Nonunion of distal radius fractures

Intramedullary Plate Fixation and Viable Bone Allografting in a Complex Intra-articular Distal Radius Fracture Nonunion: A Case Report

In this report, we detail a 69-year-old female who sustained a comminuted intra-articular left distal radius fracture that failed to heal with bridge plate fixation. Given the patient's poor subchondral bone stock and refusal of bone autograft, we designed a construct using a dorsal spanning plate and an intramedullary fragment-specific plate as a volarly placed strut in combination with viable bone allograft and cancellous bone chips to treat this nonunion. This case demonstrates an option for distal radius non-union treatment and highlights the importance of ingenuity that orthopedic surgeons should demonstrate when trying to accommodate patients' wishes.

Deep learning assisted diagnosis system: improving the diagnostic accuracy of distal radius fractures

Objectives

To explore an intelligent detection technology based on deep learning algorithms to assist the clinical diagnosis of distal radius fractures (DRFs), and further compare it with human performance to verify the feasibility of this method.

Methods

A total of 3,240 patients (fracture: n = 1,620, normal: n = 1,620) were included in this study, with a total of 3,276 wrist joint anteroposterior (AP) X-ray films (1,639 fractured, 1,637 normal) and 3,260 wrist joint lateral X-ray films (1,623 fractured, 1,637 normal). We divided the patients into training set, validation set and test set in a ratio of 7:1.5:1.5. The deep learning models were developed using the data from the training and validation sets, and then their effectiveness were evaluated using the data from the test set. Evaluate the diagnostic performance of deep learning models using receiver operating characteristic (ROC) curves and area under the curve (AUC), accuracy, sensitivity, and specificity, and compare them with medical professionals.

Results

The deep learning ensemble model had excellent accuracy (97.03%), sensitivity (95.70%), and specificity (98.37%) in detecting DRFs. Among them, the accuracy of the AP view was 97.75%, the sensitivity 97.13%, and the specificity 98.37%; the accuracy of the lateral view was 96.32%, the sensitivity 94.26%, and the specificity 98.37%. When the wrist joint is counted, the accuracy was 97.55%, the sensitivity 98.36%, and the specificity 96.73%. In terms of these variables, the performance of the ensemble model is superior to that of both the orthopedic attending physician group and the radiology attending physician group.

Conclusion

This deep learning ensemble model has excellent performance in detecting DRFs on plain X-ray films. Using this artificial intelligence model as a second expert to assist clinical diagnosis is expected to improve the accuracy of diagnosing DRFs and enhance clinical work efficiency.

Surgical outcome of upper extremity fractures in patients with Parkinson's disease

Patients with Idiopathic Parkinson’s Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.

Level of evidence level 4 case series.

Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures

Introduction There are various studies that reviewed the effect of cigarette smoking in fracture healing process. Nonunion, delayed union, and residual pain are the significant risk factors associated with smoking and fracture healing. Little has been known about the impact of smoking in distal radius fracture healing. We intend to explore in brief the effect of smoking in distal radius fracture healing and comparing it with nonsmokers having the same fracture fixation and analyze the outcomes with respect to fracture healing and return of function.

Materials and Methods Of the total 186 patients, 92 were included in the study with (n = male: 31, female: 61) mean age of 60.2 years. They were divided into two groups: smoking (n = 43) and nonsmoking (n = 49). All had surgical fixation of the distal radius with volar locking plate and started on early mobilization. The range of motion of the wrist, grip, visual analog scale, quick disabilities of the arm and shoulder and hand score, Mayo wrist score, and bone healing period were noted between these two groups and compared with statistical analysis.

Results The mean follow-up period was 8.7 months. There was a significant association of young age and male patients having distal radius fractures in the smoking group (p < 0.05). All fractures healed well in both groups without complications. There was no significant difference between these two groups in terms of range of motion, grasp, bone healing period, and functional outcomes.

Conclusion Despite the well-known fact that, smoking has negative implications in the fracture healing process, we found group of patients (smoking and nonsmoking) with distal radius fractures treated by volar locking plates healed well with good radiological union and excellent functional outcome There is no significant influence of smoking in distal radius fracture fixation.

Does osteoporosis affect the healing of subcapital humerus and distal radius fractures?

Introduction

Animal models indicate that osteoporosis may negatively influence the fracture healing process, but clinical studies on this topic are scarce. In this study we investigated the effect of osteoporosis on fracture healing in patients with an upper extremity fracture.

Methods

This retrospective cohort study included all patients aged 50 years or older, with a fracture of the proximal humerus or the distal radius treated in the period June 2012 to July 2015 and a DEXA scan within a year after fracture. The incidence of delayed-union and non-union were compared between patients with or without osteoporosis (BMD T score ≤ -2.5SD). A secondary analysis was performed with a more pragmatically definition; BMD T score ≤ -2.5SD or a proximal humerus fracture with a T-score between -2.5SD and -1.0SD.

Results

Osteoporosis was diagnosed in 133/455 patients (29.2%). A total of 461 fractures (distal radius n = 311 and proximal humerus n = 150) were treated. Radiological delayed- or non-union was described in 11/461 cases (2.4%); all proximal humerus fractures of which 6 cases (1.3%) were clinically manifest. The incidence of delayed- or non-union in fracture treatment did not differ between patients with osteoporosis (5/137 fractures) and the patients without osteoporosis (6/324 fractures) (p = 0.27). In the second analysis a significantly higher incidence was found in patients with osteoporosis (10/214 fractures vs 1/247 fractures p = 0.003).

Conclusions

The results of this study suggest that osteoporosis does not significantly influence the progress of fracture healing in distal radius and proximal humerus fractures, although there seems to be a tendency towards a negative effect.

Incidence of Complications following Volar Locking Plate Fixation of Distal Radius Fractures: An Analysis of 647 Cases

BACKGROUND

This study assessed the risk and factors of complications after volar locking plate fixation of distal radius fractures.

METHODS

A single-institution retrospective review of patients undergoing volar locking plate fixation of distal radius fractures between May of 2000 and May of 2015 was undertaken. Demographic data, major complications, minor complications, and radiographic parameters were evaluated.

RESULTS

Six hundred forty-seven distal radius fractures managed with volar plate fixation in 636 patients were reviewed. Mean follow-up was 9.1 months. Mean age was 56.5 years. Mean body mass index was 28.0, and 14.6 percent of patients had a body mass index greater than 35. Fractures were classified as Arbeitsgemeinschaft für Osteosynthesefragen class 23-C (67.2 percent), 23-A (26.6 percent), and 23-B (6.2 percent). The incidence of major and minor complications was 13.8 percent and 17.5 percent, respectively. The most common complication was transient paresthesia (9.7 percent). The incidence of tendon rupture or irritation was 0.5 percent or 2.5 percent, respectively. Hardware removal for painful/symptomatic hardware occurred in 6.2 percent at an average of 427.8 days after surgery. Major complications and minor complications were increased 2.2- and 1.9-fold, respectively, in patients with a body mass index greater than 35. Major complications were also increased 3.19 times in patients with residual intraarticular step-off. Hardware removal was 3.3 times more likely in patients with Soong grade 2 plate prominence and 2.9 times more likely in patients with a history of diabetes mellitus.

CONCLUSIONS

Volar plate osteosynthesis of distal radius fractures is associated with an overall low complication rate. Patient factors, including diabetes mellitus and obesity, and intraoperative factors, including intraarticular fracture alignment and plate prominence, were associated with a higher rate of complications or revision surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The outcome for surgical fixation of distal radial fractures in patients with idiopathic Parkinson's disease: a cohort study

Introduction

Idiopathic Parkinson’s disease (PD) is a progressive neurologic disorder causing postural instability and unsteady gait. These patients are at increased risk for fractures and have inferior outcomes after treatment. Several studies have evaluated the incidence and outcome of PD patients after hip fractures. However, there are limited studies assessing the outcome of upper extremity fractures in these patients. In this study, we evaluated the outcome of PD patients that received surgical intervention for distal radial fractures (DRF). We hypothesize that these patients have an inferior outcome after surgery in comparison with non-PD patients.

Methods

Between May 2005 and May 2017, we retrospectively reviewed all of the patients with DRF and subsequently underwent open reduction and internal fixation (ORIF) at a level 1 trauma center. All of the surgeries were performed by fellowship-trained orthopedic surgeons. The inclusion criteria include patients with a definitive diagnosis of PD, non-pathological DRF, and a minimum follow-up of 1 year or up until the time of treatment failure was noted. Each PD patient was matched for age and gender to 3 non-PD patients. The primary objective was to determine the failure rate after surgical fixation for DRF. The secondary outcomes include time to treatment failure, reoperation rate, readmission rate, length of hospital stay, and postoperative complications.

Results

A total of 88 patients were included in this study (23 PD, 65 non-PD patients). All underwent ORIF and received standard postoperative follow-ups. The overall treatment failure rate in PD was 39.1% vs. 4.6% in the non-PD group (p < 0.05). The time to treatment failure were 9.11 ± 3.86 weeks and 14.67 ± 5.8 weeks for PD and non-PD, respectively (p < 0.05). PD patients had a significantly higher rate of failure when k-wires and ESF were used (p < 0.05%), while loss of reduction was the most common mode of failure in PD (44.4%). The length of hospital stay for PD was 5.3 ± 4.69 days compared with 3.78 ± 0.96 days for non-PD (p = 0.01). There were 3 PD patients readmitted within 30 days after surgery, and 1 patient had pneumonia after the surgery.

Conclusion

This study revealed that patients with PD have a high treatment failure rate despite surgical intervention for DRF. PD patients had a longer hospital stay and had a shorter time to treatment failure. In treating PD patients complicated with DRF, the surgeon must take into consideration the complex disease course of PD and the associated comorbidities such as osteoporosis, frail status, and frequent falls. Rehabilitation and disposition plans should be discussed in advance and longer hospital stays should be expected.

Level of evidenceLevel IV, retrospective cohort study

The Use of a Vascularized Distal Ulna Autograft for Complex Distal Radius Fracture Nonunions

In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture. This technique provides a local pedicled graft that may be a simpler, more reliable, and less technically demanding alternative.

Complications in the Management of Distal Radius Fractures: How Do We Avoid them?

PURPOSE OF THIS REVIEW

Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications.

RECENT FINDINGS

Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.

A novel surgical approach for treating distal radial extraarticular malunion: Oblique osteotomy with buttress plate stabilization

PURPOSE

Distal radial extraarticular malunions are not uncommon. However, requirements of surgical correction depend on multiple conditions. Traditionally, surgical techniques include closing or opening wedge osteotomies. Each has unique advantages and disadvantages. An oblique osteotomy was developed to simplify the revision surgery.

METHODS

Forty-eight consecutive adult patients with 48 malunions were surgically treated. An oblique osteotomy of 45° vertical to the radial longitudinal axis was performed from medio-distally to latero-proximally. Consequently, the osteotomized fragments were compressed with a bone clamp. The proximal part of the distal fragment was pushed backward to correct the dorsal tilt. A 7-hole buttress plate was inserted volarly and cancellous bone graft was packed. Postoperatively, a short-arm splint or brace without restriction of all five metacarpophalangeal joints was applied for 6 weeks.

RESULTS

Forty-one patients were followed for an average of 2.8 years (range, 1.1-5.8 years). All malunions healed within 6 weeks. The union rate was 100% and no complications occurred. Radiographically, ulnar variance, volar tilt of radial articulation, and radial inclination restored to acceptable criteria in all patients. Patients with Modified Mayo Wrist Score (MMWS) improved from 17% to 80% ( p < 0.001) and Disability of Arm, Shoulder and Hand (DASH) Score improved from 0% to 80% ( p < 0.001). The relationship between MMWS and DASH Score was highly correlated (correlation coefficient = -0.90).

CONCLUSION

The described approach may be an excellent alternative for treating distal radial extraarticular malunions. The technique is not difficult but the satisfactory rate is high.

Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

Treatment of Distal Radius Fracture Nonunion With Posterior Interosseous Bone Flap

BACKGROUND

Nonunion of distal radius fractures is disabling. Treatment is difficult and the results are not predictable. However, posterior interosseous bone flap (PIBF) has been successful in treating forearm nonunion.

OBJECTIVES

To treat distal radius fracture nonunion with PIBF as a new procedure.

PATIENTS AND METHODS

This prospective non-randomized cohort study was performed at two hospitals in Tehran between January 2011 and September 2015. PIBFs were applied in nine patients (10 nonunions) with a mean age of 55 years. Union success rate, grip strength, wrist range of motion, and forearm rotation were then evaluated.

RESULTS

Although four of the patients had a history of infection, all participants achieved fracture union at a mean time of 3.8 months. Grip strength improved by 12.4 kg. There was also 36° improvement in wrist flexion, 20° improvement in wrist extension, 60° improvement in forearm supination, and 46° improvement in forearm pronation. The range of motion and grip strength improvements were significant.

CONCLUSIONS

Pedicled PIBF is a new option for treating distal radius fracture nonunion. The results are predictable in achieving union and good function, and this technique can be successfully used in cases with extensive soft-tissue damage or infection.

Complications of Distal Radius Fixation

Complications following any form of distal radius fixation remain prevalent. With an armamentarium of fixation options available to practicing surgeons, familiarity with the risks of newer plate technology as it compares with other conventional methods is crucial to optimizing surgical outcome and managing patient expectations. This article presents an updated review on complications following various forms of distal radius fixation.

Pharmacokinetic modeling of multislice dynamic contrast-enhanced MRI in normal-healing radial fractures: A pilot study

PURPOSE

To define the range of quantitative pharmacokinetic parameters in normal-healing bone with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). DCE-MRI is an established technique for characterizing abnormal tissue microvasculature within solid tumors, but has also shown promise for assessing bone and bone marrow.

MATERIALS AND METHODS

In this study ethical approval for eight patients was obtained. Inclusion criteria were an extra-articular distal radial fracture in patients aged 20-50 years which had united by 6 weeks in plaster cast. This was assessed by an experienced orthopedic surgeon. DCE-MRI was performed at 1.5T 6 weeks after initial injury. The transfer constant (K(trans) ), transfer rate (Kep ), and initial area under the curve (IAUC) values for the fracture site and adjacent marrow were obtained for each patient.

RESULTS

The mean T1 , K(trans) , Kep , and IAUC at the fracture site were 1713 (standard deviation [SD] 645), 0.09 (SD 0.07), 0.17 (SD 0.17) and 4.9 (SD 4.4). The relative standard deviation (RSD) for the fracture site ranged from 0.38 to 0.97 and for the adjacent marrow ranged from 0.95-3.88. Within each patient the range of RSDs was 0.04-0.42 for T1 , 0.26-0.91 for K(trans) , 0.14-1.06 for Kep , and 0.35-0.96 for the IAUC.

CONCLUSION

Pharmacokinetic measures of perfusion can be obtained from healing fractures using DCE-MRI with "excellent" intraclass correlation coefficients for inter- and intrarater reliability. The use of these perfusion parameters is limited by wide patient-to-patient variation and slice-to-slice variation within patients.

Non-union in 3 of 15 osteotomies of the distal radius without bone graft

BACKGROUND AND PURPOSE

Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure.

PATIENTS AND METHODS

We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing.

RESULTS

Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04).

INTERPRETATION

When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

Radiographic scoring system to evaluate union of distal radius fractures

PURPOSE

To evaluate the intra- and interobserver reliability of a scoring system for distal radius fracture union based on specific radiographic parameters obtainable from x-rays.

METHODS

Two sets of 35 anteroposterior and lateral x-rays were obtained by retrospective review of consecutive patients with distal radius fractures (AO types A and C) treated by a single surgeon in 2009. One set was assembled for those patients treated nonsurgically and 1 set for those treated with open reduction and internal fixation (ORIF) with volar plating. Radius union scoring system (RUSS) scores were compiled from a 5-person review panel consisting of hand surgeons and musculoskeletal radiologists. Union of each of the 4 cortices was graded on a 3-point scale (0, fracture line visible with no callus; 1, callus formation but fracture line present; 2, cortical bridging without clear fracture line). Reviewers also recorded their overall impression of fracture union (united or not united). Each set of radiographs was reviewed twice by the 5 reviewers, 2 weeks apart. Inter- and intraobserver reliability were determined using intraclass correlation coefficients.

RESULTS

For nonsurgically treated fractures, substantial agreement in union scores was found with regard to both intra- and interobserver reliability. For fractures treated with ORIF, substantial agreement was found in union scores with regard to intraobserver reliability and moderate agreement with regard to interobserver reliability. In addition, when using the reviewers' overall assessment of union as a reference standard, RUSS had a statistically significant predictive value in being able to differentiate between united and not united fractures.

CONCLUSIONS

This radiographic union tool demonstrated substantial intra- and interobserver reliability for the determination of fracture union in the distal radius. The RUSS is a simple method for a standardized assessment of radiographic union of DRF treated nonsurgically or with ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision analysis IV.

[Operative options for rectification after failed osteosynthesis of the distal radius]

BACKGROUND

Even in an era of clear improvements in implants and standardized treatment procedures, abortive osteosynthesis after distal radius fractures is not an uncommon complication.

DIAGNOSTICS

Although not every malunion of the radius leads to complaints, affected patients often suffer from limitations in movement, reduction in strength, pain and aesthetic deficits. Following thorough clinical and imaging diagnostics a selection from the possible treatment options must be made taking the results obtained from the diagnostics into consideration.

THERAPY

Operative possibilities are available for reconstructing the anatomical features as accurately as possible, functional improvement without correction of the malunion, pain reduction alone and combined procedures.

CONCLUSION

Despite abortive osteosynthesis of distal radial fractures there are possibilities for anatomical reconstruction, retention of mobility and pain reduction. Taking the pathological deformities into consideration, the highest priority should be given to reconstructing the anatomical joint conditions as accurately as possible, even when the conservative treatment options were unsuccessful.

Correction osteotomy of distal radius malunion stabilised with dorsal locking plates without grafting

The purpose of this study was to evaluate the results of our correction osteotomies of distal radial malunions without a bone graft. Eleven consecutive patients (mean age 52 years, range 18–71) were treated. A dorsal approach was utilised to perform an opening-wedge osteotomy which then was stabilised with two dorsal columnar plates without filling the osteotomy gap. All patients went on to radiographic union with a filling of the osteotomy gap within a mean period of 3 months (range 2–6 months). All patients had satisfactory results in terms of function and pain. Correction osteotomy and stabilisation with bicolumnar locked plate fixation without a bone graft provides sufficient stability to allow the highly vascularised metaphysis to heal. In patients without risk factors predisposing to non-union, this procedure is safe and feasible.

Corrective osteotomy of distal radial deformities: a new method of guided locking fixed screw positioning

Corrective osteotomy for distal radial malunion is a valuable but at times technically challenging operation. We have developed a new device to aid in the performance of the operation. We compared clinical use of the new technique with the standard technique. In 11 patients treated with the new technique the volar locking plate needed repositioning only once. With the standard technique in 17 patients the plate was repositioned in nine cases and needed bending in six cases. The new method corrected radial inclination (SD of 3° vs. 9°) and ulnar variance (SD of 0.9 mm vs. 1.4 mm) more predictably than the standard technique but there was no advantage in correction of volar tilt (SD of 6° vs. 4°). In our experience the new device makes corrective osteotomy of the distal radius easier and more reliable.

Radiographs late in the follow up of uncomplicated distal radius fractures: are they worth it? Clinical outcome and financial implications

Fractures of the distal radius are common. Displacement can quickly lead to secondary osteoarthritis. Early follow up radiographs are subsequently paramount to facilitate for early attempts at reduction. Developing callus eventually makes this impractical. In the absence of complications we propose that radiographs may become obsolete at the later stages of follow up. We investigate whether clinical deformity, range of wrist movement and grip strength are independent of radiographs taken later than 2 weeks into the follow up of uncomplicated cases. Local cases between May 2009 and December 2011 were reviewed. Devised criteria regulated case selection. Data was collected from radiological software and occupational therapy clinical notes. Fractures were placed in short or term follow up groups dependant on whether they were imaged later than 2 weeks into follow up. T-tests compared our outcomes measures between these groups. 138 cases were included; 77 short term; 61 long term. No cases reported visible clinical deformity. There were no significant differences between grip strength or range of wrist movement for the short and long term groups. No cases required intervention for late displacement. Although complications may justify delayed imaging, our results suggest radiographs late in the follow up of uncomplicated distal radius fractures have no impact on our outcome measures. Further studies are required to confirm this. Financial regulation means any potential benefits from the removal of these unnecessary radiographs should be recognised. Established radiological follow up regimes need to be devised.

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

Management of forearm nonunions: current concepts

Forearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location and complexity, patient characteristics and surgical technique. Treatment of diaphyseal forearm nonunions differs from that of other type of diaphyseal nonunions because of the intimate relationship between the radius and ulna and their reciprocal movement. There is a wide variation of surgical techniques, and the optimal choice of management remains subject to debate. In this review, we aim to summarize the available evidence in the literature on forearm nonunions and combine it with practical recommendations based on our clinical experience to help guide the management of this complex problem.

Nonunion of Fracture of Distal Radius: A Case Report and Literature Review

Nonunion of distal radius fracture is uncommon. Promising results in dorsally displaced fractures of distal radius were reported with the use of volar fixed-angle fixation. We report about a 75-year-old woman with nonunion of distal radius, treated successfully by using volar locking compression plate.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically into immediate, early (less than 6 weeks), and late (greater than 6 weeks).

Dorsally angulated fractures of the distal radius

Management of unstable distal radius fractures has evolved considerably in recent years. This review describes the assessment and management of distal radius fractures in light of these recent changes.

Korrektureingriffe nach distaler Radiusfraktur

After a fracture of the distal radius, especially with malunion, many patients complain of a decreased range of forearm rotation and pain on the ulnar side of the wrist. The purpose of this article is to describe the therapeutic options available in such cases. Decision making as to whether there is an indication for corrective surgery or not is based on the patient's symptoms and the clinical findings, whereas the decision as to which surgery to perform must take into account the radiological findings. If possible, reconstruction of the anatomy using a distal radius osteotomy should be carried out.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically in to immediate, early (less than 6 weeks), and late (greater than 6 weeks).

Malunion of the distal radius

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

Prosthetic devices shaped as tubular chambers for the treatment of large diaphyseal defects by guided bone regeneration

Guided tissue regeneration is based on the hypothesis that the different tissues have unequal abilities to penetrate a wounded area during the healing process. The use of a device acting as a chamber allows the growth of a particular tissue and prevents the ingrowth of other tissues which impair the healing process. At the same time the chamber protects and maintains in situ the intrinsic growth factors so that they may perform their specific activity. Guided tissue regeneration currently plays a well-recognized role mostly in dentistry and peripheral nerve surgery but interesting perspectives have also opened up in orthopedics. Considering the possibility of using guided bone regeneration in the repair of diaphyseal bone defects, this updated survey highlights some critical points and pathways related to the state-of-the-art of this promising procedure, focusing particularly on the properties of the material to make the tubular chamber, the use of osteopromotive factors and the most appropriate animal model to be used for the experimental evaluation.

Corrective osteotomy of the distal radius through volar approach

Operative correction through the malunion has become a well-accepted reconstructive procedure for symptomatic malunited extra-articular fractures of the distal radius over the last 3 decades. Now that newer plates designed specifically for the volar fixation of dorsally unstable distal radius fractures by incorporating buttress pins and screws that lock to the plate are available, more and more surgeons prefer volar fixation of dorsally unstable distal radius fractures. In the mid 1970s, the senior author (U.B.L.) developed a technique for corrective osteotomy of dorsally tilted malunions of the distal radius using a radiovolar approach and a special plate. This technique was proved to be efficient in more than 400 patients.