Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report

Characterization of Major Complications of Bridge Plating of Distal Radius Fractures at a Level I Trauma Center

BACKGROUND

Comminuted, markedly displaced distal radius fractures can cause instability requiring advanced stabilization with dorsal bridge plating. However, published complication rates of bridge plating widely vary. We hypothesize that complications of bridge plating of distal radius fractures are more prevalent than published rates.

METHODS

A retrospective review was performed on all patients at an academic level I trauma center treated with a bridge plate for a distal radius fracture from 2014 to 2022.

RESULTS

Sixty-five wrists were included in the final analysis: average age 53 years, male 51%, average plate retention 4 months, and average follow-up 6 months. Carpal tunnel release (CTR) was performed at time of primary procedure in 7 (10%) cases. Radial height, radial inclination, dorsal tilt, and ulnar variance were all significantly improved (P < .001). Grip strength, flexion, extension, and supination were significantly limited (P < .03). Twenty-one patients (32%) developed 35 major complications requiring unplanned reoperation, including mechanical hardware-related complication (15%), deep infection (11%), nonunion/delayed union (9%), adhesions (6%), median neuropathy (6%), symptomatic arthritis (5%), and tendon rupture (2%). Plate breakage occurred in 3 patients (5%) and was always localized over the central drill holes of the bridge plate.

CONCLUSIONS

Major complications for bridge plating of distal radius fractures were higher at our institution than previously published. Plate breakage should prompt reconsideration of plate design to avoid drill holes over the wrist joint. Signs and symptoms of carpal tunnel syndrome should be carefully assessed at initial presentation, and consideration for concomitant CTR should be strongly considered.

How Preoperative Closed Reduction and Time to Surgery Impact Postoperative Palmar Inclination in Distal Radius Fractures

Background: The anatomical reconstruction of the wrist is the aim when treating distal radius fractures. Current literature on the importance of preoperative reduction in fractures that are treated operatively is limited. Methods: This study investigated the effect of the preoperative closed reduction of distal radius fractures on the day of trauma and the time to surgery on postoperative palmar inclination. A total of eighty patients (48 females and 32 males, mean age 55.6 years) were studied retrospectively. All patients were treated with an open reduction and internal fixation. The palmar inclination angle was measured using X-rays by two investigators, and the interobservers and pre- and post-reduction parameters were compared. Results: When the surgical management of closed distal radius fractures is required, neither initial repositioning nor a delay of up to 14 days to the surgical treatment influences postoperative palmar inclination. Conclusions: The significance of preoperative reduction of distal radius fractures without neurovascular or extensive soft tissue damage is limited and is not leading to improved outcomes. When surgery is about to be performed, surgeons should carefully consider if reduction is really vital preoperatively. Level of evidence: III.

Volar Locking Plating of Extra-articular Distal Radius Fracture: A Retrospective Clinical Study Comparing Locking Screws versus Smooth Locking Pegs

Background  Open reduction and internal fixation of distal radius fractures is one of the most common procedures performed in wrist surgery. The use of volar locking plate has gained increasing interest in the past decade. Epiphyseal fixation can be done either with locking screws or smooth locking pegs, with no evidence supporting the use of one rather than the other. Purpose  The aim of this study is to compare the stability of distal radius fixation by volar locking plate using locking screws or smooth locking pegs. Methods  Adult patients with A2-A3 AO fractures treated with a volar plate with locking screws only or smooth locking pegs only were retrospectively included. Radiographic assessment was performed to evaluate extra-articular parameters in the intraoperative postreduction and fixation period and after bony healing. Forty-seven distal radius fractures were included. Results  Twenty-four fractures had fixation with locking screws and 23 had fixation with smooth locking pegs. For both groups, all radiographic parameters measured showed a statistically significant difference between the intraoperative postreduction and fixation period and the remote postoperative period after union of the fracture ( p  < 0.05) attesting a slight loss of reduction. Nevertheless, there were no significant differences between the groups in radiographic extra-articular parameters. Conclusion  This clinical study shows that there is no difference in stability fixation between locking screws or smooth locking pegs in A2-A3 distal radius fractures. Clinical Relevance  The use of smooth locking pegs only for epiphyseal fixation appears to be safe in volar plating of A2-A3 distal radius fractures in adult patients and could be an alternative to locking screws. More clinical data are needed to confirm these results. Level of Evidence  Level III; retrospective comparative study.

The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction

Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.

Optimizing Volar Tilt Restoration and Plate Position in Distal Radius Fractures

PURPOSE

Distal radius fractures are common and often treated surgically with a volar plate. A complication of volar plating includes tendonitis or rupture of the flexor pollicis longus (FPL) tendon. We hypothesize that failure to restore the volar tilt of the distal radius results in increased pressure on the FPL tendon.

METHODS

Ten fresh-frozen cadaveric wrists were assessed for this study. During testing, weights were suspended from the FPL tendon to stimulate muscle contraction. Reproducible fractures were created and fixed via volar plating. The contact force between FPL and the bone or plate edge was measured with a force transducer in 5 surgical conditions. These were assessed to evaluate whether failure to restore the volar tilt increases the pressure with a plate proximal or distal to the watershed line.

RESULTS

Significant increases in contact forces were observed between the control and both conditions in which volar tilt was not restored, with mean increases of 1.9 N and 3.0 N. A significant increase in the contact force was found when placing the plate distal to the watershed line with a mean increase of 2.03 N comparing the failure to restore volar tilt and after restoring the volar tilt. Significant increases in contact force were also observed between the dorsal plate condition, which failed to restore the volar tilt, and both plate conditions with placement distal to the watershed line, with mean differences of 0.94 N and 1.09 N, respectively.

CONCLUSIONS

Failure to restore the volar tilt in surgically treated distal radius fractures causes increased pressure on the FPL tendon. Plate placement distal to the watershed line also causes increased FPL tendon pressure over the plate edge.

CLINICAL RELEVANCE

This study demonstrates the importance of restoring the volar tilt of the distal radius in surgically treated distal radius fractures and confirms that plate placement distal to the watershed line will increase pressure on the FPL tendon.

Effect of uncertain clinical conditions on the early healing and stability of distal radius fractures

BACKGROUND AND OBJECTIVES

The healing outcomes of distal radius fracture (DRF) treated with the volar locking plate (VLP) depend on surgical strategies and postoperative rehabilitation. However, the accurate prediction of healing outcomes is challenging due to a range of certainties related to the clinical conditions of DRF patients, including fracture geometry, fixation configuration, and physiological loading. The purpose of this study is to investigate the influence of uncertainty and variability in fracture/fixation parameters on the mechano-biology and biomechanical stability of DRF, using a probabilistic numerical approach based on the results from a series of experimental tests performed in this study.

METHODS

Six composite radius sawboneses fitted with titanium VLP (VLP 2.0, Austofix) were loaded to failure at a rate of 2 N/s. The testing results of the elastic and plastic behaviour of the VLP were used as inputs for a probabilistic-based computational model of DRF, which simulated mechano-regulated tissue differentiation and fixation elastic capacity at the fracture site. Finally, the probability of success in early indirect healing and fracture stabilisation was predicted.

RESULTS

The titanium VLP is a strong and ductile fixation whose flexibility and elastic capacity are governed by flexion working length and bone-to-plate distance, respectively. A fixation with optimised designs and configurations is critical to mechanically stabilising the early fracture site. Importantly, the uncertainty and variability in fracture/fixation parameters could compromise early DRF healing. The physiological loading uncertainty is the most adverse factor, followed by the negative impact of uncertainty in fracture geometry.

CONCLUSIONS

The VRP 2.0 fixation made of grade II titanium is a desirable fixation that is strong enough to resist irreparable deformation during early recovery and is also ductile to deform plastically without implant failure at late rehabilitation.

Volar Barton Fracture and Ulnar Styloid Fracture With Distal Radial Ulnar Joint Disruption of the Right Wrist Without Neurovascular Deficit

Volar Barton fracture is a common condition in dislocation of the distal radius of the volar or dorsal aspect. It occurs due to violent injury or road traffic accidents. Radius is one of the most common parts to get affected. Various treatment plan is needed for this fracture like physical therapy and medication. Surgical intervention is necessary to treat the patient for a volar Barton fracture. Recovery takes time for this condition. For treatment, patient education is also important. The patient should be goal-oriented, cooperative, and motivated for the rehabilitation program. Isometric strengthening exercises for the shoulder and elbow were performed to regain the muscle's strength. The main aim is to make the patient independent of functional activities. Quality of life improved, and a rehabilitation program benefited the patient.

Risk of Volar Locking Plate Removal After Distal Radius Fractures: Time-to-Event Analysis

PURPOSE

The primary purpose of this study was to describe the rate of volar locking plate (VLP) removal after distal radius fracture and how long it takes for the risk of VLP removal to stabilize. The secondary purpose was to describe the reasons for VLP removal and analyze the relationship between it and the Soong index.

METHODS

This was a single-center retrospective cohort study. Patients aged >18 years with distal radius fracture who underwent VLP fixation were included. Hardware removal, time until VLP removal, and the primary reason for removal were recorded. The implant prominence was measured as described by Soong. We used Kaplan-Meier curves and risk tables to describe the risk of VLP removal and variation over time. Multivariable logistic regression was used to assess the relationship between Soong grade and VLP removal.

RESULTS

A total of 313 wrists were included. There were 35 cases of VLP removal, with an overall incidence of 11.2% at 15 years of follow-up. The incidence rate was 1.2 per 100 individuals per year for the entire cohort. The risk of VLP removal decreased from 6.2% in the first postoperative year to 1.7% in the second year and 1.4% in the third year. Beyond that, the rate remained <1% per year throughout the follow-up period. The median hardware removal time was 11 months. The main reasons for VLP removal were tenosynovitis, implant-associated pain, and screw protrusion. We found no association between Soong grade and VLP removal.

CONCLUSIONS

Volar locking plate removal after distal radius fracture was more common in the first year after surgery and remained notable until the third year. Regular monitoring and patient education to assess possible complications related to hardware are important during this period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment and outcome of AO/OTA type C distal radius fractures: 12 199 fractures from the Swedish Fracture Register

The aim of this study was to examine the epidemiology, treatment, and patient-reported outcome of AO/OTA type C distal radius fractures (DRF) using data from a large national fracture register. We used prospectively collected data from the Swedish Fracture Register covering all AO/OTA type C DRFs registered between April 2012 and December 2018. Data on fracture type, epidemiology, trauma-mechanism, and treatment had been recorded by the treating physician. Patients had been sent an outcome questionnaire including EQ-VAS, EQ-5D, and the SMFA at the time of injury and 12 months after. A total of 12 199 cases with AO/OTA type C fracture were identified. AO/OTA type C1 fracture was most common, with 5400 cases, followed by AO type C2 with 4304 and AO/OTA type C3 with 2495. Cast treatment and surgical treatment with volar locking plate fixation were the most common treatments. Patient-reported outcome measures worsened significantly one year after the fracture, and 56% reported moderate problems with pain and discomfort one year after the fracture. Patients treated with a volar plate reported a significantly larger deterioration in EQ-5D outcome compared to patients treated with a cast. No treatment method was found to be superior. A good outcome after a type C fracture is possible, but many patients do not recover completely. Our findings indicate a relatively better self-reported outcome for patients treated with a cast, but as treatment was not randomized the clinical relevance is unclear.

[Our preferred Approaches to the distal Radius]

This article describes our preferred approaches to the distal radius treating acute fractures and malunion by plating.

Nascent Malunion of Distal Radius Fractures Treated with Fixed Angled Volar Plates without Using Bone Grafts

Purpose

Malunion of the distal radius is a common complication. Using bone grafts is common to restore the bone to an acceptable level. This study aimed to verify if it is necessary to use bone grafts in nascent malunion of distal radius fractures treated with fixed angled volar plates and which radiographic parameters are essential to obtain satisfactory outcomes.

Methods

This single-centered prospective study included 11 patients who underwent corrective osteotomy of the radius for malunion. Patients with a metaphyseal, extraarticular osteotomy stabilized by a volar fixed angle plate within 3 months after the fracture are included. Patients underwent a standard radiological evaluation at postoperative 1 month, 3 months, 6 months, 1 year, and annually thereafter. Radial inclination, radial height, ulnar variance, and palmar tilt were measured. Wrist ranges of motion are measured throughout follow-up with a goniometer. Grip strength is measured using a Jamar Hand Dynamometer. The function is evaluated via the Gartland-Werley (GW) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results

The mean age of 11 patients, 9 (81.82%) males, included in the study was 41.45 ± 14.89 years. The mean post-fracture admission time is 39.3 ± 15.1 days. Radial inclination, radial length, and ulnar variance improved significantly after surgery (p = 0.0023, 0.0002, 0.0037). Radial inclination values are within normal limits for all patients at admission. The radial length was in the normal range for 72.73%, the ulnar variance was in the normal range for 72.73%, and palmar tilt was in the normal range for 100% of the patients. Extension 54.55%, flexion 72.73%, radial deviation 81.82%, ulnar deviation 63.64%, pronation 90.91%, and supination 72.73% were achieved after surgery. GW average was 3.09 ± 3.24 DASH score average was 12.24 ± 13.48. The mean grip strength was 29.27 ± 7.21 on the operated side, while it was 34.91 ± 5.32, on the healthy side, with a significant difference (p = 0.0108).

Conclusion

It is possible to get good results without using bone grafts in corrective osteotomy of distal radius malunions.

Ultrasonographic evaluation of contact configuration between flexor pollicis longus tendon and the volar prominence of volar plate in patients with distal radius fracture

INTRODUCTION

We classified the contact configuration between the volar prominence of volar locking plate (VLP) and flexor pollicis longus (FPL) tendon using ultrasound (US) into indentation contact and smooth contact, and investigated whether the contact configuration is associated with the flexor tendon attrition.

MATERIALS AND METHODS

Ninety-four patients who underwent VLP removal were included in this study. We assessed pain using visual analogue scale, grip strength, and Disabilities of the Arm, Shoulder and Hand score for clinical evaluations, radial inclination, palmar tilt, ulnar variance, and Soong classification for radiological evaluations, and contact configuration using US at 1 year after VLP fixation. After these evaluations, we removed the VLP with observation for the presence of fibrillation or wear of FPL tendon substance. Subsequently, we classified the patients into either of FPL attrition and FPL intact group.

RESULTS

Twenty-eight patients had indentation contact configuration and 66 patients had smooth contact configuration. The kappa value for inter-observer reliability for the contact configuration was 0.78. Twelve patients were included in the FPL attrition group and 82 in the FPL intact group. There was no significant difference in clinical outcomes and Soong classification between the groups. However, palmar tilt of the flexor tendon attrition group was significantly lower than that of the flexor tendon intact group and the FPL attrition group showed significantly higher indentation contact configuration rate than the FPL intact group. FPL tendon attrition was diagnosed using the contact configuration on US with a sensitivity of 100% and specificity of 80%.

CONCLUSION

This study demonstrated that FPL tendon attrition was significantly associated with indentation contact on US with high sensitivity. Therefore, we recommend selective implant removal in patients with indentation contact configuration.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Distraction plating for bilaterally severely comminuted distal radius fracture: a case report

We report a case in which distraction plating was performed for bilateral highly comminuted distal radius fractures. The upper extremities' range of motion and function was acceptable. Thus, distraction plating can be a good option for relatively young patients with severe comminution of the radius and soft tissue damage.

Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation

PURPOSE

To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures.

METHODS

A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated.

RESULTS

There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation.

CONCLUSIONS

Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Comparison of the conventional Henry approach and trans-flexor carpi radialis approach for the treatment of distal radius fracture: A retrospective cohort study

Few studies have compared the clinical outcomes of the conventional Henry approach and trans-flexor carpi radialis (FCR) approach. The purpose of this study was to compare the clinical and radiologic outcomes of the conventional Henry approach and trans-FCR approach for the treatment of distal radius fractures. We compared 20 wrists that underwent the conventional Henry approach with 20 wrists that underwent the trans-FCR approach for open reduction and internal fixation of distal radius fracture. The clinical and radiological parameters were checked at 3 months, 6 months, and 1 year after surgery. A visual analogue scale score, the modified Mayo wrist score, range of motion, and grip strength were collected. In addition, tenderness in the area of the FCR tendon were assessed. Regarding radiologic evaluations, the radial inclination, radial height, volar tilt, and ulna variance were measured. In the trans-FCR approach group, 15 patients complained of tenderness in the area of the FCR tendon at 3 months after surgery, which was significantly higher than those of conventional Henry approach group (P < .05). In the conventional Henry approach group, the tenderness had resolved spontaneously by 1 year after surgery in 19 patients. The trans-FCR approach can cause discomfort such as tenderness to the area of the FCR tendon compared to the conventional Henry approach, but there is no significant difference in the final clinical and radiologic outcomes.

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Dorsal Plate Osteosynthesis in Simple and Complex Fractures of the Distal Radius: A Radiological Analysis of 166 Cases

Background  To report the radiologic outcome and rate of complications of open reduction and internal fixation (ORIF) using a dorsal plate fixation of simple and complex distal radius fractures in adult patients. Methods  Patients treated with dorsal ORIF of simple and complex distal radius fractures between December 2008 and April 2013 were included in this single-center retrospective study. Type of fracture, radiographic measurements, and complications were documented. Results  One-hundred and sixty-six patients/fractures were included. Restoration of radial inclination (22° ± 3°) was achieved in 38%. Radial height (14 ± 1 mm) was least likely to be restored to normal values postoperative in 25%. Normal ulnar variance (0.7 ± 1.5 mm) could be observed in 60% and adequate volar tilt (11° ± 5°) was achieved in 50% at final follow-up. We observed one loss of reduction in an AO type C2 fracture and a total of 15 nonimplant-related minor clinical complications. Conclusion  Our radiographic findings after dorsal plating are comparable to those published on volar plating. The changes in radial height and volar tilt could be attributed to projection-related differences in the radiographs and did not signify a loss of reduction in all cases. Clinical Relevance  Dorsal plating of distal radius fractures is safe and remains an important approach in the treatment of complex distal radius fractures. Complications in our study were even less compared to those reported in the literature. Type of Study/Level of Evidence  This is a Type IV study. Level of Experience of Surgeons  The level of experience of surgeons is III-V.

Comparison of the Orientation Angles of Volar Locking Plate Distal Ulnar Locking Screw for Distal Radius Fractures

PURPOSE

This study aimed to measure the angles between the screw and plate in 16 commercially available volar locking plates (VLPs) to determine the fixable intra-articular fragment size.

METHODS

Ulnar orientation angles (axial plane) and elevation angles (sagittal plane) between the distal ulnar screw and plate were measured for 14 fixed-angle VLPs and 2 variable-angle VLPs. Each VLP was simulated by 2 surgeons to sit distally and ulnarly in 10 normal distal radius models. The distance between the screw and distal/ulnar end of the distal radius on both the volar and dorsal sides, designated as the longitudinal/lateral distance, was measured to identify the fixable size of the 2 intra-articular fragments: volar lunate fragment and dorsoulnar fragment. Relationships between the ulnar orientation angle and dorsal-side lateral length as well as the elevation angle and dorsal-side longitudinal distance were analyzed.

RESULTS

The ulnar orientation and elevation angles ranged from 6.5° to 16.9° and -5.8° to 34.3°, respectively, for fixed-angle VLPs and -12.5° to 32.2° and 3.1° to 42.1°, respectively, for variable-angle VLPs. The minimal longitudinal distances on the volar side with the fixed- and variable-angle VLPs were 4.3-10.9 mm and 5.8-5.9 mm, respectively. On the dorsal side, the lateral distance negatively correlated with the ulnar orientation angle (R = -0.74), and the longitudinal distance negatively correlated with the elevation angle (R = -0.89).

CONCLUSIONS

The Depuy Synthes variable-angle VLP provides an advantage for fixating small intra-articular fragments. For fixed-angle VLPs, the Mizuho VLP provides an advantage for fixating small volar lunate fragments. A narrow dorsoulnar fragment can be fixated using a plate with a large ulnar orientation angle, such as the Zimmer Biomet or Mizuho VLP.

CLINICAL RELEVANCE

The ability of each individual commercially available plate to capture specific intra-articular fragments should be known.

Prevalência de dor neuropática em pacientes com fratura da extremidade distal do rádio tratada com placa volar bloqueada

Objetivo Avaliar a prevalência de dor persistente no pós-operatório de fratura da extremidade distal do rádio, assim como detectar precocemente sinais de dor neuropática com o intuito de desenvolver protocolos de prevenção da dor crônica pós-operatória.

Métodos Estudo prospectivo, realizado com 56 pacientes submetidos a redução aberta e fixação interna de fratura da extremidade distal do rádio com placa volar bloqueada no período de março a setembro de 2020. Os pacientes foram submetidos a avaliação de dor neuropática e capacidade funcional através dos questionários Douleur Neuropathique 4 questionnaire (DN4) e Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH, na sigla em inglês). As variáveis qualitativas foram comparadas pelo teste de Mann-Whitney e sua correlação foi analisada pelos testes de correlação de Spearman e de Igualdade de Duas Proporções.

Resultados Foram incluídos no presente estudo 43 pacientes, com idades entre 18 e 66 anos; 39,5% dos participantes apresentaram pontuação ≥ 4 no questionário Douleur neuropathique 4 questionnaire (DN4). Em relação ao Quick-DASH, a média foi de 38,6. Não houve diferença estatística significante entre o sexo do paciente e o valor do DN4 (p = 0,921). Também não foi encontrada correlação estatística entre as variáveis quantitativas DN4 e Quick-DASH (p = 0,061).

Conclusões A prevalência de dor neuropática nos pacientes pós-operatórios analisados foi significativa e a presença de sinais e sintomas de dor neuropática foi fator preditivo positivo para a persistência da dor além de 2 meses em 100% dos casos. Assim, com diagnóstico precoce do componente neuropático de dor, associado ao componente nociceptivo, é possível obter o controle adequado da dor, impedindo sua cronificação e garantindo uma melhor reabilitação.

Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment - a biomechanical study

Complex intraarticular distal radius fractures (DRFs), commonly managed with volar locking plates, are challenging. Combined volar and dorsal plating is frequently applied for treatment, however, biomechanical investigations are scant. The aim of this biomechanical study was to investigate volar plating versus double plating in DRFs with different degrees of lunate facet comminution.Thirty artificial radii with simulated AO/OTA 23-C2.1 and C3.1 DRFs, including dorsal defect and lunate facet comminution, were assigned to 3 groups: Group 1 with two equally-sized lunate facet fragments; Group 2 with small dorsal and large volar fragment; Group 3 with three equally-sized fragments. The specimens underwent volar and double locked plating and non-destructive ramped loading in 0° neutral position, 40° flexion and 40° extension.In each tested position, stiffness: (1) did not significantly differ among groups with same fixation method (p ≥ 0.15); (2) increased significantly after supplemental dorsal plating in Group 2 and Group 3 (p ≤ 0.02).Interfragmentary displacements between styloid process and lunate facet in neutral position were below 0.5 mm, being not significantly different among groups and plating techniques (p ≥ 0.63).Following volar plating, angular displacement of the lunate facet to radius shaft was significantly lower in Group 1 versus both Group 2 and Group 3 (p < 0.01). It decreased significantly after supplemental dorsal plating in Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not differ significantly among the three groups after double plating (p ≥ 0.74).Comminution of the lunate facet within its dorsal third significantly affected the biomechanical outcomes related to complex intraarticular DRFs treated with volar and double locked plates.Double plating demonstrates superior stability versus volar plating only for lunate facet comminution within its dorsal third. In contrast, volar plating could achieve stability comparable with double plating when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicated achievable absolute stability between the articular fragments.

Distal radius fractures

The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

Grip Strength Measurement for Outcome Assessment in Common Hand Surgeries

Grip strength has been used to evaluate the upper extremity functional status and clinical outcomes following upper extremity trauma or surgery. Understanding general recovery patterns of grip strengthening can be helpful in assessing the patients’ recovery status and in assisting in preoperative consultations regarding expectations for recovery. We summarize related studies on grip strength measurement and recovery patterns in common hand conditions, including carpal tunnel syndrome, cubital tunnel syndrome, triangular fibrocartilage complex injury, and distal radius fractures.

Distal Radius Fractures and the Dorsal Spanning Plate in the Management of the Polytraumatized Patient

Distal radius fractures are some of the most common fractures treated by the orthopaedic surgeon. There are a variety of methods of fixation to treat these fractures; however, in patients with polytrauma and in high-energy fracture patterns, fixation options can be limited. In the past, these fractures were treated with plaster, Kirschner wires, or external fixators that were fraught with complications. The dorsal spanning plate is an excellent option in the treatment of high-energy fractures and patients with polytrauma, fractures with dorsal or volar comminution, fracture dislocations, and shear injuries, and in geriatric patients with poor bone quality. The dorsal spanning plate not only allows for fixation of these complex fractures but also allows for weight-bearing through the wrist, an advantage for patients with concomitant lower extremity fractures and geriatric patients who need mobility aides. Understanding the risks and benefits of dorsal spanning plates and their use for the treatment of polytraumatized patient is a vital base of knowledge for the orthopaedic traumatologist.

Loss of radial height in extra-articular distal radial fracture following volar locking plate fixation

BACKGROUND

Radial height is an important prognostic factor in treating distal radius fracture. However, does further collapse of radial height in distal radius fractures after with volar locking plate fixation have a great impact on the prognosis? The present study aimed to elucidate radial height loss and determine the associated risk factors after open reduction and internal fixation with volar locking plate in patients with extra-articular distal radius fractures.

HYPOTHESIS

Patients with radial height collapse after fracture reduction and internal fixation with a volar locking plate may have poor outcomes.

METHODS

Data of 87 patients (21 male) undergoing surgery for acute extra-articular distal radius fractures (AO: 23-A2 or 23-A3) between February 2014 and July 2016 were evaluated retrospectively. Patients were divided into two groups by radial height loss. Potential risk factors were tested by Pearson correlation coefficients. Stepwise multiple regression logistic analysis determined significant independent risk factors for extra-articular distal radius fractures. Clinical evaluation was performed by the same surgeon by determining wrist ROM. Grip strength was measured with a Jamar dynamometer and compared with non-affect wrist in percentage. In addition, all the patients were asked to grade modified Mayo wrist score and Visual Analogue Scale (VAS) score. These findings were recorded postoperative 1 year of follow-up.

RESULTS

Mean radial height loss was 1.3±0.9mm. Age (ß=0.002, p=0.003), postoperative ulnar-positive deformity (ß=0.107, p<0.001), DEXA (ß=-0.015, p=0.008), and shortest diameter of distal fracture fragment in AP and lateral views (ß=-0.050, p=0.037; ß=-0.080, p=0.043) were significantly associated with radial height loss. As for the outcome of clinical prognosis, though radial height collapse group had poorer wrist range of motion, there was no statistical difference. Besides, there were no significant differences in grips strength and VAS score between these two groups. However, in regards of modified Mayo wrist score, the percentage of patients with poor outcomes is significant higher in radial height collapse group (p=0.039). Moreover, all patients with poor outcomes in radial height collapse groups were older than 65-year-old.

DISCUSSION

Radial height loss is noted in patients undergoing open reduction and internal fixation with volar locking plate for extra-articular distal radius fractures. Risk factors for radial height collapse include advanced age, poor bone quality, shortest distance between fracture site and articular surface and postoperative ulnar-positive deformity.

LEVEL OF EVIDENCE

IV; non-comparative prospective study.

Comparison of immobilization periods following open reduction and internal fixation of distal radius fracture: A systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

INTRODUCTION

The use of volar locking plate (VLP) in the fixation of fracture fragments promised a new era in the management of distal radius fracture (DRF).

PURPOSE OF THE STUDY

To compare the patient-reported outcomes, functional outcomes, pain, and adverse events between the different periods of immobilization following open reduction and internal fixation of DRFs with VLP.

METHODS

We searched Medline/Pubmed, Web of Science, Ovid, and CINAHL. The inclusion criteria was randomized controlled trials that compared different immobilization periods after open reduction and internal fixation of DRFs with VLP. The last search was performed on 2 June 2020. The different immobilization periods were divided into the following 3 groups: ≤1-week group, 2-3-week group, and 5-6-week group.

RESULTS

Seven eligible randomized controlled trials provided data on 509 patients. We found that compared to 5-6-week group, ≤1-week and 2-3-week groups showed a reduction in overall Patient-Reported Wrist Evaluation score (SMD = -0.48, 95% CI -0.73 to -0.22, P < .001; SMD = -0.69, 95% CI -0.97 to -0.41, P < .001, respectively). We also found that there were improvements in the other patient-reported outcomes including overall Disabilities of the Arm, Shoulder, and Hand score and pain; and functional outcomes including overall grip strength and range of motion measures in favor of ≤1-week and 2-3-week groups.

CONCLUSION

This systematic review and meta-analysis showed that compared to immobilization for 5 to 6 weeks after DRF repair, immobilization for ≤1 week or 2-3 weeks showed improvements in the patients-reported outcomes and functional outcomes. The differences between the 3 immobilization groups may not be clinically important considering the small changes as follow up progresses.

Clinical, functional and radiological outcomes of the use of fixed angle volar locking plates in corrective distal radius osteotomy for fracture malunion

Background and aim:

Fractures of the distal radius are a common injury and mal-union can occur in those managed non-operatively. This can cause significant functional limitations along with pain. A corrective osteotomy with the use of a volar locking plate aims to restore articular surface congruency and improve outcomes. We present our local experience with clinical, functional and radiological outcomes of corrective osteotomy using a fixed angle volar locking plate and bone graft for management of distal radius mal-union.

Methods:

Retrospective study. All adult patients. Both pre and post operatively clinical range of motion was recorded. Post operative PROMS was measure by DASH, MAYO and SF-12 and pain by means of a VAS measured from 0-10. Mean follow up period was at 15 months.

Results:

32 patients underwent the studied procedure. 24F-8F. Mean age: 56. Radiological union of corrective osteotomy: 28 (88%) of patients. 4 patients required further operative treatment to achieve corrective union. No other reported complications post-op. Post-operatively flexion improved by 24 and extension 20. Pronation was improved by 24 and supination 22. Pain was improved from an average VAS pre-operative of 5.6 to 1.6 post-operatively. Mean DASH scored improved from 57.8 to 16.2 post-operatively and MAYO 38.5 to 58.6. The mean post-operative SF-12 score was 46.2 from 31.

Conclusions:

In this series of 32 patients (the biggest reported in the literature in our knowledge) a corrective osteotomy with fixed-angle volar locking plate for mal-united distal radius has shown to improve both clinical-radiological and patient reported outcomes and provide good results of the very few complications’ treatments. (www.actabiomedica.it)

Distal radius fracture fixation using volar plate: A comparative study evaluating the biomechanical behavior of uni and bicortical distal screws

Extensor tendon ruptures caused by bicortical screws impingement following distal radius fracture fixation with volar plates are extensively reported in the literature. Thus, a biomechanical study comparing unicortical and bicortical fixations in intra-articular distal radius fracture models is critical in decision-making regarding distal radius fracture management. Forty-two synthetic radius models were fixed using a variable angle volar distal locking plate with seven screws. They were divided into 6 groups (n = 7): G1/G3/G4 unicortical fixation (75% of anteroposterior distal radius lenght); G2/G4/G6 bicortical fixation. Each group underwent a different mechanical test: axial compression (G1/G2), dorsal flexion (G3/G4), and volar flexion (G5/G6). The load application rate was 5 mm/min and 1000 cycles of 50 to 250 N at 1 Hz were performed between both static tests. Comparative results in the first static test, in the second static test, and in failure generally showed a very similar behavior. Models depicted similar behavior in the second static test when cyclic load was performed. Therefore, one can realize that stiffness differed during dorsal flexion only in the first static test. Maximum force to break the model in axial compression was greater in bicortical than in unicortical construct. Since biomechanical properties are similar, we recommend using unicortical distal locking screws in distal radius fracture fixation with volar plates to prevent extensor tendon ruptures.

Balance Between Mechanical Stability and Mechano-Biology of Fracture Healing Under Volar Locking Plate

The application of volar locking plate (VLP) is promising in the treatment of dorsally comminuted and displaced fracture. However, the optimal balance between the mechanical stability of VLP and the mechanobiology at the fracture site is still unclear. The purpose of this study is to develop numerical models in conjunction with experimental studies to identify the favourable mechanical microenvironment for indirect healing, by optimizing VLP configuration and post-operative loadings for different fracture geometries. The simulation results show that the mechanical behaviour of VLP is mainly governed by the axial compression. In addition, the model shows that, under relatively large gap size (i.e., 3-5 mm), the increase of FWL could enhance chondrocyte differentiation while a large BPD could compromise the mechanical stability of VLP. Importantly, bending moment produced by wrist flexion/extension and torsion moment produced from forearm rotation could potentially hinder endochondral ossification at early stage of healing. The developed model could potentially assist orthopaedic surgeons in surgical pre-planning and designing post-operation physical therapy for treatment of distal radius fractures.

Fragment specific fixation with APTUS wrist system for volar rim fractures of the distal radius: a multicentric study

PURPOSE

Volar rim fractures of the distal radius are a spectrum of pathology that must be well identified and treated to achieve good outcomes and avoid surgical failures. New devices of fragment specific fixation have been developed during the last decades to fix this fragment. The purpose of this retrospective study was to evaluate the ability of APTUS^® wrist distal radius system to securely fix different types of volar rim fractures.

METHODS

Patients with at least 1 year of follow-up and a preoperative CT-scan evaluation of the fracture pattern were included in the study. Clinical, radiological and functional outcomes were assessed.

RESULTS

Sixty-eight patients with an average follow-up of 34, 1 months (12-61) were included in the study. There were no clinical and radiological complications, including loss of reduction, device failure and tendon ruptures. No patients required hardware removal. Wrist range of motion in flexion-extension averaged 96°, while in pronation-supination 144°. At final follow-up mean visual analogue scale pain was 1,8. Questionnaires, as dissabilities of the arm, shouldder and hand (DASH) score and patient-related wrist evolution (PRWE) score were 6,6 and 3 respectively. Grip strenght measured 86% compared to the normal side.

CONCLUSION

APTUS^® wrist presents a versatile set of fragment specific fixation plates able to easily and securely fix all types of volar rim fracture. The system can be used with other devices without any kind of interference between them. When correctly placed and used with the right indications, no late complications can be recorded.

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.

Development and Testing of a Novel Locking Pin Cap to Create a Fixed-Angle K-Wire Plate Construct

PURPOSE

To test the effectiveness of a novel locking pin cap to attach a K-wire rigidly to a volar locking plate and resist fracture displacement compared with commercially available alternatives.

METHODS

Two different methods of fracture fixation were tested on a total of 12 Sawbones models with volar shear distal radius fracture (6/group). The fragments were fixed with either 2 commercially available pin plates (industry standard) or a volar plate with 2 locking screws fixing the scaphoid facet and 2 pins locked to the plate with a novel locking pin cap in the lunate facet. Axial load conditioning was performed followed by sinusoidal loading to 250 N at 50 mm/s. A motion capture system was used to assess the relative movement of the fracture fragments relative to the intact shaft. The strength of the fixation construct was quantified by (1) the force required to achieve a 2-mm gap between the shaft and fracture fragments and (2) ultimate load to failure.

RESULTS

One industry standard pin plate demonstrated disassociation of the pin from the plate after fatigue conditioning. This did not occur in the locking pin cap group. The locking pin cap construct group was able to sustain a significantly higher load compared with the industry standard when the construct was displaced to the 2-mm gap. The locking pin cap also significantly increased the ultimate load to failure compared with the industry standard.

CONCLUSIONS

The novel locking pin cap creates a fixed-angle attachment of a K-wire to an existing locking screw hole in a plate. This fixed-angle K-wire is significantly stronger in preventing gap formation and resisting ultimate failure than commercially available plates that use bent K-wires.

CLINICAL RELEVANCE

The development of novel techniques to secure small articular fragments may ultimately improve clinical outcomes.

Plate Fixation of Distal Radius Fractures: What Type of Plate to Use and When?

There are several options for plate fixation of distal radius fractures. Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type. Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation. Bridge plates offer an alternative to external fixation while avoiding the complications with prominent hardware, because they span highly comminuted fractures and can be used for immediate weight bearing; however, they require plate removal. Choice of plate fixation should depend on fracture type, patient factors, and surgeon experience.

A Critical Assessment of the Most Cited Papers on Distal Radius Fractures

This article reviews the impact of the most cited works on distal radius fractures. Judged by the most cited works in this field, distal radius fracture research has followed other paradigm shifts in the history of science. Landmark papers showed that restoring premorbid anatomy led to better outcomes, and a plurality of fixation strategies emerged. A breakthrough in technology came with volar plating, and the new paradigm emerged: precise anatomic reduction is achieved typically with volar plates, unless fragment-specific approaches are needed. This paradigm is being challenged as the association among malunion, arthritis, and function continues to be understood. The best treatment of distal radius fractures in the elderly has also evolved through time.

Ilizarov ligamentotaxis versus volar locked plating in the management of AO type C2/C3 distal radius fractures-a prospective non-randomised comparative trial

PURPOSE

The aims of this study were to compare radiological and functional outcomes of Ilizarov ligamentotaxis and locked volar plating in comminuted intra-articular distal radius fractures (AO type C2/C3) using a non-randomised superiority trial.

METHODS

A total of 72 patients with AO C2/C3 distal radius fractures were allotted into Ilizarov ligamentotaxis (n = 30) and locked volar plating (n = 42) groups based on patient preference. Primary outcome was the ability to achieve and stably maintain acceptable radiological parameters (post-operative, 6 weeks, 3 months, 12 months), and secondary outcome was functional scoring (at 12 months).

RESULTS

All patients completed the study. All fractures united uneventfully. Plating was superior to Ilizarov in restoring ulnar variance (100% versus 80%, p value 0.004), but Ilizarov was superior to plating in restoring volar tilt (as opposed to neutral tilt, 83.3% versus 47.8%, p value 0.002). Both groups were comparable in restoring radial height, radial inclination and intra-articular reduction and stably maintaining all five parameters over long term. There was a statistically significant difference between the two groups with regard to mean ulnar variance (plating superior) and volar tilt (Ilizarov superior) at all stages of follow-up, whereas radial height and radial inclination were comparable at all points. There was no significant change of all radiological parameters over a follow-up period. At the end of one year, DASH score was slightly better (not clinically appreciable) in the Ilizarov group (8.47 versus 13.61, p value 0.03), but Gartland and Werley scores were comparable between both groups. Mean duration of external fixation in the Ilizarov group was 43.07 ± 8.94 days. Apart from five cases of pin site infections, there were no complications.

CONCLUSION

Ilizarov ligamentotaxis is a comparable option to locked volar plating in achieving radiological restoration and clinical function in comminuted intra-articular distal radius fractures, AO types C2 and C3. Restoration of ulnar variance needs utmost care while performing Ilizarov ligamentotaxis. Ilizarov comes with the disadvantages of reduced patient preference, pin site infections, need for removal of external fixator and slightly slower return to activity.

TRIAL REGISTRATION NUMBER

 CTRI/2018/08/015549 LEVEL OF EVIDENCE: Level III, Non-randomised prospective trial.

Minimally Invasive Surgery: Is There a Role in Distal Radius Fracture Management?

PURPOSE OF REVIEW

This review explores minimally invasive surgical techniques for distal radius fractures and guides their use in conjunction with, or as an alternative to, volar locked plating.

RECENT FINDINGS

Fractures of the lunate facet, die-punch fractures, and marginal articular shear injuries present challenges that cannot be easily addressed with volar plating. The use of external fixation, Kirschner wires, and dorsal bridge plating should all be considered. These techniques, in combination and in addition to volar locked plating, continue to play an important role in fracture management. Arthroscopically assisted surgery with minimally invasive fixation allows for detailed inspection of the radiocarpal joint. Closed treatment and casting continue to play an important role in distal radius fracture care. The role of minimally invasive surgery for distal radius fractures is still being defined. While fixation using a volar locking plate is by far the most common treatment method, other techniques should be considered to improve outcomes and decrease complications.

Incidence for volar locking plate removal following distal radius fracture surgery

INTRODUCTION

Distal radius fracture is the most common fracture in adults. The most common treatment for distal radius fracture is non-operative cast immobilization, although there are injuries that require surgical treatment. During the past decade, studies have reported a large increase in the surgical treatment of distal radius fractures with open reduction and internal fixation using volar locking plates. The aim of this study was to investigate the incidence and trends for plate removal after plate fixation of distal radius fractures.

MATERIALS AND METHODS

The study covered all patients 18 years of age and older who had a surgically treated distal radius fracture with open reduction and internal fixation in Finland between 1998 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register. The association between increased number of platings and plate removals was examined by calculating the removal rates. The study population comprises all patients on a national level, and therefore we did not use statistical testing to analyze the data.

RESULTS

A total of 18,298 patients had surgically treated distal radius fracture with volar plate in Finland during the 19-year study period from January 1, 1998 to December 31, 2016. The number of plate removal operations over the same time period was 2560. The removal rates decreased from over 20% in 1998 to less than 12% in 2016. The mean time period between plating and plate removal operations was 367 days. Most of the plate removals (n = 2235; 87.3%) were conducted during the first 2 years after plating.

CONCLUSION

Plate removals have not increased as rapidly as plating operations. The removal rate has declined markedly during the last decade. Nowadays, approximately 11% of distal radius plates are removed.

The Dorsal Periosteal Curtain for Distal Radius Osteotomy Via the Volar Approach

Volar wedge osteotomy and angle stable volar plating is now considered a standard approach for correction of distal radius malunion. In previous descriptions of the technique, soft tissue release has been performed with periosteal incision in line with the bony osteotomy. We present a technique whereby the dorsal periosteum is incised more proximally creating a dorsal vascularized periosteal "curtain." Our technique has several advantages including systematic release of restraining soft tissues to allow better distraction and reduction of the malunion; a dorsal periosteal curtain of vascular tissue with which to contain bone graft, protect extensor tendons and expedite healing; and better access to locally available bone graft. The previously described rotation-advancement of pronator quadratus is also used for plate coverage. We have found this technique straightforward to execute and teach, and useful in mitigating against some of the potential risks of the standard technique.

Minimally invasive anterior plate osteosynthesis of the distal radius: A 710 case-series

INTRODUCTION

Since the 2000s, internal fixation of distal radius fracture by volar locking plate on an extended flexor carpi radialis (FCR) approach has become the gold standard.

OBJECTIVE

The present study aimed to assess medium-term results of minimally invasive plate osteosynthesis (MIPO) in distal radius fracture.

MATERIAL AND METHODS

The series comprised of 710 cases (512 female; mean age, 58 years). The 15mm approach was on the lateral edge of the FCR. The plate was slipped under the pronator quadratus. Closure used intradermal running suture without drain or orthosis.

RESULTS

At a mean 7 months' follow-up, mean scar length was 17mm (range, 10-40mm), pain 1.13/10 (0-8), Quick-DASH 13.28 (0-86.36), and patient-rated wrist evaluation (PRWE) 11.48 (0-91). Compared to contralateral values, mean flexion was 87.23%, extension 88.52%, pronation 96.17%, supination 93.41%, and grip strength 79.68%. Hardware was removed in 45.92% of cases. There were 16 cases of secondary displacement, with 4 revision procedures, one of sepsis at 6 months, 10 of complex regional pain syndrome, and 14 of median nerve paresthesia, with 4 carpal tunnel release procedures.

DISCUSSION

The minimally invasive FCR approach can be used for volar plate fixation of distal radial fracture. It has the advantage of conserving ligamentotaxis, facilitating reduction and improving scar esthetics. The incision can be extended if need be.

LEVEL OF EVIDENCE

III; single-centre retrospective study.

Functional Outcome of Intraarticular Fracture of Distal Radius Managed by Volar Locking Plate

Objective

This study's main purpose is to determine the functional outcome of volar locking plates in the management of intraarticular fracture of the distal radius.

Methodology

This cross-sectional study was conducted from August 2016 to August 2019. Forty-nine patients with the intraarticular distal radius fractures managed by the volar locking plate were included in the study. Patients with open fractures, ipsilateral other limb injuries, polytrauma patients, pathological fractures, and patients having neurovascular injuries were excluded from the study. AO Classification was used to classify fractures. The fracture was approached through the volar approach and fixed by the volar locking plate. A modified mayo wrist score evaluated the functional outcome. All the data were recorded on predesigned performa, and Statistical Package for the Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY) was used to analyze the data.

Results

A total of 49 patients with intraarticular fractures of the distal radius were included in the study. The mean age of the patient was 37.20 ± 10.05 years. Out of 49 patients, 29 (59.2%) were males, and 20 (40.8%) were females. Union was achieved in almost all fractures except one case, which went into non-union despite the adequate initial reduction, and the mean time of union was 11.98 ± 1.64 weeks. With respect to the stratification of functional outcome very good and good functional outcome was achieved in 46 patients (93.8%) in both the groups, the satisfactory outcome was achieved in two (4.1%) cases and one patient had a bad outcome in which union was not achieved and went into non-union.

Conclusion

Open reduction and internal fixation of intraarticular fracture of the distal radius using a volar locking plate is a good option for managing these fractures as it provides stable fixation, and good to excellent outcomes can be achieved by using these plates.

Radiographic Evaluation of Patients Submitted to Percutaneous Fixation With Solid Screw for Distal Radius Fracture Treatment

Objective  The present paper aims to present results from radiographic evaluations of patients with extra-articular distal radius fractures submitted to percutaneous fixation with a 3.5 mm solid screw.

Methods  Analytical, descriptive and retrospective case series of 16 patients with evaluation of the radiographic parameters.

Results  The average age of the study population was 46.5 years old (25–60 years old); 81.25% of the sample was female. The average time until surgery was 8.8 days (4–14 days). The mean preprocedural volar tilt was - 7.41° (−23.48°–5.29°, standard deviation [SD] ± 6.59°). The mean volar tilt immediately after surgery was 5.93° (SD ± 6.23°, p  < 0.001). There was no statistical difference in volar tilt values after 6 months of follow-up. The mean preprocedural radial height was 4.13 mm (−7.8 mm–9.5 mm, SD ± 5.06 mm). There was a statistically significant increase at the immediate postoperative period to 10.04 mm ( p  = 0.002), and a significant reduction at 6 months to 9.55 mm ( p  = 0.012). The consolidation rate was 100% with the technique used, with a minimal complication rate. No patient had infection or required a reoperation.

Conclusion  The technique was effective for the treatment of distal radial extra-articular fractures at 6 months, with a low complication rate; radiographic parameters values were acceptable and close to the anatomical ones.

Biomechanical Stability of Volar Plate Only Versus Addition of Dorsal Ulnar Pin Plate: A Dorsal Ulnar Fragment, C-3-Type, Distal Radius, Cadaver Fracture Model

OBJECTIVE

To determine if the addition of a dorsal ulnar pin plate provides improved stability characteristics in the management of intra-articular distal radius fractures with an associated dorsal ulnar fragment.

METHODS

OTA/AO type C3 fractures, with a dorsal ulnar fragment of one-third or one-half the width of the distal radius, were simulated in 9 matched pairs of fresh-frozen cadaveric arms randomized between fixed-angle volar plate only versus volar plate with addition of a dorsal ulnar pin plate. Prepared specimens were mounted in a custom load frame and loaded in extension with stepwise cyclic load increase. Dorsal plane interfragmentary displacements were compared between the 2 fixation constructs at 50-N and 100-N cyclic load.

RESULTS

The addition of the dorsal ulnar pin plate significantly reduced interfragmentary displacements for the dorsal ulnar fragment at the 50 N load application, resulting in mean interfragmentary displacements of -0.1 ± 0.2 mm in comparison to -0.3 ± 0.2 mm with the volar plate-only construct. No other interfragmentary displacement comparisons were significant. No differences were found comparing the one-third and one-half size fragments.

CONCLUSIONS

The addition of a dorsal ulnar pin plate improved stability characteristics with respect to the dorsal ulnar fragment.

CLINICAL RELEVANCE

The addition of the dorsal ulnar pin plate, although statistically significant, improved displacement by less than 0.3 mm on average and thus may not prove to be important in clinical scenarios.

Anomalous Courses of the Palmar Cutaneous Branch of the Median Nerve in Relation to the Flexor Carpi Radialis Tendon for ORIF of Distal Radius Fractures

Background: The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. Methods: All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. Results: In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. Conclusions: Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.

Clinical outcomes of unstable metacarpal and phalangeal fractures treated with a locking plate system: a prospective study

We prospectively assessed clinical and radiological outcomes of locking plate fixation in treating unstable fractures in 11 metacarpals, 15 proximal phalanges, and eight middle phalanges in 34 consecutive patients from October 2011 to December 2016. Median length of follow-up was 14 months (range 12-24). The motion of finger joints, bony union, and complication rates were recorded. The median postoperative range of motion of the two interphalangeal joints and the metacarpophalangeal joint was 82% of the contralateral hands. Fractures in the three locations had significantly different recovery of the finger motion, with the best recovery for the metacarpal fractures. Closer distance between the plate edge and joint line was associated with a more limited range of the finger motion. The clinical outcomes approached an acceptable level at final follow-up. Finger stiffness is unavoidable after locking plate fixation of metacarpal and phalangeal fractures even with early hand therapy, with stiffness occurring in 10 out of 34 cases at the time of final follow-up 1 year after surgery. Level of evidence: II.

[Effects of ulnar styloid and sigmoid notch fractures on postoperative wrist function of patients with distal radius fracture]

OBJECTIVE

To study the effects of ulnar styloid and sigmoid notch fractures on postoperative wrist function in patients with distal radius fracture.

METHODS

In total, 139 patients treated for distal radius fracture in the Department of Orthopedic Trauma at Peking University People's Hospital from Jan. 2006 to June 2016 were selected for outpatient follow-ups. Evaluation was based on Sartiento's modification of the Gartland and Werley scores. Efficacy was assessed with wrist pain as the focus.

RESULTS

The excellent and good efficacy rate was 97.1% (excellent: n=107, 77.0%; good: n=28, 19.4%; and fair: n=4, 2.9%). Gender, age, and whether the ulnar styloid fracture achieved union did not significantly impact the scores (P>0.05). The scores of the basal fracture group were significantly different (P=0.001). Internal fixation of ulnar styloid fracture was associated with a significant difference in scores (P=0.005). The effect of sigmoid notch fracture was also associated with a significant difference in scores (P=0.024). This study included 22 cases of ulnar wrist pain, and the overall incidence of ulnar wrist pain was 15.8%. Gender, age, whether the ulnar styloid fracture achieved union, and whether internal fixation was conducted for ulnar styloid fracture and sigmoid notch fracture had no significant effect on the occurrence of ulnar wrist pain (P>0.05). The incidence of ulnar wrist pain was higher in basal fractures than that in tip fractures. Among ulnar styloid fractures, the union rate of basal fracture was higher than that of tip fractures. The union rates of basal fracture and tip fracture were significantly different (P<0.001). Basal fractures were significant risk factors for ulnar wrist pain (P=0.028). Basal fracture of the ulnar styloid group and sigmoid notch fracture group had poor wrist function scores. Wrist function score improved significantly after internal fixation of ulnar styloid fracture. The incidence of ulnar wrist pain was higher in basal fracture group. The union rate in basal fracture group was higher than in tip fracture group.

CONCLUSION

The overall effect of surgical treatment of distal radius fracture is satisfactory. Ulnar styloid basal fracture and sigmoid notch fracture are risk factors for postoperative wrist dysfunction in patients with distal radius fracture, and the basal fracture is one of the risk factors of ulnar wrist pain. The union rate of ulnar styloid basal fractures is better than that of tip fractures. Internal fixation of ulnar styloid fracture can improve wrist function.

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year

INTRODUCTION

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year.

METHODS

A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.

RESULTS

Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = - 0.18, p = 0.04) and Mayo Score (r = - 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (< 2 mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65 years of age.

CONCLUSIONS

Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2 mm) was not associated with a worse clinical important outcome. Age (< 65/> 65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

The Relationship of Volar Plate Position and Flexor Tendon Rupture: Should We Question the Validity of the Soong Classification?

BACKGROUND

The authors sought to determine the reliability of the Soong classification, which relates the position of the implant to the watershed line of the distal radius, for predicting flexor tendinopathy in distal radius fractures treated with volar plate fixation.

METHODS

Medical records were reviewed, including demographics, fracture and operative characteristics, tendon-related complications, and radiographic outcomes. Six hundred fifty-nine distal radius fractures were reviewed with a mean duration of clinical follow-up of 12.9 ± 0.7 months.

RESULTS

The incidence of isolated flexor tendinopathy and tendon rupture was 0.9 and 0.3 percent, respectively. The Soong classification failed to independently predict flexor tendon rupture or tendinopathy. Fractures classified as inadequately reduced were significantly associated with Soong grade 0 or grade 2, whereas adequately reduced fractures were significantly associated with Soong grade 1.

CONCLUSION

The Soong classification is not the sole predictor of flexor tendinopathy and may be viewed as a reflection of the overall appropriateness of fracture reduction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.