Dorsal approach and internal fixation of impacted intra-articular distal radius fractures with 2.4 mm locking plates

Management of Extra-Articular and Intra-Articular Distal Radius Malunion

This article presents a comprehensive overview of managing extra-articular and intra-articular distal radius malunions (DRM), discussing the pathoanatomy, clinical, and radiologic evaluation, conservative treatment, and surgical strategies. Corrective osteotomy remains the primary surgical intervention for symptomatic DRM. Surgical planning should consider factors such as timing, approach, correction technique, implant, graft, and associated injuries. The correction of extra-articular malunion necessitates brachioradialis tenotomy, circumferential periosteum release, and intrafocal elevation with grafting to facilitate distal radius realignment following osteotomy. Computer-assisted planning with 3D-printed patient-specific instrumentation (PSI) could help execute extra-articular osteotomy with high precision. As for the management of intra-articular malunion, it may require wrist arthrotomy, arthroscopy, or PSI assistance for precise articular osteotomy and reduction of the joint surface. This review highlights the importance of early intervention, thorough preoperative planning, and appropriate surgical techniques to optimize outcomes and minimize complications. Future research should focus on large-scale randomized controlled trials to compare different surgical methods, particularly for intra-articular DRM.

Dorsal wrist plating for the management of intra-articular distal radius fractures

The aim of the study was to evaluate the results of Dorsal Wrist Plating in intra-articular distal radius fractures with a dorsal displacement. In this prospective study, a single surgeon treated 20 patients with a (partially) intra-articular distal radius fracture with a dorsal rim avulsion or a dorsal Barton's type fragment. They all underwent an open reduction and internal fixation by Dorsal Wrist Plating. A total of 17 patients had a follow-up period of at least 12 months (mean follow- up of 17 months) and these patients were included in the study. Both functional and radiological outcome parameters were measured. The total range of motion was 92 % of the contralateral side. The mean grip strength and key pinch were 24.6 kg and 6.9kg respectively compared to 29.5 kg and 7.4 kg on the non-operated side. The average Mayo Wrist Score was 89.7 (range 80-100) and the mean Disability of the Arm, Shoulder and Hand score was 4.5 (range 0-9.2). An articular step-off was only noted in 2 patients (1 and 2 mm respectively). Radial inclination was restored in all patients. Palmar tilt was anatomically restored in five patients. In all other patients, the palmar tilt was acceptably restored. There was no significant radial shortening in any of the patients. No infections, no tendon ruptures, no Complex Regional Pain Syndrome, or union problems were observed. Dorsal wrist plating seems to be a safe and reliable procedure in the treatment of intra-articular distal radius fractures with dorsal displacement.

Minimally Invasive Fixation with Dorsal Suspension Button and Volar Plate in Distal Radius Fractures with Dorsal Die Punch Fragments: A Preliminary Study

Objective  The objective of the study is to analyze the clinical and radiological results obtained using a minimally invasive fixation technique with a volar locking plate and a suspension system with a dorsal button in distal articular radius fractures with dorsal comminution. Materials and Methods  Six patients with distal radius fractures, between 19 and 68 years of age, were included in the study. Mean follow-up was of 15 weeks. Range of motion (ROM) in flexion, extension, radial deviation, ulnar deviation, pronation, supination, the strength in kilograms, and values on the Visual Analog Scale (VAS), Disabilities of Arm, Shoulder and Hand (DASH), and Mayo Wrist Score (MWS) scales were evaluated at 4, 8, and 12 weeks postoperative. Correction of anteroposterior diameter of the radius and concordance between postoperative anteroposterior diameter and the contralateral wrist diameter were evaluated radiologically. Results  The following mean values were obtained at 12 weeks postoperative: ROM in flexion: 40.5°, ROM in extension: 49.5°, ROM in radial deviation: 24.5°, ROM in ulnar deviation: 15°, ROM in pronation: 87°, ROM in supination: 89°, strength: 37.5 kg, pain in VAS scale: 2 points, DASH: 54.5 points, and MWS: 67.5 points. At 12 weeks postoperative, the mean correction of anteroposterior diameter was 0.49 mm. The anteroposterior diameter and that of the contralateral wrist were strongly correlated. Conclusion  Fixation with the volar locking plate and dorsal suspension button could be considered an alternative to dorsal plate fixation for treatment of distal radius fractures with comminution or associated dorsal die punch fragments.

Biomechanical investigation of a novel hybrid dorsal double plating for distal radius fractures by integrating topology optimization and finite element analysis

BACKGROUND

Currently available dorsal locking plates for the treatment of distal radius fractures are far less then volar locking plates, and there is limited evidence about biomechanical strength of dorsal plates. The aim of this study is to develop a novel hybrid dorsal double plating, which enhance biomechanical strength in the articular fixation region and achieve the minimally invasive surgical technique requirement of distal radius fracture treatment by combining weighted topology optimization and finite element (FE) analysis METHODS: A dorsal template bone plate design (based on dorsal double plating (DDP)) was constructed to perform weighted topology optimization and FE analysis under six fracture models with 50%, 30%, and 20% weighting of the joint subjected to axial, bending, and torsion moments, respectively. A novel hybrid dorsal double plating (HDDP) was generated using the union of six single dorsal plates to subtract the intersection of the original template dorsal model. A 100 N axial load with 1 Nm bending and torsion moments were applied at the end of the distal radius onto six fracture FE models to investigate the biomechanical differences between the DDP and HDDP approaches.

RESULTS

Results of weighted topology optimization showed that the profile of the HDDP presented a "Y" shape. Simulation results showed that the bone plate stress values for the distal radius fractures fixed with HDDP was much smaller than those with DDP regardless of the type of bone fractures and load conditions. The maximum bone stress value of the DDP approach was much higher than that of HDDP when the distal radius was a complete sagittal articular fracture and partial articular fracture involving lunate fossa. The corresponding maximum bone stress values for different loads might be higher than the ultimate strength of bone (150  MPa) and induced the risk of future bone fractures.

CONCLUSIONS

It is concluded that the novel HDDP demonstrated better resistance to functional loads, provided sufficient screw fixation at the articular surface, and can be placed on the dorsal site of the distal radius through the standard dorsal approach to minimize invasive surgeries and eliminate tendon irritations.

Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients

INTRODUCTION

Treatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients.

HYPOTHESIS

The outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications.

MATERIAL AND METHODS

Non-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed.

RESULTS

The mean follow-up was 30.9 (range, 24-53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3mm at baseline but not by age.

DISCUSSION

The study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger.

LEVEL OF EVIDENCE

III, cohort study.