Management of Unstable Distal Radius Fractures: A Survey of Hand Surgeons

Teardrop Alignment Changes After Volar Locking Plate Fixation of Distal Radius Fractures With Volar Ulnar Fragments

BACKGROUND

We assessed factors associated with change in radiographic teardrop angle following volar locking plate (VLP) fixation of volarly displaced intra-articular distal radius fractures with volar ulnar fragments (VUF) within the ICUC database. The primary outcome was change in radiographic alignment on follow-up imaging, defined as a change in teardrop angle from intra-operative fluoroscopy greater than 5°.

METHODS

Patients with distal radius fractures treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50°, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Descriptive statistics were used to assess variables' distributions. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. Volar rim loss of reduction and final ROM in degrees and as compared with contralateral unaffected limb were also assessed.

RESULTS

Fifty patients with volarly displaced, intra-articular distal radius fractures treated with a VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and postfixation axial plate position in relation to the sigmoid notch were significantly associated (P < .05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less.

CONCLUSIONS

The size of the VUF was the most important variable for predicting volar rim loss of reduction followed by postfixation plate position in an axial position to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm. There were no significant differences in ROM between patients with volar ulnar escape and those without.

Distal Radius Fracture Therapy Utilization Following Traditional Open Reduction and Internal Fixation and Dorsal Bridge Plate Fixation

Background Many distal radius fractures are treated with a volar locking plate, but a minority undergo dorsal bridge plate fixation. This study's primary purpose was to compare therapy utilization following distal radius fractures treated with traditional open reduction and internal fixation (ORIF) versus dorsal bridge plate fixation. Secondary outcomes were time to first and last therapy visits and therapy costs. Methods Patients over 18 years old who underwent distal radius ORIF between January 2021 and August 2022 at a single regional orthopedic practice were identified. Patients who underwent post-operative hardware removal were retrospectively reviewed to identify dorsal bridge plate fixation patients. This resulted in "traditional ORIF" and "dorsal bridge plate" groups. Therapy visit number, cost, and payor (insurance type including Medicare, private insurance, worker's compensation, automobile policy, and private pay) were collected. Results In total, 1,376 patients met the inclusion criteria. Of these, 713 of the 1,283 (55.6%) patients in the traditional ORIF group and 25 of the 44 patients (56.8%) in the dorsal bridge plate group attended therapy at our institution. Traditional ORIF and dorsal bridge plate patients averaged 12.6(±10) and 24(±18.7) therapy visits in the one-year following ORIF, respectively. Time to last therapy visit was 90.9(±60) and 175.2(±72.1) days in the traditional ORIF and dorsal bridge plate groups, respectively. Total therapy cost was $1,219(±$1,314) and $2,015(±$1,828) in the traditional ORIF and dorsal bridge plate groups with similar out-of-pocket costs. Conclusions Dorsal bridge plate fixation patients attended a greater number of therapy sessions, had a longer time from surgery until therapy end, and had a higher therapy total cost relative to traditional ORIF, but both groups had similar patient out-of-pocket therapy costs.

A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating

Background  Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose  We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion  Large prospective studies of the "WRIST" protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.

Comparative clinical and radiographic outcomes between early and delayed wrist mobilization after volar fixed-angle plate fixation of distal radius fracture

Postoperative immobilization protocols after volar fixed-angle plate fixation of distal radius fractures (DRF) vary among surgeons. This study aimed to compare functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate fixation of DRF. This study is a randomized controlled trial. The early group was allowed to perform wrist motion exercise immediately after surgery and the delayed group was allowed to perform it after 2 weeks of external immobilization. Postoperative patient-rated wrist evaluation (PRWE), disabilities of arm, shoulder, and hand (DASH), wrist range of motion, visual analog scale (VAS) pain score, and grip strength were evaluated. Forty-eight patients with DRF were enrolled and randomly allocated to the early or delayed mobilization groups. The PRWE, DASH, VAS pain score, grip strength, and wrist motion of both groups significantly improved over time. However, there were no significant differences between groups at any timepoint. Radiographic parameters were not different between groups. There were no significant differences in functional outcomes, radiographic parameters, and complications between early and delayed mobilization after volar fixed-angle plate of DRF. Immediate postoperative wrist range-of-motion exercise can be safely initiated after volar fixed-angle plate fixation of DRF without external immobilization.Clinical trial registration: Thaiclinicaltrials.org identifier: TCTR20180927005. Registered 27/09/2018-retrospectively registered. https://www.thaiclinicaltrials.org/show/TCTR20180927005 .

Single Incision, Dual Window Approach for a Comminuted Distal Radius Fracture

Introduction  Complex distal radius fractures often involve a fragment of the volar-ulnar articular surface and the radial styloid. The volar ulnar corner of the distal radius is an important constraint to volar translation of the carpus and thus requires stable fixation to prevent wrist displacement. The traditional volar Henry approach often requires undue tension on the median nerve while retracting for access to the ulnar aspect of the radius. To protect the median nerve from iatrogenic injury and to improve exposure of the surgical site, we propose a single incision, dual window approach to the distal radius for complex bi-columnar fractures. Methods  This technique combines the trans-Flexor Carpi Radialis (FCR) approach with a subcutaneous dissection to the ulnar aspect of the wrist. This window utilizes the interval between the ulnar neurovascular bundle and the carpal tunnel contents. Results  This technique allows the surgeon to work through either window and thus visualize and directly fixate the various fracture fragments. We have treated complex articular distal radius fractures associated with ulnar communition with this novel technique and it has provided direct reduction with improved fragment access. The surgical technique, a case presentation and results are detailed in this report. Conclusion  This case report has demonstrated that complex bi-columnar fractures of the distal radius can be effectively approached and fixated with a single incision dual window approach.

In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis

Objectives

It remains debatable if early mobilization (EM) yields a better clinical outcome than the late mobilization (LM) in adults with an acute and displaced distal radial fracture (DRF) of open reduction internal fixation (ORIF). Therefore, we aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing clinical results with the safety of EM with LM following ORIF.

Methods

Databases such as Medline, Cochrane Central Register, and Embase were searched from Jan 1, 2000, to July 31, 2021, and RCTs comparing EM with LM for DRF with ORIF were included in the analysis. The primary outcome of study included disabilities of the Arm, Shoulder, and Hand (DASH) score at different follow-up times. Wherever the secondary outcomes included patient-rated wrist evaluation (PRWE), grip strength (GS), visual analog scale (VAS), wrist range of motion (WROM), and associated complications, the two independent reviewers did data extraction for the analysis. Effect sizes of outcome for each group were pooled using random-effects models; thereafter, the results were represented in the forest plots.

Results

Nine RCTs with 293 EM and 303 LM participants were identified and included in the study. Our analysis showed that the DASH score of the EM group was significantly better than LM group at the six weeks postoperatively (− 10.15; 95% CI − 15.74 to − 4.57, P < 0.01). Besides, the EM group also had better outcomes in PRWE, GS and WROM at 6 weeks. However, EM showed potential higher rate for implant loosening and/or fracture re-displacement complication (3.00; 95% CI 1.02–8.83, P = 0.05).

Conclusion

Functionally, at earlier stages, EM for patients with DRF of ORIF may have a beneficial effect than LM. The mean differences in the DASH score at 6 weeks surpassed the minimal clinically important difference; however, the potentially higher risk of implant loosening and/or fracture re-displacement cannot be ignored. Due to the lack of definitive evidence, multicenter and large sample RCTs are required for determining the optimal rehabilitation protocol for DRF with ORIF.

PROSPERO registration number: CRD42021240214 2021/2/28.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02837-0.

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.

A systematic review of how daily activities and exercises are recommended following volar plating of distal radius fractures and the efficacy and safety of early versus late mobilisation

Introduction

Following surgical repair of distal radius fractures, mobilisation timeframes and interventions vary. Early mobilisation (<2 weeks postoperatively) usually includes range of motion exercises and may include recommendations to perform daily activities. The review investigated (i) how early mobilisation was recommended, particularly with respect to wrist use during daily activities and (ii) the efficacy and safety of early versus delayed mobilisation (< or ≥2 weeks).

Methods

The study protocol was registered on PROSPERO (CRD42019136490). Five databases were searched for studies that compared early and delayed mobilisation in adults with volar plating of distal radius fractures. The Downs and Black Quality Index and the Template for Intervention Description and Replication checklist were used for quality evaluation. Effect sizes were calculated for range of movement, function and pain at 6–8, 10–12 and 26 weeks. A descriptive analysis of outcomes and mobilisation regimes was conducted.

Results

Eight studies with a mean Quality Index score of 20 out of 28 (SD=5.6) were included. Performing daily activities was commonly recommended as part of early mobilisation. Commencing mobilisation prior to two weeks resulted in greater range of movement, function and less pain at up to eight weeks postoperatively than delaying mobilisation until two weeks or later.

Discussion

Performance of daily activities was used alongside exercise to promote recovery but without clearly specifying the type, duration or intensity of activities. In combination with exercise, early daily activity was safe and beneficial. Performing daily activities may have discrete advantages. Hand therapists are challenged to incorporate activity-approaches into early mobilisation regimes.