Fractures comminutives du radius distal traitées par ostéosynthèse et substitut osseux injectable

What happens to the posterior comminution in extra-articular fractures of the distal radius treated with volar locking plates?

Extra-articular fractures of the distal radius with posterior displacement are typically treated with volar locking plates. However, this fixation method does not address the posterior comminution, which seems to have no impact on the final result. The purpose of this study was to determine the fate of the posterior comminution. This was a retrospective study of 22 patients over 50 years old with a distal radius fracture. A preoperative computed tomography (CT) scan was performed to evaluate the comminution. All fractures were fixed with a volar locking plate. All patients underwent a bone density scan. Patients were reviewed at 6 months post-operative to determine their clinical, radiological and functional outcomes. The CT scan was performed again to determine the fate of the comminution. At 6 months post-operative, 82% of patients had an oval metaphyseal defect. The mean volume of this defect was 1.86 mL. The contents of this defect most closely resembled fat. There was no statistical link between the defect's volume and the various parameters studied. On the other hand, the defect's density was positively related to the functional outcome and negatively related to the patients' body mass index. Because of the compression experienced by the cancellous bone, a distal metaphyseal defect often persists after consolidation in dorsally displaced distal radius fractures. The posterior comminution is ultimately of little consequence.

Role for cementoplasty in intra-articular distal radius fractures: Cadaver study and application to arthroscopy

BACKGROUND

Die-punch intra-articular fractures of the distal radius raise surgical challenges. The residual articular step-off must be less than 1mm to prevent the development of radio-carpal osteoarthritis. The objectives of this cadaver study were to evaluate whether cementoplasty was effective in reducing die-punch fractures and to determine whether this technique was feasible as an arthroscopic procedure.

HYPOTHESIS

Cementoplasty performed as an arthroscopic procedure is effective in treating die-punch fractures.

MATERIAL AND METHODS

Eleven cadaver forearms collected at a laboratory were studied. In each, a depressed fracture of the lunate fossa of the radial articular surface was created using a Tinius Olsen H25K-S compression test machine. A Kyphon XPander^® balloon (Medtronic) was used to lift the depressed area, and calcium-phosphate cement was then injected to stabilise the reduction. Cementoplasty under arthroscopic guidance was performed on an additional forearm.

RESULTS

Computed tomography of the wrists after fracture induction showed a mean depression of 4.66mm (range, 4.01-5.25mm). Arthroscopic cementoplasty proved feasible with the arthroscope inserted through the 3-4 radio-carpal portal. Positioning the balloon under the depressed area ensured satisfactory reduction and allowed the injection of cement.

DISCUSSION

Cementoplasty may be useful for the treatment of die-punch fractures. Additional indications may be other types of distal radius fractures with articular surface depression.

LEVEL OF EVIDENCE

IV, cadaver study.

[Treatment of extra-articular distal radius fractures in active elderly patients]

Extra-articular distal radius fractures in active elderly patients are common and predominantly affect females. The high number of patients lost to follow-up compromises the evaluation of outcomes. Treatment aims to control the comminution and allow fast recovery of pre-injury activity levels. Fixation with volar locking plates is the gold standard. The role of bone substitutes in this type of injury is unclear.

Improvements in Pinning Fixation for Distal Radius Fractures

Despite the increasingly widespread use of the volar plate, the pinning of the distal radius keeps its place as a basic technique in the treatment of extra-articular and intra-articular fractures with dorsal displacement and little comminution. To date, there are 2 types of pinning recognized as stable and reliable: the "cross-pinning" with 2 styloid pins and a dorso-ulnar one and the multiple mixed pinning, which is an improved version of the classical technique of Kapandji. This article offers a modified technique of mixed multiple pinning: the pinning type Fort-de-France, which offers a more stable reduction. However, our technique would have to be confirmed by clinical and biomechanical studies.

Dorsally displaced distal radius fractures: comparative study of Py's and Kapandji's techniques

INTRODUCTION

Within the framework of a regional clinical study, the radiographic results of Py's and Kapandji's fixation techniques for dorsally displaced distal radius fractures were compared.

PATIENTS AND METHODS

A prospective randomised monocenter and multi-operator study (phase III clinical trial) comparing the Py's (isoelastic pinning) and Kapandji's (intrafocal pinning) techniques was conducted. Two comparable groups were established: the Py (P) and Kapandji (K) groups. The frontal radial tilt (FRT), sagittal radial tilt (SRT), radial length and ulnar variance were measured. Analysis of subjective and objective function was based on the range of motion according to six parameters, the DASH and Jakim scoring systems. The quality of anatomical restoration was assessed arthroscopically during pin removal at 6 postoperative weeks.

RESULTS

Ninety-seven patients were included in the study with a follow-up period of 1 year. The preoperative FRT was 15.17° and SRT was -19.2°. At one-year follow-up, the FRT was 25.5° in the PY group and 22.6° in the K group (p=0.009), the SRT was 10.5° in the PY group and 6.7° in the K group (p=0.04). For fractures with postero-medial fragment and Gerard Marchand's fractures, the DASH score at last follow-up was 22 in the Py group, 42 and 32 respectively in the K group. The Jakim score was 71 in the PY group and 58 in the K group (p=0.03) for fractures with postero-medial fragment. There was no report of tendon rupture in our study.

DISCUSSION

Besides the good results achieved with both pinning techniques in the treatment of distal radius fractures, this series also underlines the importance to adapt the type of fixation to the fracture pattern and patient.

CONCLUSION

Pinning for treating dorsally displaced distal radius fractures appears a suitable option provided that the indications and the surgical technique for each method are respected. However, pinning is not suitable for all types of fractures.

LEVEL OF EVIDENCE

Level II. Randomised prospective therapeutic study.

Extension fractures of the distal radius in patients older than 50: a prospective randomized study comparing fixation using mixed pins or a palmar fixed-angle plate

We randomized 103 patients over the age of 50 with an unstable closed intra- or extra-articular dorsally displaced distal radius fracture to have either palmar fixed-angle plating (n=50) or 'mixed pinning' (n=53) and compared the clinical and radiological outcomes at 3, 6, 12 and 26 weeks after surgery in a prospective study. Postoperative palmar tilt was significantly better in those stabilized with K-wires, but loss of reduction was statistically less in those stabilized with a plate. At 26 weeks, functional results, assessed by DASH and Herzberg scores, were better in those fixed with a plate.