[Distal radius fractures--aetiology, treatment and outcome]

Arthroscopic debridement of the dorsal capsule in intraarticular distal radius fractures: does it provide superior outcomes?

INTRODUCTION

Distal radius fractures (DRFs) are very common. One of the most significant complications after intraarticular DRF is arthrofibrosis with loss of wrist motion and pain. Wrist arthroscopy has become increasingly popular in the treatment of DRF with the advantage of good visualization of the joint surface and soft tissue injuries. In intraarticular DRFs injuries of the dorsal capsule are a characteristic finding which potentially cause loss of wrist motion. In this study, we investigated if arthroscopic debridement of dorsal capsule injuries at time of surgical fixation provides superior outcomes compared to the same treatment without debridement.

MATERIALS AND METHODS

Between 2013 and 2017, we included 42 patients who underwent arthroscopy-assisted palmar plating for intraarticular DRFs in a prospective randomized controlled study. In group A (intervention group), the dorsal capsule tears were debrided during primary surgery, while in group B these were left in place. Active range of motion (AROM), grip strength, subjective outcomes and radiographic results were assessed 3, 6 and 12 months after primary surgery. A subgroup analysis was performed for patient age, fracture severity and duration of immobilization.

RESULTS

Arthroscopic debridement of the dorsal capsule improved AROM in patients over 60 years of age, more severe fractures (AO 23 C2/C3) and prolonged postoperative immobilization for more than two weeks, while it was not relevant for younger patients with simple fractures and short immobilization.

CONCLUSIONS

Debridement of the injured dorsal capsule in arthroscopic-assisted surgical treatment of intraarticular DRFs can improve surgical performance and optimize patient outcomes in a specific subgroup of patients.

The Outcome of Distal Radius Fractures with Concomitant Injuries Is Similar to those of Isolated Distal Radius Fractures Provided that an Arthroscopically Supported Treatment Is Performed

BACKGROUND

Concomitant injuries of distal radius fractures (DRF) can have a fatal impact on the patients' outcome. However, wrist arthroscopy is a costly and complex procedure. It remains elusive whether patients benefit from an additional arthroscopy.

METHODS

Patients with a DRF who were treated arthroscopically were enrolled. Fifty-six wrists were evaluated regarding their function by self-assessment with the Munich Wrist Questionnaire (MWQ). Thirty-nine patients were examined for postoperative strength and motion. Concomitant injuries were detected.

RESULTS

A total of 75% of the DRF were type C injuries (AO classification). Twenty-four cases (43%) were triangular fibrocartilaginous complex (TFCC) lesion, eight cases (14%) of scapholunate ligament (SL) injuries and seven cases (12%) were a combination of TFCC and SL ligament lesion. No difference in function could be detected between DRF with surgically addressed concomitant lesions and isolated DRF. Dorsalextension, palmarflexion and grip strength were significantly reduced in patients with DRF and concomitant injuries compared to the healthy wrist. However, patients with DRF and arthroscopically treated concomitant injuries had similar results to those suffering only from an isolated DRF.

CONCLUSION

The increased occurrence of concomitant injuries is to be expected in intraarticular DRF. Patients with concomitant injuries benefit from an arthroscopically assisted fracture treatment and show similar results compared to isolated DRF.

Comparison of volarly and dorsally displaced distal radius fracture treated by volar locking plate fixation

INTRODUCTION

In case of distal radius fractures (DRF) the distal fragment generally displaces either dorsally or volarly. Scientific literature however, seldom differentiates between volarly and dorsally displaced DRFs when reporting results. It is no clear, if the direction of displacement has an influence on the clinical and radiological outcome. This study was intended to evaluate the influence of displacement direction in adult patients with surgically treated Colles or Smith type fractures.

PATIENTS AND METHODS

After a mean follow up (FU) time of above 5 years, 50 patients who underwent open reduction and internal fixation for DRFs (25 Smith type fractures, 25 Colles type fractures) were included. Upon FU, standard X-rays and a clinical evaluation as well as evaluation scores were raised and analysed.

RESULTS

Clinical evaluation showed no difference between the Colles and the Smith group. Radiologic and clinical results for the Colles group showed diminished flexion compared to the healthy wrist, decreased radial inclination and dorsal tilt during FU and progression of osteoarthritis. For the Smith group decreased grip strength compared to the healthy wrist and osteoarthritis-progression was found. For both groups there was no correlation between radiologic values, grip strength, arthrosis grading, disability of arm, shoulder and hand score and patient rated wrist evaluation score.

DISCUSSION

Decreased flexion in combination with a decreased dorsopalmar tilt might hint towards a mechanical inhibition in the Colles group. Altogether, the study showed good clinical outcome with satisfactory radiological result. As all patients showed arthrosis progression, the fracture per se is to be seen as a prearthrotic factor. It still remains unclear which measures could be taken to prevent this.

Characteristics of secondary arthrofibrosis after intra-articular distal radius fracture

PURPOSE

The purpose of this study was to assess characteristics of radiocarpal arthrofibrosis after intra-articular distal radius fractures (DRF).

PATIENTS AND METHODS

In this study 20 patients who underwent wrist arthroscopy at the time of implant removal after volar plating for intra-articular DRF were included retrospectively. The direction of fibrous tissue formation (FTF) and its rigidity were investigated. The findings were correlated to the course of intraarticular fracture lines seen in the preoperative CT, patient age and AO fracture types.

RESULTS

In all patients FTF spanned the radiocarpal joint. Fibrous tissue formations extended from previous fracture gaps to the scapholunate interosseous ligament and/or capsule. Four basic types of FTF (Type 1-4) and two combination types (Type 1a, 2a) were found. Fibrotic fans with dorsal capsular attachment (Type 1, 30 %) and its combination with dorsal capsule obliteration (Type 1a, 40 %) were the most common findings. Mild rigidity was present in 3 (15 %), moderate in 7 (35 %), and severe rigidity in 10 cases (50 %). Fracture lines crossing the radius extensor compartments or interfacet ridge, cartilage defects and C3 fractures showed the highest risk to develop severely rigid fibrous tissue formations. In older patients and in more comminuted fractures the number of rigid fibrous tissue formations was higher.

CONCLUSIONS

Fracture severity correlates with the development of rigid intra-articular FTF. In case of rigid FTF with restricted wrist motion arthroscopic debridement may be considered at the time of hardware removal.

1-Year outcome of concomitant intracarpal lesions in patients with dislocated distal radial fractures: a systematic assessment of 78 distal radial fractures

INTRODUCTION

Ligamentous lesions are concomitant to dislocated distal radius fractures in a high percentage. The purpose of this study was to evaluate the relevance of intracarpal lesions.

METHODS

Seventy eight of an original cohort of 104 distal radius fractures (74%) were studied over a follow-up period of one year after surgery with complete data (X-rays, CT, MRI, follow-up X-rays and questionnaire).

RESULTS

Most of our radius fractures (AO 23 type: A 39, B 9, C 30) present additional lesions: 97%. One-year evaluation showed an average Castaing score of 4.5 ± 2.5 points, means a "good" result of a scale of 0-27. Fifty five of seventy eight had an "excellent" or "good" result (<6 points). No patient had more than 12 points ("fair").

CONCLUSIONS

The dislocated distal radial fracture implies severe and complex injury to the whole wrist, mostly concerning intracarpal concomitant lesions (MRI). Surgical therapy of dislocated radius fractures followed by 6 weeks relief through thermoplastic splint seems to be sufficient to achieve good 1-year results. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance.

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review

Background Unstable distal radius fractures are a popular research subject. However, to appreciate the findings of studies that enrolled patients with unstable distal radius fractures, it should be clear how the authors defined an unstable distal radius fracture. Questions In what percentage of studies involving patients with unstable distal radius fractures did the authors define unstable distal radius fracture? What are the most common descriptions of an unstable distal radius fracture? And is there one preferred evidence-based definition for future authors? Methods A systematic search of literature was performed to identify any type of study with the term unstable distal radius fracture. We assessed whether a definition was provided and determined the level of evidence for the most common definitions. Results The search yielded 2,489 citations, of which 479 were included. In 149 studies, it was explicitly stated that patients with unstable distal radius fractures were enrolled. In 54% (81/149) of these studies, the authors defined an unstable distal radius fracture. Overall, we found 143 different definitions. The seven most common definitions were: displacement following adequate reduction; Lafontaine's definition; irreducibility; an AO type C2 fracture; a volarly displaced fracture; Poigenfürst's criteria; and Cooney's criteria. Only Lafontaine's definition originated from a clinical study (level IIIb). Conclusion In only half of the studies involving patients with an unstable distal radius fracture did the authors defined what they considered an unstable distal radius fracture. None of the definitions stood out as the preferred choice. A general consensus definition could help to standardize future research.

Closed reduction of distal radius fractures: does instability mean irreducibility?

INTRODUCTION

The belief that not all distal radius fractures can be initially anatomically reduced with conservative means is rising. The aim of this study was to examine whether adequate reduction with a closed reduction technique is possible and to assess the importance of each step.

MATERIALS AND METHODS

We prospectively enrolled 63 distal radius fractures (62 patients). A standardized reduction technique was implemented. Reduction was radiologically evaluated in hanging traction, after reduction, and in plaster. Subgroup analysis was performed for fracture-dependent and fracture-independent factors on their influence on reduction.

RESULTS

The mean radiological values (radial inclination, dorsal tilt, ulnar variance) showed near anatomic reduction of all fractures in plaster. Fracture severity according to AO classification, initial displacement, number of instability criteria and patient age did not affect the reduction outcome.

CONCLUSIONS

All types of enrolled fractures were nearly anatomically reduced. This contradicts the opinion that some "severe" fractures are too unstable to be initially reduced by closed means.

[The significance of displacement in dorsally angled distal radial fractures]

BACKGROUND

Distal radial fractures occur very frequently. Most are dorsally displaced (Colles' fracture). In contrast to previously, approximately a quarter of these patients now undergo surgery. This is more than the number that is reduced and immobilised in a plaster cast. Volar plate osteosynthesis is now the most common type of surgery. There is great uncertainty regarding indications for surgery.

METHOD

The article is based on own research, a search in PubMed and a review of reference lists to identify articles that compare radiological and clinical outcomes after Colles' fractures.

RESULTS

A number of national orthopaedic associations have reviewed the literature in an attempt to draw up guidelines for indications for performing surgery on distal radial fractures, without being able to arrive at definite recommendations based on randomised studies. Our review of the literature indicates a very uncertain correlation between radiological displacement and the final clinical outcome. This applies particularly to elderly patients (over 55-65), where by far the majority of the studies do not find any such correlation. Complications and reoperation are common among patients who have undergone volar plate surgery.

INTERPRETATION

There is surprisingly little correlation between the radiological and clinical outcome after Colles' fractures. A practice where a large proportion of patients undergo surgery is probably not justified. Elderly patients will very seldom benefit from surgery in the longer term.

The relationship between displacement and clinical outcome after distal radius (Colles') fracture

We reviewed 260 patients who had been treated non-operatively for a dorsally displaced distal radius fracture a mean 6.3 (range 2.5-12.7) years earlier, in an attempt to find the limits of displacement compatible with a good clinical outcome. We excluded patients with previous or later injuries to the same limb. Bivariate analysis revealed a highly statistically significant relationship between radiographic displacement at review and clinical outcome scores. Correlation coefficients varied between 0.14 and 0.30. However, multiple linear regression analysis using most factors commonly thought to be of importance in determining the clinical outcome as independent variables explained only 23% of the variability of the clinical outcome. Dorsal angulation, ulnar variance, and radial inclination together accounted for only 11% of the variability. We conclude that the final alignment of the distal radius as shown radiologically has only a minor influence on the clinical outcome of Colles' type distal radius fractures.

Multidirectional volar fixed-angle plating using cancellous locking screws for distal radius fractures--evaluation of three screw configurations in an extra-articular fracture model

INTRODUCTION

Volar fixed-angle plating is a popular treatment for unstable distal radius fractures. Despite the availability of plating systems for treating distal radius fractures, little is known about the mechanical properties of multidirectional fixed-angle plates. The aim of this study was to compare the primary fixation stability of three possible screw configurations in a distal extra-articular fracture model using a multidirectional fixed-angle plate with metaphyseal cancellous screws distally.

MATERIAL AND METHODS

Eighteen Sawbones radii (Sawbones, Sweden, model# 1027) were used to simulate an extra-articular distal radius fracture according to AO/OTA 23 A3. Plates were fixed to the shaft with one non-locking screw in the oval hole and two locking screws as recommended by the manufacturer. Three groups (n = 6) were defined by screw configuration in the distal metaphyseal fragment: Group 1: distal row of screws only; Group 2: 2 rows of screws, parallel insertion; Group 3: 2 rows of screws, proximal screws inserted with 30° of inclination. Specimens underwent mechanical testing under axial compression within the elastic range and load controlled between 20 N and 200 N at a rate of 40 N/s. Axial stiffness and type of construct failure were recorded.

RESULTS

There was no difference regarding axial stiffness between the three groups. In every specimen, failure of the Sawbone-implant-construct occurred as plastic bending of the volar titanium plate when the dorsal wedge was closed.

DISCUSSION

Considering the limitations of the study, the recommendation to use two rows of screws or to place screws in the proximal metaphyseal row with inclination cannot be supported by our mechanical data.

[Biomechanical study of four palmar locking plates and one non-locking palmar plate for distal radius fractures: stiffness and load to failure tests in a cadaver model]

Five different palmar fixation plate designs were compared in a distal radial osteotomy cadaver model with regard to their biomechanical properties. A metaphyseal osteotomy gap of 1 cm was performed and the osteosynthesis was plated according to the manufacturer's instructions. Axial load was applied to the construct by a pneumatic material testing machine. Five implant groups with eight cadavers each were tested concerning stiffness. None of the constructs developed deformity and movement of the fracture gap larger than 2 mm with a load of 100 N. Increasing the load to 250 N revealed significant differences in stiffness and failure load between the different plates. The mean stiffness under axial load (mean+/-standard deviation) was 356.4+/- 138.6 N/mm for the radius correction plate without lateral tongue, 299.7+/-86.3 N/mm for the radius correction plate with lateral tongue, 132.8+/-41.5 N/mm for the distal volar radius plate, 112.5+/-40.2 N/mm for the 3.5 mm titanium locking compression plate and 91.9+/-29.2 N/mm for the standard stainless steel 3.5 mm T-Plate. The non-angular stable implant (STP plate) had the lowest stiffness. Unexpectedly, there were differences over 100% concerning the stiffness between the at first glance nearly similar angular stable implants. Additionally, a review of the literature concerning biomechanical investigations of the distal radial fracture was performed.

Promontory of radius: a new anatomical description on the distal radius

Surgical treatment of distal radius fractures with palmar plates has gained popularity as the preferred approach to achieve anatomical fracture reposition. One hundred and thirty four radii of human cadavers were examined to elucidate the anatomy of the distal radius, especially the transition of the anterior into the lateral surface and a new term was given: promontory of radius. The promontory was located on the lateral surface between the changing of the convex to the concave curvature and the base of the styloid process. The anterior surface increased gradually from the ulnar notch to the lateral surface and formed the "base" of the promontory. The length of the promontory on the lateral surface measured 14-28 mm (mean 20.766 mm, SD 2.69 mm). The width of the promontory was found in between 10 and 27 mm (mean 13.857 mm, SD 2.14 mm). The width of the distal radius was 16-38 mm (mean 31.015 mm, SD 3.26 mm) and did not show any statistical correlation to the promontory. On the anterior surface the minimal width of promontory measured 4.9 mm, the maximal one 17.9 mm (mean 8.95 mm, SD 3.60). The height of the promontory on the anterior surface ranged in between 1.2 and 4.3 mm (mean 2.90 mm, SD 1.05 mm). The promontory of radius must be kept in mind to avoid any dorsal dislocation of the radial fragment often described as complication of intraarticular fractures. Based on this anatomical survey the data can be used for a new palmar radius plate designs.