries, arthroscopic support can be indicated. There is no uniform consensus on the best choice of procedure. This article discusses the possible procedures including the approaches, fixation techniques and specific follow-up treatment.

Impact of Pronator Quadratus Muscle Tear in Distal Radius Fractures on Patient Outcomes: Analyses of 55 Patients in a Volar Locking Plate Arm of a Randomized Clinical Trial

Background The advantage of pronator quadratus (PQ) repair following internal fixation via the volar approach in distal radius fracture (DRF) surgery remains unconfirmed in the literature. The aim of this study was to compare grip strength, patient-reported outcomes, and functional results between patients with an intact PQ and those with a ruptured PQ before undergoing surgery with a volar locking plate for dorsally displaced unstable extra-articular DRFs. Methods A total of 120 patients aged 55 years and older were included in a randomized controlled trial comparing a volar locking plate with a dorsal nail plate. Of the 60 patients randomized to the volar plate group, the integrity of the PQ muscle was recorded during surgery for 55 patients, who were included in this study. The outcomes measured were the Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE) score, the EQ-5D index, the visual analog scale (VAS) score, grip strength, and range of motion (ROM). Results The median age was 67 years (range 55 to 88), and the one-year follow-up rate was 98%. Patients with an identified intact PQ (28/55) before surgical release had better QuickDASH scores after one year (2.5 vs 8.0, mean difference 5.5, 95% CI: 1.3 to 9.8, p=0.028). Patients in the intact group also had better EQ-5D Index scores after one year (0.94 vs 0.85, mean difference 0.089, 95% CI: 0.004 to 0.174, p=0.031), and demonstrated better grip strength throughout the trial; after one year: 24 kg vs 20 kg (mean difference 3.9; 95% CI: 0.3 to 7.6, p=0.016). After one year, the intact group had regained 96% of their grip strength and the nonintact group had regained 93% of their grip strength compared to the uninjured side. The observed differences may be of questionable clinical importance, as they were lower than those of previously proposed minimal clinically important differences (MCIDs). Conclusions Patients with a DRF and a ruptured PQ prior to surgery exhibited higher QuickDASH scores and lower EQ-5D index scores after one year. The integrity of the PQ should be reported in future studies.

Is pronator quadratus muscle repair required after anterior plate fixation for distal radial fractures? A prospective randomized comparative study

In this prospective, randomized comparative study in patients with distal radial fractures, we aimed to determine whether surgical repair of the superficial head after anterior locking plate fixation of the radius improves clinical or functional outcomes or both, and distal radioulnar joint stability. One hundred patients were randomized to undergo distal radial fixation with or without repair of the superficial head. Twenty-one patients were lost to follow-up, leaving a final sample of 79 patients. No differences were observed between the groups in functional scores or complication after operation. Surgical repair of the superficial head of the pronator quadratus muscle after osteosynthesis with an anterior locking plate for distal radial fractures does not appear to substantially contribute to preserving distal radioulnar joint stability or improving the consolidation process.Level of evidence: II.

The Outcome of under 10 mm Single-Incision Surgery Using a Non-Specialized Volar Plate in Distal Radius Fractures: A Retrospective Comparative Study

BACKGROUND

The distal radius fracture is a common orthopedic injury. We aimed to share the surgical steps and investigate the outcomes of treating distal radius fractures with wounds ≤10 mm using a globally accessible locking plate.

METHODS

We collected 46 patients who underwent surgery via a <10 mm wound, with a control group consisting of 40 patients who underwent conventional procedures. Both groups were treated using the same volar plate. We compared the radiographic reduction quality, including volar tilt angle, radial inclination angle, and ulna variance. Additionally, clinical outcomes, such as pain assessed using VAS, Q-Dash score, and PRWE, were evaluated. Patient satisfaction with the wound was also analyzed. The follow-up time for the clinical outcomes was 24.2 ± 13.47 months.

RESULTS

There were no differences in the quality of reduction in parameters such as the volar tilt angle (p = 0.762), radial inclination angle (p = 0.986), and ulna variance (p = 0.166). Both groups exhibited comparable results in pain VAS (p = 0.684), Q-Dash score (p = 0.08), and PRWE (p = 0.134). The ≤10 mm incision group displayed an increase in satisfaction with the wound (p < 0.001).

CONCLUSIONS

Treating distal radius fractures with a <10 mm wound using a non-specialized locking plate is a feasible approach. It does not compromise the quality of fracture reduction or functional scores and improves wound satisfaction.

[Distal radius fracture-tactic and approach]

OBJECTIVE

The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare.

INDICATIONS

Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement.

CONTRAINDICATIONS

The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation.

SURGICAL TECHNIQUE

The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen.

POSTOPERATIVE MANAGEMENT

In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization.

RESULTS

Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

A New Repair Technique in Pronator Quadratus in Management of Distal Radius Fracture: Comparison with Primary Repair and Unrepaired Techniques

Objective  We aimed to compare the functional and clinical results between our new repair technique in the groups with and without pronator quadratus (PQ) repair in distal radius fractures treated with plate fixation using the volar approach. Methods  The medical records of patients who underwent open reduction and volar plate fixation due to distal radius fracture between 2018 and 2020 were studied. In group A, PQ cannot be sutured or tension may occur, the intact radial fascia of the deep anterior fascia (DAF) was placed under the flexors toward the PQ and it was sutured with a 3-0 slow-absorbable monofilament suture to DAF. In group B, no repair was performed. In group C, PQ was sutured with traditional method. Range of motion (ROM) of wrist and handgrip strengths were measured at final examination. Pain was assessed with Visual Analogue Score (VAS), and functional status was evaluated with Quick - Disabilities of the Arm, Shoulder, and Hand (DASH). Complications which included tendinopathy, neuritis, tendon rupture due to plate irritation, implant failure, and malunion were also compared. Results  Seventy-seven patients (group A, 21, group B, 24, group C, 32 patients) were included in the final follow-up examination who met our inclusion criteria. Among the clinical, functional, and radiological results such as ROM, VAS, DASH, grip strength, and complications in the all group at a mean postoperative of 16.6 months no significant difference was observed. Conclusion  Although there was no significant difference between the groups in this study, we think that covering the plate may prevent long-term complications.

Evaluation of the treatment of distal radial volar fracture by different methods sparing the pronator quadratus

OBJECTIVE

The traditional volar approach requires the release of the pronator quadratus (PQ) muscle in the treatment of distal radius fractures. However, intraoperative repair of the PQ muscle often fails due to tissue injury and unstable muscle repair. This study compared the outcomes of different methods of sparing the PQ muscle combined with the volar plate in treating distal radius fractures.

METHODS

A total of 95 patients with distal radius fractures sparing the PQ muscle were enrolled with the brachioradialis (BR) splitting approach (group A, 33 people), the volar plating insertion PQ muscle approach (group B, 35 people) and traditional Henry approach without sparing PQ muscle (group C, 27 people). Postoperative internal fixation, fracture healing and postoperative complications were observed in the three groups. The visual analog scale (VAS) of postoperative wrist pain was compared between three groups. The Dienst joint scale was used to evaluate the wrist function of patients, and imaging indexes were used to evaluate the surgical efficacy.

RESULTS

A total of 95 patients with distal radius fractures were followed up for more than one year after surgery. All fractures obtained good union, with no vascular injury, nerve injury or wound infection. Outcomes at three days, one month and three months all showed no significant differences in postoperative imaging indexes among three groups and no significant differences in various indexes among three groups during the same period. The mean operative time in group C was significantly lower than that in groups A and B. There was significant difference in the mean operation time between group A and group B. The amount of mean operative blood loss or mean bone union time in groups A and B was significantly lower than those in group C. No significant difference was shown in mean operative blood loss or mean bone union time between group A and group B. No significant differences in limb function scores, VAS scores and the mean range of motion existed among three groups at the 12-month postoperative follow-up. However, outcomes assessed one week, one month and three months after surgery demonstrated significant differences in the VAS scores and the mean range of motion among three groups, and the group B had lower VAS score and greater the mean range of motion. According to Dienst score, the excellent rate in groups A, B and C was 91.0% (30/33), 94.2% (33/35) and 85.2% (23/27), respectively, at 12 months after surgery. Tendon irritation occurred in 2 cases and joint stiffness in 1 case in group A. In group B, there were 2 cases traumatic arthritis and 2 cases delayed carpal tunnel syndrome and 1 case tendon irritation. In group C, tendon irritation and delayed carpal tunnel syndrome occurred, respectively, in 3 cases.

CONCLUSION

Our results demonstrated that these two different surgical approaches were effective ways to reserve PQ and had good clinical outcomes. The volar plating insertion PQ muscle approach could reduce early postoperative pain, promote early activity and return to normal life, while the BR splitting approach was more advantageous in intraoperative fracture exposure and could shorten the operative time. However, some defects also existed. At 12 months of follow-up, no significant advantage was seen in sparing the PQ muscle. Therefore, surgeons should be aware of their individual characteristics and choose patients carefully.

Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating

Background

Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes.

Methods

A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap.

Results

Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation.

Conclusions

The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.

Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial

BACKGROUND

This study aimed to compare functional outcomes of a volar plate osteosynthesis for distal radius fractures (DRF) performed with either a standard volar approach (SVA), which required detachment of the pronator quadratus muscle, or a pronator-sparing approach (PqSA).

MATERIALS AND METHODS

This prospective randomized controlled study included 106 patients scheduled for volar plate osteosyntheses. Patients were allocated to either the SVA group (n = 53) or the PqSA group (n = 53). Patients were blinded to treatment until completion of the study. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcome parameters were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Modified Mayo Wrist Score (MMWS). Follow-up examinations were performed at 8 weeks and 3, 6, and 12 months postoperatively.

RESULTS

Overall, 91 patients were included in the final analysis: 48 in the SVA group and 43 in the PqSA group. The two cohorts were not significantly different in demographic characteristics, including age, sex, injuries on the dominant side, type of injury, and fracture classification. We found significant differences between groups at 6 months in the mean PRWE (SVA: 12.3 ± 10.4, PqSA: 18.9 ± 14.11 points) and in the mean DASH score (SVA: 12.3 ± 11.9, PqSA: 19.3 ± 16.7 points), which favoured the SVA. We found no significant differences between groups in the MMWS or in the PRWE and DASH scores at any other time points.

CONCLUSIONS

This randomized comparative clinical trial failed to demonstrate that a volar plate osteosynthesis performed with a PqSA could improve the outcome, compared to the SVA, in patients with DRF.

LEVEL OF EVIDENCE

II Trial registration Comparison of Two Volar Plating Systems for Distal Radius Fractures, ClinicalTrials.gov (NCT03474445), registered 22 March 2018, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03474445?cond=radius&cntry=AT&draw=2&rank=1.

Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients?

INTRODUCTION

Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing.

MATERIALS AND METHODS

From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device.

RESULTS

212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%.

CONCLUSION

The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus.

Does pronator quadratus repair affect functional outcome following volar plate fixation of distal radius fractures? A systematic review and meta-analysis

Introduction

The study aimed to evaluate the efficacy of pronator quadratus (PQ) repair versus no repair following volar plate fixation of distal radius fractures.

Methods

A comprehensive search was performed in PubMed, CNKI, EMBASE, Web of Science, Ovid, and Cochrane Library databases. All randomized controlled trials comparing PQ repair with no repair in distal radius fractures before January 2023 were included. Two investigators independently screened eligible articles, assessed the study quality, and extracted data from included studies. Continuous variables used standardized mean difference and 95% confidence interval as efficacy statistics. The meta-analysis was performed using the Revman 5.4 software.

Results

A total of 430 patients in 7 RCT studies were included in this meta-analysis, of which 218 underwent PQ repair, while 212 patients underwent no repair. The results of the meta-analysis displayed statistically significant differences in grip strength (short-term), pronation angle (short-term), and pronation strength (short- and long-term) between the two groups. No significant difference in other outcomes was found between the two treatment arms.

Discussion

The repair of PQ may further increase grip strength and pronation function in the short-term and enhance long-term pronator muscle strength compared to no repair. However, due to the small number of articles included in the study, the above conclusions need to be verified by a larger sample and multi-center clinical study.

Use of free radial forearm and pronator quadratus muscle flap: Anatomical study and clinical application

The authors present an anatomical study and clinical experience with radial forearm flap (RFF) and pronator quadratus muscle (PQM) application in the reconstruction of various body areas. The aim was to describe the anatomical placement and proportions of the PQM, the anatomical location of the major arterial branch of the radial artery supplying the PQM, and the application of this knowledge in clinical practice. The anatomical study was based upon an analysis of 13 fresh adult cadaver upper extremities, of which nine were female and four male; both arms from the same donors were used in four cases. The study of the PQM was performed using a dye-containing intraarterial injection, standard macro- and micro-preparation techniques, and chemical digestion. The data on the PQM size in males and females, thickness of the radial artery branch (the principal artery nourishing the muscle), and its position were analysed. The radial artery branch nourishing the PQM was identified in all cadaveric specimens of the anatomical study. In addition, 12 patients underwent reconstructions of soft and bony tissue defects using a RFF + PQM (pedicled or free flap). The radial artery branch perfusing the PQM was identified in all cases. The flap was used for the management of defects of the head (seven cases), arm (three cases) and lower leg (two cases). The harvest site healed well in all cases and, with the exception of one case in which a partial necrosis of the flap was observed, all flaps remained viable, which demonstrated the safety of the method.

Evaluation of sparing the pronator quadratus for volar plating of distal radius fractures: a retrospective clinical study

BACKGROUND

The most commonly used approach for distal radius fractures is the traditional Henry approach. However, it requires an intraoperative incision of the pronator quadratus (PQ) muscle, which results in a series of complications if the repair of the PQ fails.

AIM

The objective of this study was to investigate the efficacy of sparing the pronator quadratus for volar plating of the distal radius fractures.

METHODS

Seventy-six patients who suffered from distal radius fractures of types 23-B, 23-C1, and 23-C2 as per the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification were treated with volar locking plate fixation using either the PQ muscle incision and repair (group A, n = 39) or the PQ muscle preservation approach (group B, n = 37). Intraoperative index, postoperative efficacy and complications of patients were recorded and evaluated.

RESULTS

All patients were followed up for more than one year after surgery. All fractures achieved union. There were significant differences in mean operative time, mean intraoperative blood loss, and mean fracture healing time between the two groups. Still, there were no significant differences in limb function scores between the two groups at the 12-month postoperative follow-up. Outcomes assessed at 1 week, 1 month, and 3 months after surgery demonstrated significant differences in the mean range of motion and pain-related visual analog scale (VAS) between the two groups. As the range of motion and grip strength increased, the VAS scores decreased, and there was no significant difference between the two groups at 12 months postoperatively. Although tendon irritation and delayed carpal tunnel syndrome were more common in group A than in group B (7.6% vs. 0% and 5.1% vs. 0%, respectively), the differences were not statistically significant.

CONCLUSION

The modified Henry approach with sparing pronator quadratus muscle has no significant advantage in the range of wrist motion and upper limb function in the late stage. Nevertheless, the intraoperative placement of the plate under the pronator quadratus muscle can shorten the operation time, reduce intraoperative bleeding, reduce early postoperative pain, promote early activity, and improve the patient's quality of life. It is recommended that the pronator be preserved at the time of surgery.

Neurovascular anatomy of pronator quadratus for reanimation of blepharoptosis

PURPOSE

Pronator quadratus (PQ) is a quadrilateral muscle on a volar distal side of the forearm. The purpose of this study was to establish a novel surgical technique for reanimation of the upper eyelid for severe ptosis using PQ functional free muscle flap.

METHODS

The current study is a cadaveric study, designed to assess a PQ free flap transfer that lies between the frontalis muscle and the upper eyelid. Fourteen PQ from fourteen embalmed cadavers were dissected, and their neurovascular pedicles were isolated. Then they were transferred to the area on the contralateral side between the frontalis muscle and upper eyelid tarsal cartilage. Measurements of the PQ flap, antebrachial region, orbitofrontal region, recipient vessels, and motor nerve were performed using a caliper. The extendibility of neurovascular pedicles was evaluated by measurements of lengths. In addition, the diameter of PQ flap vascular pedicle vessels was compared with recipient vessels.

RESULTS

The mean width of the proximal border of PQ was 41.92 ± 2.05 mm and the distal border of the PQ was 42.84 ± 4.04 mm. The mean PQ artery (type II, Mathes-Nahai flap classification) length was found to be 117.72 ± 7.77 mm. The mean diameter of the anterior interosseous nerve was 1.89 ± 0.08 mm. The mean diameter of the uppermost branch of the frontal branch of the facial nerve was 1.18 ± 0.25 mm. The length and diameter of neurovascular pedicles of muscle flaps were adequate for microvascular anastomoses and neurorrhaphy.

CONCLUSIONS

The results of this anatomical study demonstrate that the PQ free flap transfer has anatomical features that are suitable and compatible with the surgical treatment of blepharoptosis.

Minimally Invasive Pronator Quadratus Sparing Approach versus Extended Flexor Carpi Radialis Approach with Pronator Quadratus Repair for Volar Plating in Distal Radial Fractures

Background  Several volar plating techniques exist to treat distal radial fractures. Question  We investigated minimally invasive plate osteosynthesis (MIPO) with pronator quadratus (PQ) sparing versus conventional flexor carpi radialis approach for volar plating with PQ repair after distal radial fractures during the first postoperative year. Patients and Methods  Prospective data of two consecutive cohorts were compared: 62 patients in MIPO group with an average age of 61.2 years and 66 patients in PQ repair group with an average age of 61.4 years completed the entire follow-up period. Results  Range of motion was not significantly different, except flexion-extension that was significantly higher in the MIPO group. Quick Disabilities of the Arm, Shoulder and Hand was significantly lower in the MIPO group. Pain visual analogue scale was only significantly lower at 6 weeks. Grip strength measurements and patient satisfaction were not significantly different. Conclusions  MIPO volar plating with PQ sparing is a surgical technique that can be chosen according to surgeon's preference and expertise, resulting in a better flexion-extension mobility and function score according to our study. Level of evidence  This is a Level 3 study.

IS VOLAR PLATING IN DISTAL RADIUS FRACTURES SAFE REGARDING PRONATOR QUADRATUS?

ABSTRACT Objective: This study aimed to investigate whether isokinetic strength decrease significantly after using volar plating for distal radius fractures and evaluate the pronator quadratus muscle regarding atrophy. Methods: This study took place between 2011 and 2015 and included 18 distal radius fracture patients (group 1) who were treated via volar plating at least one year prior and 14 healthy controls (group 2). All participants were tested isokinetically. Grip strength, radiological evaluation, wrist range of motion, disabilities of the arm, shoulder, and hand and visual analog scale scores were assessed for clinical and functional outcomes. Ultrasonography evaluated the pronator quadratus muscle thicknesses. Results: The peak supination torque (PT) and supination work per repetition (WPT) strength values significantly decreased (p:0.039, p:0.025, respectively). Although we determined an 11% pronation PT deficit and a 19% pronation WPT deficit, neither were significant. In group 1, the pronator quadratus muscle thickness decreased 5.9% ± 13.3 in the radial area and 9.7% ± 10.5 in the interosseous area according with ultrasonography; these results were not statistically significant compared to group 2. All clinical and functional outcomes were not statistically significant between the groups. Conclusion: The use of volar plating after distal radius fractures is a safe method regarding isokinetic strength and pronator quadratus muscle atrophy. Level of evidence III; Retrospective case-control study .

Should We Repair the Pronator Quadratus in a Distal Radius Fracture with an Ulnar Styloid Base Fracture? A Biomechanical Study

Background  Merits of repairing the pronator quadratus (PQ) to restore distal radioulnar joint (DRUJ) stability after a volar approach remain controversial. Distal radius fractures are often associated with ulnar styloid fractures (USF). When involving the fovea, this USF can lead to a DRUJ instability. The PQ repair may be key in reducing this DRUJ instability. Methods  This study aims to assess the biomechanical role of PQ repair in a cadaveric model of USF. In 17 forearm specimens, a USF including the fovea was executed. Positional changes of the DRUJ in forearm rotation and dorso-palmar (DP) translation were measured with variable loads (0, 2.5, and 5N) applied to the PQ origin. Results  Forearm rotation and DP-translation decreased significantly with PQ loading of 5N, changing on average by 5 degrees and 0.6 mm, respectively. Conclusion  We found a significant decrease in forearm rotation and DP-translation comparing a fully loaded PQ to an unloaded PQ in our cadaveric model.

Correlation of Flexor Pollicis Longus Tendon Status by Ultrasonography with Plate Position on Radiographs Following Volar Plate Fixation of Distal Radius Fractures with Pronator Quadratus Repair

BACKGROUND

Purpose was to correlate flexor pollicis longus tendon (FPL) attrition using Ultrasonography with plate position on radiographs following volar locked compression plate fixation (LCP) in patients who have undergone pronator quadratus (PQ) repair for distal radius fractures.

METHODS

Status of flexor pollicis longus tendon was analyzed by ultrasonography in patients who underwent volar locked compression plating with pronator quadratus repair at a minimum of one year follow up. Soong's criteria was used to assess the plate position and then correlated the ultrasonography findings of flexor pollicis longus.

RESULTS

There were 33 patients included in our study, of which 15 belonged to Soong's grade zero, 10 were grade one and eight were grade two. Flexor pollicis longus attrition was noted in all cases with grade two plating.

CONCLUSION

Pronator quadratus repair may not prevent attritional changes in higher grades of Soong's, hence follow up may be required in these patients to identify attritional changes and early implant removal to prevent complications.

The Pronator Quadratus Muscle After Volar Plating: Ultrasound Evaluation of Anatomical Changes Correlated to Patient-Reported Clinical Outcome

Background: Repair of the pronator quadratus (PQ) muscle with sutures has been reported durable after volar plating of distal radius fractures (DRF). It is unclear how the muscle reacts if not repaired and if a retracted muscle correlates to worse functional outcome or complications. In this study, we use ultrasound to investigate the anatomy of the PQ muscle after volar plating with PQ repair or nonrepair and correlate the ultrasound findings with patient-reported outcome. Methods: Participants were recruited from a clinical trial where they were randomly allocated to repair or nonrepair of the PQ muscle after volar plating of DRF. The participants and radiologist were blinded to group allocation. Ultrasound imaging of both fractured and contralateral wrists was performed 3 months after surgery. Ultrasound measurements included the difference in length of PQ muscle between the injured and uninjured side, retraction of PQ muscle, and tendon complications. The length and number of retractions were correlated to complications and Patient-Rated Wrist Evaluation (PRWE). Results: The mean difference of the difference in length measurements was 4.4 mm in the nonrepair group and 2.7 mm in the repair group with a mean difference between groups of 1.7 mm. This was statically significant; however, there were no clinical or statistical differences in complication rate or PRWE between the two groups. Conclusion: The PQ length was significantly shorter and the number of retractions significantly larger without repair of the PQ muscle; however, neither length nor retraction correlated significantly with complication rate or PRWE.

Is pronator quadratus repair necessary to improve outcomes after volar plate fixation of distal radius fractures? A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was conducted to compare functional outcomes with or without pronator quadratus (PQ) repair after volar plate fixation of distal radius fractures.

METHODS

An electronic search was conducted for PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google Scholar databases up to 15th January 2020. Both retrospective case-control and randomised control trials (RCTs) were included.

RESULTS

A total of 6 studies met the inclusion criteria. 4 were RCTs and 2 were retrospective studies. The primary outcome was the difference in the Disabilities of the Arm, Shoulder, and Hand (DASH) scores between the two groups. On analysis of 203 patients with PQ repair and 180 patients with no repair, our results indicated no statistical significant difference in DASH scores between the two groups (SMD: 0.43, 95% CI: -0.12 to 0.98, I2=85%, p=0.12). Also, meta-analysis did not demonstrate any difference in grip strength (SMD: -0.10, 95% CI: -0.53 to 0.33, I2=64%, p=0.64) and pronation strength (SMD: -0.02, 95% CI: -0.82 to 0.78, I2=82%, p=0.96) with or without PQ repair. The pooled analysis did not demonstrate any benefit of PQ repair in improving postoperative ROM.

CONCLUSION

Our results indicate that repair of PQ muscle may not be necessary after volar plate fixation of distal radius fractures. Further large scale RCTs shall validate our conclusions.

LEVEL OF EVIDENCE

II, systematic review and meta-analysis.

Corrective Osteotomy of Distal Radius Malunion Using a Rectangular-shaped Iliac Bone Graft and Volar Plating

Distal radius fractures are one of the most common injuries seen by orthopedists at the emergency room and clinics. Severity and configuration may vary, and therapeutic options are broad, but regardless of the course of treatment, all cases can potentially lead to malunion. When malunion requires surgical correction, the surgery can be technically demanding. Here, we demonstrate an alternative technique to perform corrective osteotomies for extra-articular or minimally displaced articular distal radius malunion. We provide simplification of the procedure by eliminating one of the planes taken into consideration when performing an osteotomy. This technique includes the use of a tricortical iliac bone graft, which we feel, provides dependable structural support, preventing collapse. The technique allows the surgeon an easy means to access the osteotomy gap and apply the graft. Finally, we supplement this surgical technique by providing our outcomes. Our data suggest that the technique effectively restores radiographic wrist parameters and provides good union rates.

Pronator quadratus repair after volar plate fixation in distal radial fractures: evaluation of the clinical and functional outcome and of the protective role on the flexor tendons-a randomized controlled study

The objective was to evaluate pronator quadratus (PQ) repair following volar plating of distal radial fractures on clinical and functional outcome, as well as flexor tendon friction, during the first 12 months in ideally positioned plates (Soong 0). Confounding factors like variation in plate positioning, anatomical consolidation of the fracture and associated lesions were excluded. Eighty patients were included with distal radius fractures treated by volar locking plate in Soong grade 0 position, who were randomized to group PQ repair and group no repair. Sixty-five patients completed the 1-year follow-up: group PQ repair (n = 35) and group no repair (n = 30). Primary outcomes included range of motion, grip strength, pain level and QuickDASH. Secondary outcomes included distance between flexor pollicis longus (FPL) and volar rim and the largest distance between FPL and plate (soft tissue thickness occupied by PQ), assessed by ultrasonography. Mobility, grip strength and QuickDASH revealed no significant differences, except extension was significantly higher only in first 3 months and radial deviation was significantly higher only at 6 weeks after PQ repair. Pain level was significantly lower after PQ repair only in the first 3 months. Distance between FPL and volar rim and the largest distance between FPL and plate were significantly higher after PQ repair. No friction contact between FPL and volar rim was measured in both groups at all measurement moments. Consequently, protective flexor tendon effect of PQ repair could consequently not be concluded. In conclusion, clinical and functional short term benefits, except improved wrist extension and reduced pain in the first 3 months, were not proven in this study. In Soong grade 0, PQ repair is probably not necessary to prevent flexor tendon pathology. In Soong grade 1 or 2, this is still to be investigated. LEVEL OF EVIDENCE: 2.

Surgical comfort and clinical outcomes of MIPO with an extra-short plate designed for distal radius fractures

OBJECTIVES

Volar locking plates (VLPs) are increasingly used for distal radius fractures (DRFs) with minimally invasive plate osteosynthesis (MIPO), but surgery learning curves could be long. The purpose of this study was to assess a new extra-short plate with two locking diaphyseal divergent screws, specifically designed for MIPO, preserving the pronator quadratus muscle.

MATERIALS AND METHODS

This retrospective study consisted of three phases: (i) the evaluation of surgical comfort with the incision size and the duration of 59 consecutive surgeries using the extra-short plate in DRFs; (ii) the verification of the implant ability to maintain radiographic indices compared immediately postoperatively and at consolidation. They included radial inclination (RI), volar tilt (VT) and ulnar variance (UV); (iii) the assessment of clinical outcomes at last follow-up through: pain measured on the visual analogue scale (VAS), QuickDASH score, patient-rated wrist evaluation (PRWE) score, grip strength, range of motion and complications.

RESULTS

In the first phase: mean incision size was 32 mm, and mean operative time was 28.5 min. In the second phase, there was no statistical difference between the two measures of the indices studied. In the third phase, mean follow-up time was 14.2 months, VAS score was 1.1, QuickDASH score was 11.4/100, and PRWE score was 9.5/100. Flexion was 91%, extension was 94%, and grip strength was 86% compared to the contralateral side.

CONCLUSION

The surgical comfort may be related to short operative time and incision. The implant allowed maintaining the radiographic indices without secondary displacement. Functional clinical outcomes were satisfactory. This extra-short plate design belongs to a novel generation of VLPs.

Prognostic Factors Affecting Clinical Outcomes of Arthroscopic Assisted Reduction and Volar Plating through Preservation of Pronator Quadratus for Intra-Articular Distal Radius Fracture

Background: This study aimed to evaluate the clinical and radiological outcomes following an arthroscopic-assisted reduction and volar plating (AR-VP) surgery through pronator quadratus (PQ) preservation for treating intra-articular distal radius fractures (IA-DRFs) and to assess prognostic factors that affect functional outcomes. Methods: Between March 2014 and February 2017, 54 patients who had intra-articular DRF and underwent AR-VP through the PQ preservation technique and completed 1-year follow-up were enrolled. Patients were divided into the satisfactory group (excellent and good results) and an unsatisfactory group (fair and poor results) based on the modified Mayo Wrist Scoring System (MMWS) scored at 1-year follow-up to determinate prognostic factors that affected clinical outcomes. Patients' demographics, clinical outcome measures (VAS, DASH, PRWE, etc.), and pre-and post-operative radiographic parameters were analyzed. Results: The outcomes according to MMWS were 10 excellent, 22 good, 14 fair, and 8 poor. A univariate analysis showed a significant difference between the groups (p < .05) for all radiographic parameters, sex, and the presence of an intra-articular comminution. In the multivariate analysis, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to uninjured wrist (> 20.1°) at trauma were considered as significant poor prognostic factors of functional outcome. Conclusions: AR-VP surgery through PQ preservation for intra-articular DRFs has reliable clinical and radiological outcomes. However, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to the uninjured wrist (> 20.1°) at initial injury were considered poor prognostic factors for AR-VP through PQ preservation for intra-articular DRF.

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.

Residual rotation of forearm amputation: cadaveric study

Background

The purpose of this study was to investigate residual rotation of patients with forearm amputation and the contribution of involved muscle to residual rotation.

Methods

Testing was performed using five fresh-frozen cadaveric specimens prepared by isolating muscles involved in forearm rotation. Amputation was implemented at 25 cm (wrist disarticulation), 18 cm, or 10 cm from the tip of olecranon. Supination and pronation in the amputation stump were simulated with traction of involved muscle (supinator, biceps brachii, pronator teres, pronator quadratus) using an electric actuator. The degree of rotation was examined at 30°, 60°, 90°, and 120° in flexion of elbow.

Results

Average rotation of 25 cm forearm stump was 148° (SD: 23.1). The rotation was decreased to 117.5° (SD: 26.6) at 18 cm forearm stump. It was further decreased to 63° (SD 31.5) at 10 cm forearm stump. Tendency of disorganized rotation was observed in close proximity of the amputation site to the elbow. Full residual pronation was achieved with traction of each pronator teres and pronator quadratus. Although traction of supinator could implement residual supination, the contribution of biceps brachii ranged from 4 to 88% according to the degree of flexion.

Conclusions

Close proximity of the amputation site to the elbow decreased the residual rotation significantly compared to residual rotation of wrist disarticulation. The preservation of pronosupination was 80% at 18 cm forearm stump. Although the pronator teres and the pronator quadratus could make a full residual pronation separately, the supinator was essential to a residual supination.

Sparing the pronator quadratus for volar plating of distal radius fractures: a comparative study of two methods

Objectives

The objective of this study was to compare the results of two methods for sparing the pronator quadratus in volar plating of distal radius fractures.

Methods

A total of 110 patients were randomized to volar plating with sparing of the pronator quadratus either by a transverse incision along the distal border of the pronator quadratus (Group A, 55 people) or by the brachioradialis splitting method (Group B, 55 people). The operative and radiation time, range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Visual Analog Scale (VAS) scores, and complications were recorded.

Results

There were no significant differences in the mean operative time, radiation time, mean bone union time, or total complication rate between the groups. We found no significant differences in range of motion, grip strength, VAS scores, and DASH scores at any of the study intervals between the groups. Although neurapraxia of the superficial branch of the radial nerve was more common in Group B than in Group A (6.7% vs. 0%), the difference was not significant.

Conclusions

Both methods were efficient approaches for sparing the pronator quadratus and had similar clinical outcomes, but they had different indications.

No effect on functional outcome after repair of pronator quadratus in volar plating of distal radial fractures: a randomized clinical trial

Aims

The aim of this study was to investigate the difference in functional outcome after repair and non-repair of the pronator quadratus muscle in patients undergoing surgical treatment for a distal radial fracture with volar plating.

Patients and Methods

A total of 72 patients with a distal radial fracture were included in this randomized clinical trial. They were allocated to have the pronator quadratus muscle repaired or not, after volar locked plating of a distal radial fracture. The patients, the assessor, the primary investigator, and the statistician were blinded to the allocation. Randomization was irreversibly performed using a web application that guaranteed a secure and tamper-free assignment. The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) after 12 months. Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) score, pronation strength, grip strength, the range of pronation and supination, complications, and the operating time.

Results

Of the 72 patients, 63 (87.5%) completed follow-up for the primary outcome measure: 31 (86.1%) from the non-repair group and 32 (88.9%) from the repair group. At the 12-month follow-up, the mean difference in PRWE of 5.47 (95% confidence interval (CI) -4.02 to 14.96) between the repair (mean 18.38 (95% CI 10.34 to 26.41)) and non-repair group (mean 12.90 (95% CI 7.55 to 18.25)) was not statistically significant (p = 0.253). There was a statistically significant difference between pronation strength, favouring non-repair. We found no difference in the other secondary outcomes.

Conclusion

We found that repairing pronator quadratus made no difference to the clinical outcome, 12 months after volar plating of a distal radial fracture. We conclude that there is no functional advantage in repairing this muscle under these circumstances and advise against it. Cite this article: Bone Joint J 2019;101-B:1498–1505

Do we really need to repair the pronator quadratus after distal radius plating?

PURPOSE

Fractures of distal radius are one of the common orthopaedic injuries. Placing the plate on volar surface requires release of underlying pronator quadratus (PQ) muscle. No consensus is present in the literature about the repair or not of the PQ. The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications.

METHODS

Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated. Demographic data, operative notes and physical therapy records were retrieved. Patients were divided into group A where PQ repair was done and group B where no repair was done. Functional data such as range of motion (ROM), grip strength, visual analogue scale (VAS) score and disabilities of arm, shoulder and hand (DASH) score at 4 weeks, 3 months, 6 months and finial follow-up were retrieved.

RESULTS

Totally 63 patients (n = 29 in group A and n = 34 in group B) with the mean age of 51.64 years were examined. Patients were followed up for a mean of 35.2 months (range 27.2-47.1 months) in group A and 38.6 months (range 28.6-51.0 months) in group B. Though functional outcome of the affected limb was not significantly different between two groups after 3 months, PQ repair did affect the recovery at an early stage. Repair group had significantly better ROM (p = 0.0383) and VAS score at 4 weeks (p = 0.017) while grip strength (p = 0.014) was significantly better at 3 months.

CONCLUSIONS

Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.

Pronator quadratus muscle flap: a preliminary cadaveric study

There are very few studies regarding the neurovascular anatomy of pronator quadratus (PQ) or the technique of harvesting it as free functional muscle transfer. The aim of the study was to describe the neurovascular anatomy of PQ, to provide the harvesting technique and review the reported clinical applications. Dissections were performed on four fresh cadaver upper extremities. Measurements of PQ's dimensions, its neurovascular pedicle length, diameter and branching pattern were taken, and photographs were taken. The relation of the neurovascular pedicle to important anatomic landmarks of the forearm was also documented. Identification and raising of the PQ was performed within 30 min on all cases. The neurovascular pedicle was lying over the flexor surface of the interosseous membrane and entered the PQ on its dorsal surface. In all cases, PQ was received its blood supply from the anterior interosseous artery (AIA) with an average length of 12 cm and average diameter of 2.25 mm and it was accompanied by two veins. There were interconnections between the AIA and the ulnar and radial arteries. PQ was innervated by the anterior interosseous nerve with an average length of 12.25 cm. PQ can be easily harvested either as a free or as a pedicled muscle. The learning curve is short. The accompanying vessels and nerve are of adequate length/diameter for microvascular anastomoses and/or neurorrhaphy, respectively. There is no donor site morbidity except the scar. Although there have been sporadic reports on PQ clinical applications, more studies are needed in order to identify the indications/applications in reconstructive surgery.

Investigating the minimum distance between the finger flexor tendons and distal radius during wrist and finger positions in healthy people

PURPOSE

Rupture of the flexor pollicis longus (FPL) and index flexor digitorum profundus (FDP2) tendons often occurs after locking plate fixation for distal radius fracture. This study aimed to determine the shortest tendon-radius distances of different hand positions.

METHODS

Fifty-nine hands of 30 healthy volunteers were studied. Distances between the FPL or FDP2 and distal radius were calculated in six wrist positions: 30° palmar flexion, neutral, 30° dorsiflexion, 60° dorsiflexion, maximum dorsiflexion, and 40° ulnar deviation with three finger positions (full extension and flexion of fingers, full flexion of the thumb or index finger, and full extension of the other four fingers). The shortest distance between the FPL or FDP2 and distal radius was noted.

RESULTS

The shortest distance between the FPL and distal radius was during maximum wrist dorsiflexion with isolated thumb flexion. The distance between the FDP2 and distal radius was shortest with all-finger flexion in 30° wrist dorsiflexion.

CONCLUSIONS

It is necessary to measure the distance between the FPL and distal radius in maximal wrist dorsiflexion with full flexion of the isolated thumb, as the shortest distance was observed with flexion of the isolated thumb. On the contrary, we recommend measuring the distance between the FDP2 and distal radius in 30° wrist dorsiflexion with flexion of all fingers.

A systematic review of the quality of distal radius systematic reviews: Methodology and reporting assessment

Background

Many systematic reviews (SRs) have been published about the various treatments for distal radius fractures (DRF). The heterogeneity of SRs results may come from the misuse of SR methods, and literature overviews have demonstrated that SRs should be considered with caution as they may not always be synonymous with high-quality standards. Our objective is to evaluate the quality of published SRs on the treatment of DRF through these tools.

Methods

The methods utilized in this review were previously published in the PROSPERO database. We considered SRs of surgical and nonsurgical interventions for acute DRF in adults. A comprehensive search strategy was performed in the MEDLINE database (inception to May 2017) and we manually searched the grey literature for non-indexed research. Data were independently extracted by two authors. We assessed SR internal validity and reporting using AMSTAR (Assessing the Methodological Quality of Systematic Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). Scores were calculated as the sum of reported items. We also extracted article characteristics and provided Spearman’s correlation measurements.

Results

Forty-one articles fulfilled the eligibility criteria. The mean score for PRISMA was 15.90 (CI 95%, 13.9–17.89) and AMSTAR was 6.48 (CI 95% 5.72–7.23). SRs that considered only RCTs had better AMSTAR [7.56 (2.1) vs. 5.62 (2.3); p = 0.014] and PRISMA scores [18.61 (5.22) vs. 13.93 (6.47), p = 0.027]. The presence of meta-analysis on the SRs altered PRISMA scores [19.17 (4.75) vs. 10.21 (4.51), p = 0.001] and AMSTAR scores [7.68 (1.9) vs. 4.39 (1.66), p = 0.001]. Journal impact factor or declaration of conflict of interest did not change PRISMA and AMSTAR scores. We found substantial inter observer agreement for PRISMA (0.82, 95% CI 0.62–0.94; p = 0.01) and AMSTAR (0.65, 95% CI 0.43–0.81; p = 0.01), and moderate correlation between PRISMA and AMSTAR scores (0.83, 95% CI 0.62–0.92; p = 0.01).

Conclusions

DRF RCT-only SRs have better PRISMA and AMSTAR scores. These tools have substantial inter-observer agreement and moderate inter-tool correlation. We exposed the current research panorama and pointed out some factors that can contribute to improvements on the topic.

Pronator quadratus repair with a part of the brachioradialis muscle insertion in volar plate fixation of distal radius fractures: a prospective randomised trial

INTRODUCTION

Stable pronator quadratus repair following volar plate fixation of distal radius fractures with complete plate coverage is difficult.

MATERIALS AND METHODS

This study compares a modified pronator quadratus repair technique involving the brachioradialis muscle insertion (test group) with a conventional radial incision through the muscle without pronator quadratus repair (standard group). This prospective randomised study included 16 patients in the test group and 12 in the standard group; all were available for clinical, radiographic and ultrasound examination at a mean follow-up of 15 months.

RESULTS

Pronator quadratus repair was feasible in all test group patients, and complete coverage of the distal plate was achieved in 11. No differences in functional outcome were observed between the groups.

CONCLUSION

Pronator quadratus repair with a part of the brachioradialis muscle insertion is a reliable technique for coverage of a volar plate by slight distal transposition. In the repair of distal radius fractures, this may better protect the finger flexor tendons against irritation and/or rupture. That likelihood should now be studied.