Recurrent dorsal angulation of the distal radius fracture during dynamic external fixation

Volar locking plate versus external fixation for unstable distal radius fractures: a systematic review and meta-analysis based on randomized controlled trials

Background

The outcomes for volar locking plate (VLP) and external fixation (EF) in distal radius fracture cases remain controversial. The current study of randomized controlled trials (RCTs) aimed to assess VLP and EF, which might benefit distal radius fracture cases.

Methods

RCTs comparing VLP and EF in distal radius fracture cases, until 18 March 2020, were systematically reviewed and summarized. The functional and radiographic outcomes, together with complications, for distal radius fracture cases, were evaluated.

Results

In total, 12 studies comprising 1205 distal radius fracture cases were included. The VLP group had observed lower disability in the arm shoulder and hand score (DASH) at 3rd, 6th, and 12th -month post-operation, with the mean differences (MDs) of − 10.43 (95 % CI = − 15.77 to − 5.08, P < 0.01), − 3.48 (95 % CI = − 6.37 to − 0.59, P = 0.02), and − 4.13 (95 % CI = − 6.94 to − 1.33, P < 0.01), respectively. The VLP group also had lower visual analog scale scores (VAS) compared to the EF group, with MDs of − 0.10 (95 % CI = − 0.18 to − 0.03, P < 0.01) for the former at 6th -month post-operation. Also, the EF group exhibited better grip strength than that in the VLP group, with MD of 12.48 (95 % CI = 7.00–17.95, P < 0.01) at the 3rd month and 4.54 (95 % CI = 0.31–8.76, P = 0.04) at 6th month. No significant differences in radiographic outcomes were observed between the VLP and EF groups (P > 0.05). The VLP group had a lower complication rate than that in the EF group.

Conclusions

VLP had a lower DASH score and VAS score but with lower grip strength. No significant differences in radiographic outcomes were observed. VLP had a lower complication rate than that of EF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04312-7.

Volar locking plate versus external fixation in distal radius fractures: A meta-analysis

The purpose of this meta-analysis is to evaluate the efficacy of plate or external fixator treatments in distal radius fractures, based not only on clinical and radiographic parameters but on Health Related Quality of Life (HRQOL) parameters. The Preferred Reporting Items for Systematic Reviews and Metanalyses (PRISMA) guidelines were followed when conducting this systematic review. The Revised Assessment of Multiple Systematic Reviews (RAMSTAR) checklist was additionally consulted in order to ensure a high-quality methodological process, encompassing such elements as an ‘a priori’ design, independent reviews and comprehensive search. The literature search was carried out on PubMed, MEDLINE and Scopus. The search terms used were “Radius fracture AND osteosynthesis”, “Wrist fracture AND external fixator” and “Wrist fracture AND plate”. Two reviewers independently screened titles, abstracts and full texts. To determine inter-reviewer agreement, a k score was calculated after each screening state. Of the 5753 studies collected through the initial databases search, two studies were included in the final meta-analysis (125 treated with external fixator vs 132 with volar plate). There was a substantial inter-reviewer agreement as to the title (0.73; 95% confidence interval, 0.67-0.79) abstract (0.65; 95% CI, 0.46-0.83) and fulltext screening stages (0.89; 95%CI, 0.67-1). The meta-analysis reported a mean difference equal to 0.00 (95%CI= -0.05 – 0.05), in accordance with I²= 0% and p test for the heterogeneity value=0.089. This meta analysis confirms and quantifies that the two techniques are superimposable as regards the quality of life reported by patients at least one year of follow-up.

Volar Locking Plate versus External Fixation for Distal Radius Fractures: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Volar locking plate (VP) and external fixation (EF) are the two most commonly used methods for treating distal radius fractures. The aim of this study was to identify which of the two treatments leads to better outcomes (clinically and radiographically) with fewer complications.

MATERIALS AND METHODS

A metaanalysis was performed. All available randomized controlled trials (RCTs) which compared the clinical results of VP to EF were obtained and the reported means and standard deviations were extracted to perform data synthesis.

RESULTS

A total of 9 published RCTs with 776 patients fulfilled all inclusion criteria. Data analysis revealed that VP gives better clinical results in the early postoperative period in terms of disabilities of the arm, shoulder, and hand (DASH) scores (3 and 6 months), grip strength (3 months), flexion, extension, and supination (3 months). VP is also advantageous over EF regarding the DASH scores, maintenance of ulnar variance, and total and mild surgical complications at 12 months.

CONCLUSIONS

This meta analysis supports the use of VP in treating distal radius fractures.

Internal Versus External Fixation for the Treatment of Distal Radial Fractures: A Systematic Review of Overlapping Meta-Analyses

Although a serious of meta-analyses have been published to compare the effects of internal versus external fixation (IF vs EF) for treating distal radial fractures (DRF), no consensus was obtained.B y performing a systematic review of overlapping meta-analyses comparing IF versus EF for the treatment of distal radial fractures, we attempted to evaluate the methodology and reporting quality of these meta-analyses, interpret the source of discordant results, and therefore determine the dominant strategy for the treatment of distal radial fractures based on the best evidence currently. An electronic databases search was conducted in MEDLINE, Embase, and Cochrane library to retrieve meta-analyses comparing IF versus EF for treating DRF. Reference lists of relevant literatures were also screened manually to retrieve additional ones. Two investigators independently assessed the eligibility of retrieved articles using predefined inclusion and exclusion criteria. All characteristics as well as outcome variables including functional outcomes, range of motion, radiological results, and complication rates with relevant heterogeneity information presented in each included study were extracted. Heterogeneity was thought to be significant when I² > 50%. We adopted the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument to assess the methodological quality of every included study, and applied the Jadad decision algorithm to select studies with more likely reliable conclusions. A total of 8 studies met the inclusion criteria. The AMSTAR scores ranged from 5 to 9 with a median of 7.75. Following the Jadad algorithm, the meta-analyses with most reliable results can be selected based on the search strategies and application of selection. Finally, 2 meta-analyses with most RCTs and highest AMSTAR scores were selected in this systematic review of overlapping meta-analysis. The best available evidence suggested that compared with EF, IF was significantly associated with lower Disabilities of the Arm, Shoulder and Hand (DASH) scores, better rehabilitation of volar tilt and radial inclination, and lower infection rate at 1-year follow-up. Therefore, we could conclude that internal fixation is superior to external fixations for the treatment of distal radial fractures.

A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures

PURPOSE

To compare surgical outcomes of volar locking plates (VP) and external fixation (EF) (with or without intra-focal fixation) for AO-type C2 and C3 fractures of the distal radius.

METHODS

From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were enrolled in a prospective, randomized study comparing volar plate fixation with external fixation (with or without intra-focal fixation), 74 patients were studied. The researchers evaluated functional assessments (wrist range of motion, grip strength, and Michigan Hand Questionnaire) at each patient visit and measured radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity) at 12 months.

RESULTS

The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6 months. The range of motion was significantly greater in the VP group than in the EF group at 3 months. There were no significant differences in the range of motion and grip strength between the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group than in the EF group at 3 months but was same at 12 months. There was no significant difference between groups with respect to volar tilt or radial inclination. The VP group showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group and 3 in the EF group had an intra-articular stepoff deformity greater than 2 mm. This difference did not reach statistical significance.

CONCLUSIONS

These results for functional recovery after distal radius surgery offer insight into treatment decisions and interpretations of treatment outcomes for patients with comminuted intra-articular distal radius fractures.

Volar locking plate versus external fixation for the treatment of unstable distal radial fractures: a meta-analysis of randomized controlled trials

BACKGROUND

The choice between volar locking plates (VLP) and external fixation (EF) for unstable distal radius fractures have not reached a consensus. The meta-analysis of randomized controlled trials was performed to compare VLP with EF to determine the dominant strategy.

MATERIALS AND METHODS

Meta-analysis was performed with a systematic search of studies conducted by using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The randomized controlled trials that compared VLP with EF was identified. Characteristics, functional outcomes, radiological results, and complications were manually extracted from all the selected studies.

RESULTS

Six studies encompassing 445 patients met the inclusion criteria. There was significant difference between two procedures in disabilities of the arm shoulder and hand scores at 3,6, and 12 mo, visual analogue scale at 6 mo, grip strength at 3 mo, supination at 3 and 6 mo, extension at 3 mo, ulnar variance at 12 mo, and reoperation rate at 12 mo, postoperatively. However, there was no significant difference between flexion, pronation, radial deviation, and ulnar deviation at all follow-up points postoperatively and overall complications at 12 mo, postoperatively.

CONCLUSIONS

EF had less reoperative rate due to complications, however, VLP had advantages in functional recovery in the early period after surgery, but two methods had similar functional recovery at 12 mo, postoperatively. Clinician should make the treatment decision with great caution for the patients who sustained unstable distal radial fractures.

Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating

The traditional treatment of severely impacted fractures of the distal radius involves bridging external fixation and maintaining reduction by applying continuous traction. The recent technique using fixed-angle screws within volar plates is reported restore the radial length and the articular profile whilst avoiding joint distraction. It is also believed to produce better and quicker clinical results. To test these claims, we carried out a randomised controlled comparison of the efficiency of external fixation (EF) 'versus' open reduction and internal fixation (ORIF) in treating severely impacted fractures of the distal radius. A total of 39 patients were treated with EF, eventually associated with percutaneous pinning, whereas 36 underwent ORIF with a locked volar plate. There was no significant difference in the two groups with regard to changes in the ulnar variance. Articular reduction was poor in two patients in the EF group with residual step-offs exceeding 2mm; another patient of the EF group suffered a secondary loss of reduction, healing with a severe articular malunion (>2mm). By contrast, articular reduction was satisfactory in all the patients of the ORIF group. The clinical results on the Green and O'Brien rating were significantly better in the ORIF group than in the EF group (p<0.01 at 6 weeks, p<0.05 at 6 months). Nevertheless, open reduction and volar plating did not yield better subjective results than EF. However, although not statistically significant, patients treated by ORIF seemed to resume their usual activities quicker than those treated with EF, suggesting that this technique may be adapted to a greater extent in the case of active, young individuals.

Nonbridging external fixation of distal radius fractures

Surgical management of distal radius fractures continues to evolve because of their high incidence in an increasingly active elderly population. Traditional radiocarpal external fixation relies on ligamentotaxis for fracture reduction but has several drawbacks. Nonbridging external fixation has evolved to provide early wrist mobility in the setting of anatomic fracture reduction. Several studies of the nonbridging technique have demonstrated satisfactory results in isolated nonbridging external fixation series and in comparison with traditional spanning external fixation. Nonbridging external fixation for surgical treatment of distal radius fractures can be technically demanding and requires at least 1 cm of intact volar cortex in the distal fracture fragment for successful implementation.

External fixation of distal radius fractures

External fixation has been used for the treatment of distal radius fractures for more than 50 years. Although the fixator configurations have undergone considerable modification over time, the type of fixator itself is not as important as the underlying principles that provide the foundation for external fixation. Although volar plate fixation is currently in vogue, the indications for external fixation remain largely unchanged. Newer fixator designs have also expanded the traditional usage to include nonbridging applications that allow early wrist motion. The following discussion focuses on the myriad uses for external fixation as well as the shortcomings and potential pitfalls.

Biomechanical stability of a fixed-angle volar plate versus fragment-specific fixation system: cyclic testing in a C2-type distal radius cadaver fracture model

PURPOSE

To compare the biomechanical stability of 2 recently introduced fixation systems in an intra-articular, dorsal comminution distal radius fracture model.

METHODS

AO/ASIF type C2 fractures were simulated in 10 matched pairs of fresh-frozen cadaveric arms randomized between fixed-angle volar plate and fragment-specific fixation systems. Specimens were loaded in extension cyclically for 2,000 repetitions followed by a single cycle to failure. Initial, intermediate, and final stiffness values and failure load values were obtained and compared.

RESULTS

Both systems were able to sustain physiologic cyclic loading. The fragment-specific system was significantly stiffer than the fixed-angle volar plate system for the ulnar segment in both the precycle and postcycle values. No other comparisons were significant with respect to stiffness. No significant difference in load to failure was found between the systems with respect to ulnar, radial, or overall fragment displacement.

CONCLUSIONS

Both fixed-angle volar plate and fragment-specific fixation systems performed comparably in a simulated early postoperative motion protocol. Fragment-specific fixation had improved stiffness characteristics only with respect to the smaller ulnar-sided fragment.

Fractures of the distal radius treated with a nonbridging external fixation technique using multiplanar k-wires

PURPOSE

Joint-bridging external fixation is a minimally invasive treatment option for distal radius fractures. Although radial length can be restored easily the anatomic reduction of articular fragments and restoration of the normal volar tilt proves to be more difficult. A method of nonbridging hybrid fixation of distal radius fractures facilitates fracture reduction and allows for free wrist movement.

METHODS

Twenty-five consecutive patients with fractures of the distal radius were treated with nonbridging external fixation for 6 weeks. The stepwise surgical technique comprised a preliminary joint-bridging construction for reduction purposes, the subsequent insertion of 3 to 4 K-wires in the distal fragment, the assembling of wires to a bar nearly parallel to the fracture line, and lastly the removal of the joint-bridging part. Clinical and radiologic evaluation was performed on the first and seventh days and at 6 weeks and 2 years after surgery.

RESULTS

All fractures united. Palmar tilt (> or =0 degrees ) and articular surface (articular step-off < 2 mm) were restored in all patients whereas loss of radial length occurred in 4 patients having the distal fracture fragment secured with 3 K-wires. No radial shortening was seen in fractures with 4 K-wires inserted in the distal fragment. Functional results at 2 years after surgery showed an average extension of 55 degrees and flexion of 64 degrees without significant differences between extra-articular and intra-articular fractures. There was no extensor tendinitis or pin loosening in the distal fragment; however, 3 pin track infections of proximal pins occurred.

CONCLUSIONS

This surgical technique of nonbridging external fixation is a good treatment option for distal radius fractures: it permits wrist movement. We recommend the insertion of 4 K-wires in the distal fracture fragment.

Combined internal and external fixation of distal radius fractures

Combined internal and external fixation of distal radius fractures is used most commonly to treat injuries with joint surface or metaphyseal comminution. External fixation aids reduction intraoperatively and facilitates arthroscopic, per-cutaneous, or open manipulation of the fracture. Internal fixation maintains precise reduction of critical anatomy, principally the contour and orientation of the articular surface. Postoperatively the fixator functions as a neutralization device, preventing fracture collapse and decreasing the biomechanical demands on the internal fixation hardware. The combined technique exploits the benefits of both forms of fixation, allowing each to be used to full advantage in the treatment of complex distal radius fractures.

Nonbridging external fixation of intra-articular distal radius fractures

New solutions to difficult problems are always welcome, but nonbridging external fixation of intra-articular fractures is still in its infancy. Multicenter clinical trials are necessary to deter-mine whether the superior results obtained with nonbridging fixation of extra-articular fractures can be duplicated. With further study and new fixator designs, it is anticipated that nonbridging external fixation of intra-articular distal radius fractures will become another viable treatment option.

A biomechanical comparison of fragment-specific fixation and augmented external fixation for intra-articular distal radius fractures

The biomechanical stability of an internal fixation system that uses low-profile modular implants to stabilize individual fracture components was studied in a validated cadaver fracture model that incorporated physiologic muscle forces and wrist motion. Fragment-specific fixation with immediate range of motion was compared with static augmented external fixation in simulated, unstable 3- and 4-part intra-articular distal radius fractures (n = 20). Fixation was applied and specimens were loaded via their major wrist tendons. Because the wrist joint was not constrained in the internal fixation group, full wrist motion occurred during load application in these specimens. A 3-dimensional motion tracking system calculated individual fracture fragment motion in both groups. In the 3-part fracture pattern fragment-specific fixation showed comparable stability to static augmented external fixation despite the full wrist range of motion that occurred during application of load in these specimens. In the 4-part fracture pattern fragment-specific fixation was shown to be significantly more stable when compared with static augmented external fixation in 4 of 6 axes of motion. Our findings confirm the stability of this low-profile plating system and support the consideration of early wrist motion when treating complex, intra-articular distal radius fractures with fragment-specific fixation.

Antegrade intramedullary K-wire fixation for distal radial fractures

Manual reduction and antegrade intramedullary K-wire fixation were performed for 29 selected Colles-type distal radial fractures in 29 patients. Severely comminuted intra-articular fractures and Barton's fracture were not included in this study. The tips of the K-wires supported an articular surface of the distal radius. Except for 1 case of skin irritation in the forearm, there were no complications related to tendon or nerve injuries or reflex dystrophy. There was no pin loosening, but protrusion of sharp tips of K-wires into the wrist joint occurred in 3 patients. Average volar tilt, radial shortening, and step-off at follow-up evaluation were 5 degrees, 2.6 mm, and 0.2 mm, respectively. These radiologic results were consistent with values reported in other pinning studies; however, radial shortening was not controlled effectively. Fourteen (48%) of 29 patients had radial shortening >3 mm. The advantages of this surgical procedure are the low occurrence rate of soft-tissue complications and prevention of dorsal angulation of fractures.

Wrist fractures

The benefits of a well-reduced and well-healed wrist fracture are predictable. This knowledge has prompted the development of myriad treatment methods and fixation devices. The choice of open versus closed reduction and the devices used to maintain that reduction could most often be determined with a well-defined and reproducible closed reduction maneuver. With this maneuver, the integrity of the critical volar ulnar corner of the radius is determined as is articular stepoff, metaphyseal comminution, and distal radionular joint (DRUJ) stability. Reconstruction of the subluxed or dislocated DRUJ starts with the reduction of the radius, frequently obviating the need to address fractures involving the ulnar head and styloid. Most importantly, the results of treatment reflect surgical decision over the fixation method.

Treatment of the unstable distal radius fracture with external fixation and a hydroxyapatite spacer

A prospective study was performed on 25 patients (15 women, 10 men) with unstable fractures of the distal radius selectively treated with a dynamic type of external fixation combined with a hydroxyapatite spacer. The fractures ranged from type VI to type VIII according to Frykman's classification. The patients' mean age at surgery was 49 years (range, 19-75 years). The mean follow-up period was 2.5 years, and overall outcome was assessed using Gartland and Werley's demerit point system as modified by Sarmiento. Radial inclination was 26 degrees +/- 4 degrees at the time of reduction and 26 degrees +/- 5 degrees at follow-up, palmar tilt was 9 degrees +/- 2 degrees at reduction and 8 degrees +/- 3 degrees at follow-up, and ulnar variance was 1.4 +/- 0.6 mm at reduction and 2.1 +/- 0.9 mm at follow-up. The mean range of motion at follow-up was 80 degrees +/- 10 degrees in flexion, 80 degrees +/- 10 degrees in extension, 85 degrees +/- 10 degrees in supination, and 80 degrees +/- 5 degrees in pronation. The outcome in 24 of 25 patients was evaluated as excellent. In the surgical treatment of unstable fractures of the distal radius using external fixator, the fracture reduction should be supported with bone graft or a bone substitute, and a hydroxyapatite spacer was considered to be a useful substitute for a bone graft.

Computerized analysis of radiographs in Colles' fractures

Several radiographic parameters correlate with clinical outcome in distal radius fractures. This study describes a new, computerized routine that automatically defines the longitudinal axis of the radius, deriving the radial tilt, radial width, and radial height on anteroposterior radiographs of the wrist. The intraobserver and interobserver variability is reported in a series of 33 anteroposterior radiographs of the wrist. An edge-finding filter is used to determine accurately the cortices in several lines of each image. The midpoints between these two edges are used to determine the best-fit line, thereby defining the longitudinal axis of the bone. The operator marks the tip of the radial styloid and the lunate angle of the radius at the distal radioulnar joint. Radial shortening, widening, and loss of angle are calculated. The 33 radiographs were measured twice by two independent observers, and 12 sets of paired readings were analyzed using the two-tailed paired t test. The mean difference between readings was reduced to a fraction of degree or millimeter, virtually eliminating the intraobserver and interobserver errors. Thus, the current study shows the computer is a reliable and effective instrument for measuring radiographs. The computer-aided system of measurements can be extended to prostheses, fractures, and to other orthopaedic measurements.