Combined volar and dorsal plating vs. volar plating of distal radius fractures. A single-center study of 105 cases

A new distal radius fracture classification depending on the specific fragments through machine learning clustering method

PURPOSES

The objective of this study was to investigate intra-articular distal radius fractures, aiming to provide a comprehensive analysis of fracture patterns and discuss the corresponding treatment strategies for each pattern.

METHODS

294 cases of intra-articular distal radius fractures lines were collected and clustered thorough K-means and hierarchical clustering algorithm. The demographic data of patients and the clinical treatment outcomes were recorded. For functional evaluation, quick Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) pain score, range of motion (ROM) of the wrist joint and the percentage of the grip strength relative to the healthy wrist at 12 months follow-up were evaluated and recorded; For radiographic parameters of volar tilt (VT), radial inclination (RI), and ulnar variance (UV) were obtained; The occurrence of complications was carefully assessed and documented.

RESULTS

Totally 294 patients were included and divided into the volar side affected group and the dorsal side affected groups. And each group was further categorized into three types: type I, with two parts fractures with either one volar/dorsal side intact; type II, with three parts fractures with  volar/dorsal side simply affected; and type III, with four parts fractures with volar/dorsal side communited affected. The volar plate fixation was performed as the standard treatment, while the combined plate fixation was used for comminuted dorsal bone defects of the metaphysis and impaction. There were no differences in the postoperative radiograph parameters, functional outcomes and incidences of complications for each type of volar side group and dorsal side group except that the 3.2 type DRFs showed less range of flexion (75.56±7.48)° and extension (61.65±9.9)° than other dorsal types.

CONCLUSIONS

A new intra-articular distal radius fractures classification was proposed based on the affection condition of volar or dorsal side. The volar plate fixation is an effective treatment for the intra-articular distal radius fractures, while combined plate fixation can be considered as an alternative treatment for dorsal side comminuted fractures.

LEVEL OF EVIDENCE

III a.

Pulp-to-palm distance after plate fixation of a distal radius fracture corresponds to functional outcome

INTRODUCTION

Several factors can influence the outcome after a distal radius fracture (DRF). The aim of this study was to assess whether postoperative pulp-to-palm (PTP) distance correlated with functional outcomes after plate fixation of DRF.

MATERIALS & METHODS

This is a secondary analysis of a randomized controlled trial aimed to investigate the effects of plate fixation in patients with type-C fractures. Subjects (N = 135) were divided into 2 groups based on PTP distance (equal to or higher than 0 cm) at 4 weeks postoperatively. Outcome measures were collected prospectively at 3, 6 and 12 months and included Patient-Rated Wrist Evaluation (PRWE), Quick Disabilities of the Arm Shoulder and Hand (QuickDASH) scores, wrist range of motion (ROM), Visual Analog Scale (VAS) pain scores, and hand grip strength.

RESULTS

Overall, at 3 and 6 months patients with PTP > 0 cm had significantly worse outcomes (PRWE, QuickDASH, wrist ROM) than those with PTP =0 cm. At 12 months, QuickDASH and wrist ROM were still significantly worse. In the volar-plating subgroup, patients with PTP > 0 cm had significantly worse wrist ROM and grip strength at 3 months, but no significant differences were found in subsequent follow-ups. In the combined-plating group, patients with PTP > 0 cm had significantly worse QuickDASH, wrist ROM and grip strength at 3 months. At 6 and 12 months, wrist ROM was still significantly worse.

CONCLUSIONS

Measurement of PTP distance appears to be useful to identify patients likely to have worse outcome after plating of a DRF. This could be a tool to improve the allocation of hand rehabilitation resources.

Posttraumatic Arthritis After Combined Plating of Distal Radius Fractures AO Type C: A 7-Year Follow-up of 97 Cases

BACKGROUND

Volar locking plate fixation is the most common method of operative fixation of distal radius fractures (DRFs). For more complex cases, combined plating is an option for stabilizing intra-articular fragments. The prevalence of posttraumatic arthritis (PA) after an intra-articular DRF, and its relation to patient-reported outcome measures (PROMs), remains unclear. The purpose of this study was to study the prevalence of PA and its correlation to clinical outcome measures.

METHODS

We evaluated 97 consecutive patients with intra-articular DRF, operated with combined plating, 7 years postoperatively. The primary outcome measure was the prevalence of radiographic PA. Secondary outcome measures included visual analog scale (VAS) pain score, hand grip strength, wrist range of motion (ROM), Patient-Rated Wrist Evaluation (PRWE) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographic examination was performed between 1 and 7 years postoperatively.

RESULTS

The prevalence of PA was 29% at the 7-year follow-up. No correlation was found between PA and ROM, hand grip strength, PRWE, QuickDASH, VAS pain scores, or radiographic reduction. Median wrist ROM and grip strength were significantly inferior compared with the uninjured side. Hardware removal was performed in 51.5% of cases. There were 2 cases of tendon ruptures.

CONCLUSIONS

Combined plating can yield a good clinical outcome 7 years postoperatively and a low prevalence of PA. The presence of PA did not correlate to clinical outcome measures or to the accuracy of anatomical reduction 1 year postoperatively. The frequency of tendon ruptures was acceptable, but the high frequency of hardware removal is a concern.

Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases

PURPOSE

The optimal way to stabilize intra-articular distal radius fractures is unclear despite recent advances in surgical management. Volar plating is the most common treatment but may not be sufficient for more complex intra-articular AO type C fractures. The purpose of this randomized controlled study was to evaluate the radiographic and clinical outcomes following surgical treatment of AO type C distal radius fractures, comparing volar with combined plating.

METHODS

In this study, 150 patients were randomized to volar locking plate (n = 75) or combined plating (n = 75) following a distal radius fracture AO type C. The 1-year follow-up included radiographic outcome (Batra score), visual analog scale pain score, hand grip strength, wrist range of motion, Patient-Rated Wrist Evaluation score, and Quick Disabilities of the Arm, Shoulder, and Hand score.

RESULTS

Overall, 147 patients (median age 61 years) completed the 1-year follow-up (73 patients with volar plate and 74 with combined plating). No difference was found in radiographic outcome between the treatment groups. The volar plate group had significantly better Patient-Rated Wrist Evaluation scores, Quick Disabilities of the Arm, Shoulder, and Hand scores, hand grip strength, visual analog scale scores during activity, and flexion, extension, ulnar and radial deviation than the combined plate group. Hardware removal was performed in 10% in the volar plate group and in 31% in the combined plate group. There was no postoperative infection in the volar plate group but 3 cases in the combined plate group.

CONCLUSIONS

In patients with complex AO type C intra-articular fractures, volar and combined plating yielded the same radiographic result. The differences in Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores between the groups did not reach the thresholds for minimal clinically important differences, suggesting similar clinical outcome. The combined plating group had a considerably higher frequency of hardware removal and postoperative infections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Open Reduction and Internal Fixation by Volar Locking Plates and the "Poking Reduction" Technique in Distal Radius Fractures with Displaced Dorsal Ulnar Fragments: A Retrospective Study

Objective

To investigate the clinical and radiological outcomes of distal radius fractures (DRFs) with displaced dorsal ulnar fragments treated with volar locking plate (VLP) and the “poking reduction” technique.

Methods

Between January 2014 and January 2019, 78 unilateral DRFs with displaced dorsal ulnar fragment (AO type C3) treated with VLP were conducted. According to the reduction technique of the dorsal ulnar fragment, the patients were divided into the conventional reduction (CRG) group (33 patients, 14 males and 19 females, mean age 57.2 ± 12.1 years old) and the “poking reduction” (PRG) group (45 patients, 11 males and 34 females, mean age 60.1 ± 12.4 years old). According to the AO classification, there were 21 cases of C3.1 and 12 of C3.2 in the CPG group, 27 cases of C3.1 and 18 of C3.2 in the PRG group. Clinical and radiographic data were extracted from the electronic medical record system. These data were reviewed for clinical outcomes (range of motion, grip strength), radiological outcomes (volar tilt, radial inclination, radial height, step of articular surface), and postoperative complications. The final functional recovery was evaluated by the disabilities of the arm, shoulder, and hand (DASH) score.

Results

The mean duration of follow‐up was 27 months (range from 12 to 56). The average operation time and intraoperative blood loss did not significantly differ between groups (p > 0.05). Postoperative CT examination showed that the step of articular surface in CPG group (0.8 ± 0.3 mm) was larger than that in PRG group (0.5 ± 0.2 mm) (p < 0.001). The DASH score did not significantly differ between groups (26.1 ± 4.6 in CRG and 24.7 ± 4.0 in PRG, p > 0.05) at 3 months postoperatively. At 6 months and 12 months postoperatively, the DASH score was better in PRG group (11.8 ± 2.5 and 10.4 ± 2.0) than in CRG group (13.6 ± 2.7 and 12.2 ± 2.5) (p = 0.004, p = 0.001, respectively). At 12 months postoperatively, wrist range of motion did not significantly differ between groups (p > 0.05). There was no significant difference in radiological parameters between the two groups (p > 0.05). The incidence of complications was higher in the CRG group (7/33) than in the PRG group (2/45) (p = 0.009).

Conclusion

The “poking reduction” technique is a wise option for reduction of dorsal ulnar fragment in DRFs. This innovative technique could restore smoothness of the radiocarpal joint effectively, and the dorsal ulnar fragment could be fixed effectively combined with the volar plate.