Volar approach to dorsal displaced fractures of the distal radius

Biomechanics of Subcutaneous Locked Plating Versus Burke Plate and External Fixator for Comminuted Distal Radius Fractures

Background External fixators that span the wrist have been the historical norm in treating distal radius fractures. We have modified a dorsal distraction approach by using a subcutaneously applied locked bridge plate through two small incisions superficial to the extensor tendons and outside the extensor compartment. The purpose of this study was to biomechanically evaluate this modified method of fixation for comminuted distal radius fractures in comparison with two established constructs. Methods Matched cadaver specimens were used to model an AO Type 23-C3 distal radius fracture. Biochemical testing for stiffness during axial compressive loading was done on three constructs: a conventional Burke distraction plate, the subcutaneous internal fixation plating technique, and an external fixator. All specimens were cyclically loaded for 3000 cycles and then retested. Results The modified construct was found to be stiffer than the external fixator (p=0.013). When compared to the Burke plate, the modified construct was significantly less stiff before axial cycling (p=0.025). However, the difference was not maintained after cycling, and the post-axial loading stiffness difference was non-significant (p=0.456). Conclusion Our data demonstrate the biomechanical integrity of the subcutaneous plating technique for the fixation of comminuted distal radius fractures. It is stiffer than an external fixator and has the theoretical advantage of avoiding pin-tract infections. In addition, it is subcutaneous and not a cumbersome external construct. Our construct is minimally invasive, and it does not violate the dorsal extensor compartments. This allows for finger movement even while the construct is in place.

A Comparative Study Between Plate Osteosynthesis and Intramedullary Nailing for Diaphyseal Fracture of Radius and Ulna in Adults

INTRODUCTION

In this era of active living, industrial growth, increasing automobile accidents, and athletic activities, fractures of the forearm bones are becoming more frequent. The incidence of diaphyseal fractures of both bone forearms is reported to be approximately 10 per 10,000 persons per year, although rates may vary according to age and sex. If not properly treated, a fracture of the forearm bones might cause a serious loss of function. Therefore, to restore function, these fractures require adequate anatomical reduction and internal fixation. The majority of forearm fractures in adults are treated surgically, and various modes of internal fixation are available. In this study, we evaluated and compared the clinical, functional, and radiological outcomes of both bone forearm diaphyseal fractures treated with plate osteosynthesis and intramedullary nailing.

MATERIAL AND METHOD

This prospective and comparative study was conducted in a tertiary care medical teaching hospital in southern Rajasthan, India. Forty patients with diaphyseal fractures of the radius and ulna bones who presented to the casualty or orthopedic outpatient departments of our institute were included. Patients were divided into two groups, 20 patients in each group and treated by intramedullary nailing (group A) and plate osteosynthesis (group B), and regularly followed up and evaluated for clinical, functional, and radiological outcomes.

RESULT

Final results were calculated according to the modified Grace-Eversmann scoring system. In group A, out of 20 cases excellent score was seen in six cases (30%), good score in nine cases (45%), fair score in three cases (15%), and at last, two cases (10%) showed poor results. In group B, excellent score was in eight cases (40%), good score was in eight cases (40%), fair score was in three cases (15%), and at last, one case (5%) was poor in our study.

CONCLUSION

Based on our findings, we conclude that for the treatment of diaphyseal fractures of the radius and ulna, both treatment modalities provide equally satisfactory results.

Surgical Management of Acute on Chronic Distal Radius Fractures: Correcting Malunion Deformities Through the Secondary Fracture Plane

It is challenging to restore the clinically acceptable alignment of the distal radius after an acute on chronic fracture or after a secondary fracture occurring after malunion of a primary distal radius fracture. In cases of insignificant primary deformity, restoration to the primary deformity may suffice to obtain a successful clinical result. A borderline acceptable primary radial deformity can be unacceptable after the second injury, resulting in functional disability. If surgery is indicated, the surgeon must contend with both primary and secondary deformities to restore proper distal radius anatomy. We present our technique to correct both primary and secondary distal radius deformities through the new or secondary fracture plane.

Outcomes of Arthroscopic-Assisted Distal Radius Fracture Volar Plating: A Meta-Analysis

PURPOSE

The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature.

METHODS

A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength).

RESULTS

Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes.

CONCLUSIONS

The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Diagnosis of dorsal screw penetration after volar plating of a distal radial fracture

Aims

The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging.

Methods

A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard.

Results

In order to detect dorsal screw penetration, the sensitivity of dorsal tangential views was 39% with a negative predictive value (NPV) of 91% and an accuracy of 91%; compared with a sensitivity of 25% for 3D fluoroscopy with a NPV of 93% and an accuracy of 93%. On the postoperative CT scans, we found penetrating screws in: 1) 40% of patients in the 2D fluoroscopy group; 2) in 32% of those in the 2D fluoroscopy group with AP, lateral, and dorsal tangential views; and 3) in 25% of patients in the 3D fluoroscopy group. In all three groups, the second compartment was prone to penetration, while the postoperative incidence decreased when more advanced imaging was used. There were no penetrating screws in the third compartment (extensor pollicis longus groove) in the 3D fluoroscopy groups, and one in the dorsal tangential views group.

Conclusion

Advanced intraoperative imaging helps to identify screws which have penetrated the dorsal compartments of the wrist. However, based on diagnostic performance characteristics, one cannot conclude that 3D fluoroscopy outperforms dorsal tangential views when used for this purpose. Dorsal tangential views are sufficiently accurate to detect dorsal screw penetration, and arguably more efficacious than 3D fluoroscopy. Cite this article: Bone Joint J 2020;102-B(7):874–880.

A retrospective comparison of clinical and radiological outcomes using palmar or dorsal plating to treat complex intraarticular distal radius fractures (AO 2R3 C3)

INTRODUCTION

Complex intraarticular distal radius fractures are common, and treatment with open reduction and internal fixation (ORIF) can be done through either the palmar or dorsal approach. There is scant evidence, however, indicating which approach is more suitable. We compared clinical and radiological outcomes of patients with AO 2R3 C3 fractures surgically treated with one of these approaches.

MATERIALS AND METHODS

From January 2015 to November 2018, 72 surgically treated patients with AO 2R3 C3 fractures were radiologically (12 months) and clinically (mean 26 months) evaluated. Forty-one patients underwent ORIF using the palmar approach (Group 1), and the dorsal approach was used in 31 patients (Group 2). Radiological parameters were measured using the AO scoring system immediately following surgery and 12 months later. Clinical assessments included the range of motion, PRWE and DASH scores.

RESULTS

At the immediate postoperative assessment, the median AO score was 5.5 (IQR 2-9.5, range 0-30.5) for Group 1 and 8 (IQR 5-15, range 0-27) for Group 2, and 12-month follow-up results were 4.5 (IQR 1.5-10, range 0-41) and 6.5 (IQR 5-11, range 0-29.5), respectively. Group 1 had more favorable results for the flexion, extension, radial abduction, PRWE and DASH parameters. The plate removal and reoperation rates were higher in Group 2.

DISCUSSION

When treating complex intraarticular distal radius fractures, we found the palmar approach was more advantageous for this fracture pattern. Nevertheless, a dorsal approach may still be suitable for intraarticular comminuted distal radius fractures with dorsally displaced joint fragments.

Using mini-arthrotomy for dorsal plating to treat intraarticular distal radius fractures: can it improve radiological and clinical outcomes?

PURPOSE

Using palmar plating to treat complex intraarticular distal radius fractures is standard of care. However, fracture fragments can also be managed using a dorsal approach with arthrotomy, which is useful when treating fractures involving the dorsal joint aspect. We compared radiological and clinical outcomes after dorsal plating with or without an intraoperative arthrotomy.

METHODS

31 of the 359 patients with a distal radius fracture had an AO Type 2R3 C3 fracture surgically treated using a dorsal approach (01/2015-10/2018). Fractures other than C3 were excluded from this analysis. Group 1 (n = 14) had no arthrotomy, Group 2 (n = 17) underwent intraoperative dorsal mini-arthrotomy. Clinical results were measured by range of motion (ROM), Patient-rated wrist evaluation (PRWE) and Disabilities of arm, shoulder and hand (DASH) scores. Radiological results were evaluated using the AO scoring system.

RESULTS

ROM, DASH and PRWE did not differ significantly between groups. Joint surface restoration was insufficient in five patients in Group 1 (p = 0.05). A trend towards better radiological results, although not statistically significant, was noted in Group 2 (p = 0.06). Plate removal was performed in 12 patients due to limited ROM (6 patients in each group). One patient (Group 2) with chronic pain and step off in the joint line underwent corrective osteotomy.

CONCLUSIONS

We did not detect a difference in patient outcomes using the dorsal longitudinal mini-arthrotomy; however, it may prevent incongruent joint reconstruction since all cases occurred in Group 1. In the absence of intraoperative CT scan, longitudinal mini-arthrotomy may be used to enhance visualization and achieve joint surface reconstruction.

Lift-Off Screw Results in Accurate Sagittal Tilt Correction in a Distal Radius Fracture Model

PURPOSE

To determine the accuracy of a distal-first open reduction internal plate fixation technique in achieving correction of volar tilt in dorsally angulated distal radius fractures.

METHODS

Twenty foam radius models were divided evenly into groups N (normal) and O (osteoporotic). Dorsally angulated extra-articular distal radius fractures were then created. Group O underwent further modification to simulate an osteoporotic model. After static pinning in various degrees of dorsal angulation, opaque fiducial markers were placed and fluoroscopy was used to measure prereduction volar tilt. A variation of the distal-first plate application technique was used where a lift-off screw (LOS) was placed in the proximal most locking hole and propped the proximal aspect of the plate by the screw's length. The LOS length corresponded to the volar tilt correction needed. After fracture reduction using this technique, we measured the volar tilt again. We then compared the actual volar tilt correction with what was predicted based on the LOS length used. We also compared the tilt correction accuracy in the normal and osteoporotic models.

RESULTS

Prereduction tilt ranged from 3° to 52° of dorsal tilt from normal (10° volar tilt). Corresponding LOSs ranged from 5 to 42 mm in length. Tilt correction correlated with screw length in a linear fashion (R = 0.9). The mean difference between actual and predicted tilt correction for a given screw length was 0.5° ± 3.0°, and the mean absolute difference was 2.4° ± 1.7° for all specimens. There was no difference between normal and osteoporotic models.

CONCLUSIONS

Prereduction dorsal tilt can be accurately corrected within a few degrees of the goal by using the distal-first technique with an LOS. The LOS length can be calculated, and this technique can potentially be used with any distal radius periarticular locking plate with locking options in the shaft.

CLINICAL RELEVANCE

A technique that provides accurate tilt correction would be of benefit to surgeons treating distal radius fractures with volar plates.

Operative Treatment of Intra-Articular Distal Radius Fractures With versus Without Arthroscopy: study protocol for a randomised controlled trial

Background

In the past several years, an increase in open reduction and internal fixation (ORIF) for intra-articular distal radius fractures has been observed. This technique leads to a quicker recovery of function compared to non-operative treatment. However, some patients continue to have a painful and stiff wrist postoperatively. Arthroscopically assisted removal of intra-articular fracture haematoma and debris may improve the functional outcomes following operative treatment of intra-articular distal radius fractures. The purpose of this randomised controlled trial is to determine the difference in functional outcome, assessed with the Patient-Rated Wrist Evaluation (PRWE) score, after ORIF with and without an additional wrist arthroscopy in adult patients with displaced complete articular distal radius fractures.

Methods

In this multicentre trial, adult patients with a displaced complete articular distal radius fracture are randomised between ORIF with an additional wrist arthroscopy to remove fracture haematoma and debris (intervention group) and conventional fluoroscopic-assisted ORIF (control group). The primary outcome is functional outcome assessed with the PRWE score after three months. Secondary outcomes are wrist function assessed with the Disability of the Arm, Shoulder and Hand (DASH) score, postoperative pain, range of motion, grip strength, complications and cost-effectiveness. Additionally, in the intervention group, the quality of reduction, associated ligamentous injuries and cartilage damage will be assessed. A total of 50 patients will be included in this study.

Discussion

Although ORIF of intra-articular distal radius fractures leads to a quicker resume of function compared to non-operative treatment, some patients continue to have a painful and stiff wrist postoperatively. We hypothesise that, due to the removal of fracture haematoma and debris by an additional arthroscopy, functional outcomes will be better compared to the non-arthroscopically treated group.

Trial registration

ClinicalTrials.gov, NCT02660515. Registered on 13 January 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2409-2) contains supplementary material, which is available to authorized users.

Wrist denervation of the posterior interosseous nerve through a volar approach: a new technique with anatomical considerations

PURPOSE

Full or selective wrist denervation is an effective treatment for chronic wrist pain. In this cadaveric study, a volar approach for prophylactic denervation of the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN) was assessed, which can simultaneously be performed during volar approaches for distal radius fracture fixation or in combination with metalwork removal.

MATERIALS AND METHODS

In total 40 adult upper limbs, embalmed using Thiel's method, were investigated. Group 1 included 20 limbs of which the distances between AIN and PIN to the ulnar margin of radius were measured at levels 6, 8 and 10 cm proximal to the styloid process and the distance radial styloid process to proximal border of pronator quadratus which might be useful as an intraoperative landmark. Subsequently further additional 20 adult limbs (group 2) were used. Transection of the PIN via this volar approach at the evaluated best level of step 1 was performed and evaluated by dissection via a dorsal approach.

RESULTS

In group 1, the PIN runs within the interosseous membrane, from the ulnar border of the radius, 6.4 mm (SD 2.66) at 6 cm, 8.4 mm (SD 2.28) at 8 cm and 3.75 mm (SD 5.46) at 10 cm proximal to the radial styloid. The AIN runs within the interosseous membrane, from the ulna edge of the radius, 7.5 mm (SD 2.4) at 6 cm, 7.3 mm (SD 1.95) at 8 cm and 2.35 mm (3.42) at 10 cm proximal to the radial styloid. AIN and PIN were in close proximity at the 8-cm level which equals a 1-cm distance proximal to the pronator quadratus border. Group 2 showed a successful transection of the PIN through a single volar surgical approach in additional 18 out of 20 adult upper limbs.

CONCLUSIONS

This study shows the local anatomy of the PIN, allowing denervation via a volar approach.

Internal plate fixation versus plaster in displaced complete articular distal radius fractures, a randomised controlled trial

Background

Of all distal radius fractures, 25 % are complete articular fractures (AO/OTA type C fractures). Two thirds of those fractures are displaced and require reduction. According to several International Guidelines, adequately reduced intra-articular distal radius fractures are best treated non-operatively with plaster immobilisation, while surgical fixation is suggested only when the articular step exceeds 2 mm after reduction. However, these recommendations are based on studies that did not differentiate between intra- and extra-articular distal radius fractures. Thus, no clear consensus about the best treatment for patients with displaced intra-articular distal radius fractures can be reached. Despite the lack of evidence, an increase in internal fixation of intra-articular distal radius fractures has been observed over the last decade. The aim of this study is to determine the difference in functional outcome following open reduction and plate fixation compared with non-operative treatment with closed reduction and plaster immobilisation in patients with a displaced intra articular distal radius fracture.

Methods/Design

This multicentre randomised controlled trial will randomise between open reduction and internal plate fixation (intervention group) and closed reduction and plaster immobilisation (control group). All consecutive adult patients from 18 to 65 years with a displaced intra-articular distal radius fracture (AO/OTA type C), which has been adequately reduced at the Emergency Department according to the Dutch National Guidelines, are eligible for inclusion in this study. The primary outcome is function and pain of the wrist assessed with the Patient-Rated Wrist Evaluation score (PRWE). Secondary outcomes are the Disability of the Arm, Shoulder and Hand score (DASH), pain, quality of life (SF-36), range of motion, grip strength, radiological parameters, complications, crossovers and cost-effectiveness of both treatments. A total of 90 patients will be included in this study.

Discussion

Although displaced intra-articular distal radius fractures are common, there is still no evidence on the optimal treatment for these fractures in patients aged 18 to 65 years. Therefore we aim to determine the difference in functional outcome between open reduction and plate fixation and closed reduction and plaster immobilisation.

Trial registration

This study is registered at ClinicalTrials.gov (NCT02651779) on January 4^th 2016.

Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study

BACKGROUND

There are relatively few studies in the literature that specifically evaluate accelerated rehabilitation protocols for distal radial fractures treated with open reduction and internal fixation (ORIF). The purpose of this study was to compare the early postoperative outcomes (at zero to twelve weeks postoperatively) of patients enrolled in an accelerated rehabilitation protocol with those of patients enrolled in a standard rehabilitation protocol following ORIF for a distal radial fracture. We hypothesized that patients with accelerated rehabilitation after volar ORIF for a distal radial fracture would have an earlier return to function compared with patients who followed a standard protocol.

METHODS

From November 2007 to November 2010, eighty-one patients with an unstable distal radial fracture were prospectively randomized to follow either an accelerated or a standard rehabilitation protocol after undergoing ORIF with a volar plate for a distal radial fracture. Both groups began with gentle active range of motion at three to five days postoperatively. At two weeks, the accelerated group initiated wrist/forearm passive range of motion and strengthening exercises, whereas the standard group initiated passive range of motion and strengthening at six weeks postoperatively. Patients were assessed at three to five days, two weeks, three weeks, four weeks, six weeks, eight weeks, twelve weeks, and six months postoperatively. Outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) scores (primary outcome) and measurements of wrist flexion/extension, supination, pronation, grip strength, and palmar pinch.

RESULTS

The patients in the accelerated group had better mobility, strength, and DASH scores at the early postoperative time points (zero to eight weeks postoperatively) compared with the patients in the standard rehabilitation group. The difference between the groups was both clinically relevant and statistically significant.

CONCLUSIONS

Patients who follow an accelerated rehabilitation protocol that emphasizes motion immediately postoperatively and initiates strengthening at two weeks after volar ORIF of a distal radial fracture have an earlier return to function than patients who follow a more standard rehabilitation protocol.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Distal radius fractures: Should we use supplemental bone grafts or substitutites in cases of severe osteoporotic or conminution?

OBJECTIVES

The purpose of this study was to assess the need of bone graft or bone substitutes in unstable distal radius fractures (DRF) treated with locking compression plates (LCP) PATIENTS AND METHODS: An observational and prospective study was conducted on 60 patients with DRF AO-type A3 and AO-type C3, treated surgically by LCP plates without bone grafts or substitutes. Ranges of motion in flexion (F), extension (E), pronation (P), and supination (S) were measured in the injured wrist and compared with the healthy contralateral wrist. X-ray parameters: palmar tilt (PT), radial inclination (RI), ulnar variance (UV), and radial height (RH) were calculated in the injured wrist one year after surgery and then compared, with those parameters in the healthy contralateral wrist and in the follow-up postoperative x-ray of the injured wrist. PRWE and DASH scores were used to evaluate patient satisfaction.

RESULTS

The range of motion loss was F 12° ± 16.1°, E 9° ± 13.1°, P 2.5° ± 7.5°, and S 5°±10°, but they remained within functional parameters. Good results were also obtained in the PRWE and DASH scores (DASH 12.6 ± 14.16 and PRWE 9.5 ± 9.5). All the fractures were healed without significant collapse (IP 0.55 ± 1.7°, IR 0.31 ± 1.5°, VC 0.25±0.8mm, and AR 0.1 ± 0.9 mm).

CONCLUSIONS

All fractures healed without problems or with significant loss of reduction. Bone graft and bone substitutes are not mandatory for treatment of unstable DRF with LCP plates. Their use increases the cost and is not exempt of morbidities. This study also reinforces the role of LCP plates in surgical treatment of unstable DRF.

Leveraging the plate: reliably restoring volar tilt of distal radius fractures

Restoration of volar tilt is critical when performing open reduction and internal fixation of distal radius fractures. A reproducible technique is required to consistently achieve this goal. A simple technique using the locking plate and an electrocautery scratch pad as reduction tools can reliably generate volar tilt. This technique can be performed with minimal aid from surgical assistants.

Complications following palmar plate fixation of distal radius fractures: a review of 665 cases

INTRODUCTION

Palmar plate fixation of unstable distal radial fractures is quickly becoming the standard treatment for this common injury. The literature reporting complications consists mainly of isolated case reports or small case series.

METHOD

Between February 2004 and December 2009 palmar plate fixation was performed in 665 cases. The overall complication rate was 11.3 % (75 complications). Revision surgery was necessary in 10 % (65 procedures).

RESULTS

The reasons for revision surgery were: postoperative median nerve compression (22 patients) and secondary dislocation (9 patients). An ulna shortening osteotomy for ulnar impingement syndrome was necessary in eight cases. Intraarticular screw placement occurred in three patients. There were two flexor pollicis longus, one finger flexor and three extensor pollicis longus tendon ruptures. Posttraumatic compartment syndrome of the forearm requiring fasciotomy occurred in four cases. There were three cases of infection. Nonoperative treatment was necessary in nine patients, who developed a complex regional pain syndrome. Hardware failure occurred in three cases. Hardware removal was performed in 232 (34 %) cases.

CONCLUSION

Palmar plate fixation of distal radius fractures is a safe and effective procedure. Nevertheless, complications necessitating a second intervention are relatively common. A proportion of these complications is iatrogenic and can be avoided by improving the surgical technique.

Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bone-graft harvest

The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: is there an advantage of palmar plates in the long term?

Background

Current surgical approaches to the distal radius include dorsal and palmar plate fixation. While palmar plates have gained widespread popularity, few reports have provided data on long term clinical outcomes in comparison. This paper reports the result of a randomised clinical study comparing dorsal Pi plates and palmar, angle-stable plates for treatment of comminuted, intraarticular fractures of the distal radius over the course of twelve months.

Methods

42 patients with unilateral, intraarticular fractures of the distal radius were included and randomised to 2 groups, 22 were treated with a palmar plate, 20 received a dorsal Pi-plate. Results were evaluated after 6 weeks, 3, 6 and 12 months postoperatively focussing on functional recovery as well as radiological results.

Results

The palmar plate group demonstrated significantly better results regarding range of motion and grip strength over the course of 12 months. While a comparable increase in function was observed in both groups, the better results from the early postoperative period in the palmar plate group prevailed over the whole course. Radiological results showed a significantly increased palmar tilt and carpal sag in dorsal plates, with other radiological parameters being comparable. Pain levels were decreased in dorsal plates after hardware removal and failed to show significant differences after 12 months. However, complications such as tendon ruptures were more frequent in the dorsal plate group.

Conclusions

Functional advantage of palmar plates gained within the first 6 weeks prevails over the course of a year. Both groups demonstrate further gradual increase of function after 6 months, although dorsal plates did not catch up completely. Improved early postoperative function seems to be the cornerstone for the best possible results. Patients with dorsal plates benefit from hardware removal more than palmar plates in terms of reduction of pain levels. The advantage of palmar plates is a faster functional recovery with lower complication rates. This is especially important in the elderly population. Radiological results did not show a superiority of palmar plates over dorsal plates.

The treatment of distal radius articular fractures of C1-C2 type with DVR plate: analysis of 40 cases

The aim of this investigation was to evaluate the efficiency of fixed angle plates DVR in the treatment of C1 and C2 type articular wrist fractures according to the AO classification. From July 2005 to March 2009, 40 wrist fractures were treated: 18 were of C1 type while 22 of C2 type according to AO classification. The age of patients varied from 25 to 79 years old. The average length of follow-up was 17 months (range, 4-37 months). The average articular motility was flexion 59.4° and extension 62.7°. Final radiographic parameters were of 18.7° of average ulnar inclination, 10.3° of average dorsal inclination, and 1.45 mm of negative ulnar variance. All patients were reassessed according to Mayo Modified Wrist Score getting a very good/good result in 82% of cases and a medium/poor one in 18%. The DASH score pulled off 46.3 points in the first group, 5.1 in the second group, and 6 in the third one. The statistical analysis based on Student's t test showed how C1 and C2 classification did not influence the results using the same treatment. DVR plate showed a very good reliability and a sufficient stability with both C1 and C2 fractures.

A PROSPECTIVE PLAN TO MINIMISE MEDIAN NERVE RELATED COMPLICATIONS ASSOCIATED WITH OPERATIVELY TREATED DISTAL RADIUS FRACTURES

Loss of median nerve function or a neuropathic pain syndrome may occur in around 20% of distal radius fractures if post-traumatic oedema in the carpal canal generates excessive pressure on the median nerve. No method currently exists to reliably distinguish which patients may benefit from a concomitant carpal tunnel release. This case series details the results of following a prospective plan designed to minimise median nerve related complications associated with distal radius fractures by measuring Semmes-Weinstein monofilament scores in 374 radius fracture patients who underwent surgical stabilisation. One hundred and sixty-nine patients with the clinical symptoms of median nerve compression, a decrement in monofilament score of grade 1 (out of 5) compared to the contralateral side or at least 4.31 g underwent concomitant carpal tunnel release. The remaining 205 patients did not have carpal tunnel release. There were no cases of neuropathic pain or loss of median nerve function.

Results of volar locking plate osteosynthesis for distal radial fractures

BACKGROUND

To evaluate functional, radiologic, and subjective outcome after volar locking plate osteosynthesis (VLPO) for unstable distal radius fractures (DRF).

METHODS

In this study, patients treated with VLPO for isolated DRF between March 2005 and December 2007 were prospectively evaluated. Patients with multiple injuries or those unavailable for follow-up were excluded from further evaluation. Range of motion, grip strength, and the subjective Patient-Rated Wrist Evaluation score were monitored for 6 weeks, 3 months, 6 months, and finally 1 year after surgery. The uninjured contralateral wrist served as control. The radiologic outcome after 1 year was scored using the Lidstrom score.

RESULTS

In total, 245 patients were included in the study with a mean age of 62 years ± 18 years. At the final follow-up, 1 year after surgery, 228 patients (93%) could be controlled. Range of motion significantly increased during follow-up. One year after surgery, mean flexion was 64° ± 15°, and mean extension reached 64 ° ± 15 ° corresponding with >90% of the uninjured contralateral wrist function. Grip strength increased from 14 kg ± 8 kg (54%) 6 weeks after surgery to 25 kg ± 11 kg (91%) at the final follow-up. Patient-Rated Wrist Evaluation score resulted in mean 8 points ± 16 points after 1 year. Lidstrom score reached a mean of 1.3 points ± 0.6 points, demonstrating a good initial fracture reduction and stable fixation. A complication rate of 15% could be seen in our series, among secondary fracture displacement in two patients (1%).

CONCLUSIONS

VLPO for the treatment of unstable DRF is a reliable technique with excellent subjective, objective, and radiologic outcome.

Does osteoporosis increase complication risk in surgical fracture treatment? A protocol combining new endpoints for two prospective multicentre open cohort studies

Background

With an ever-increasing elderly population, orthopaedic surgeons are faced with treating a high number of fragility fractures. Biomechanical tests have demonstrated the potential role of osteoporosis in the increased risk of fracture fixation complications, yet this has not been sufficiently proven in clinical practice. Based on this knowledge, two clinical studies were designed to investigate the influence of local bone quality on the occurrence of complications in elderly patients with distal radius and proximal humerus fractures treated by open reduction and internal fixation.

Methods/Design

The studies were planned using a prospective multicentre open cohort design and included patients between 50 and 90 years of age. Distal radius and proximal humerus fractures were treated with locking compression 2.4 mm and proximal humerus internal locking plates, respectively. Follow-up examinations were planned for 6 weeks, 3 and 12 months as well as a telephone interview at 6 months. The primary outcome focuses on the occurrence of at least one local bone quality related complication. Local bone quality is determined by measuring bone mineral density and bone mineral content at the contralateral radius. Primary complications are categorised according to predefined factors directly related to the bone/fracture or the implant/surgical technique. Secondary outcomes include the documentation of soft tissue/wound or general/systemic complications, clinical assessment of range of motion, and patient-rated evaluations of upper limb function and quality of life using both objective and subjective measures.

Discussion

The prospective multicentre open cohort studies will determine the value of local bone quality as measured by bone mineral density and content, and compare the quality of local bone of patients who experience a complication (cases) following surgery with that of patients who do not (controls). These measurements are novel and objective alternatives to what is currently used.

Trial registration numbers

Clinical Trials.gov NCT01144208 and NCT01143675

Radial column and volar plating (RCVP) for distal radius fractures with a radial styloid component or severe comminution

Individual fracture patterns demand specific and adequate fixation. Locked volar plating has become popular in the operative fixation of distal radius fractures. However, in cases in which there is a radial styloid fragment or in cases of severe comminution, the amount of fixation from volar plating alone can be inadequate and may lead to loss of reduction. The use of locked radial column plates or Kirschner (K) wires provides additional radial column fixation and allows the surgeon to tailor the amount of fixation to the individual fracture pattern. Outlined here is the technique of combining volar plating with locked radial column plating or K-wire fixation, as well as a step-by-step outline to help achieve fracture reduction.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Complex fractures of the distal radius treated with angular stability plates

Complex fractures of the distal radius are articular lesions and comminuted at the level of the epiphysis and metaphysis. Their treatment is difficult and in most cases surgical. Of all the different osteosynthesis methods available, internal fixation with plate and screws is the most commonly used. In particular, angular stability plates are superior in terms of rigidity and stability to conventional volar and dorsal plates. DVR plate has these mechanical characteristics, and its low profile has reduced frictions with surrounding soft tissues. For these reasons, this device implanted through a single volar approach, can stabilize the majority of volarly and dorsally displaced unstable distal radius fractures. In this study, 48 patients, affected by complex fractures of the distal radius treated with DVR volar plates, were assessed by the Mayo modified wrist score, the Italian version of the disability of the arm, shoulder and hand. The satisfactory results observed confirm the efficacy of this device.

Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results

BACKGROUND

With an incidence of about 2-4 per 1,000 residents per year, the distal radial fracture is the most common fracture in the human skeleton. The introduction of fixed-angle plate systems for extension fractures at the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new system. The focus of our interest was whether a secondary loss of reduction can be avoided by this plating system.

METHODS

We reviewed 80 patients treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, a wrist splint used for 4 weeks and physiotherapy. Standard radiographic and clinical fracture parameters after 12 months (range 12-14 months) were measured and final functional results where assessed.

RESULTS

Bone healing had occurred in all patients at the time of follow-up after 1 year. On X-rays taken at the time of follow-up 60 patients (75%) had no radial shortening, 20 patients (25%) had a mean radial shortening of only 1.8 mm (range 1-3 mm) compared to the contralateral side. The radial tilt was on average 22 degrees (range 14 degrees-36 degrees); the volar tilt was on average 6 degrees (range 0 degrees-18 degrees). Comparing the first postoperative X-rays with those taken at final evaluation showed no measureable loss of reduction in the volar or radial tilt. Castaing's score, which includes the radiographic results, yielded a perfect outcome in 30 cases, a good outcome in 49 cases and an adequate outcome in one case. The range of motion was on average reduced by 21% during extension/flexion, by 11% during radial/ulnar deviation and by 7% in pronation and supination compared to the contralateral side. Grip strength was 65% that of the contralateral side. The mean DASH score was 25 points.

CONCLUSION

Fixed-angle plate osteosynthesis at the distal radius signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist. The technically simple palmar access, with a low rate of complications, allows exact anatomical reduction of the fracture. The multidirectional fixed-angle system we used provides solid support for the joint surface even in osteoporotic bone and allows simple subchondral placement of screws with sustained retention of the outcome of reduction. Secondary correction loss can be avoided by this procedure. Early mobilisation can be achieved and is recommended.

Operative treatment of distal radius fractures

The incidence of distal radius fractures is increasing together with the average age of population. Intra-articular incongruity is the most probable cause of unsatisfactory outcome of distal radius fractures in younger and more active patients. Thus, the main goal in the treatment of distal radius fractures should be restoration of articular congruence. A computed tomography (CT) is recommended to help surgeon in preoperative planning in the treatment of comminuted intra-articular fractures. New implants have been designed to provide stable enough fixation for early mobilisation after surgery and to lower rather high complication rates related to conventional fixation methods such as external fixation and dorsal plating. The most common complications related to volar fixed angle plating such as flexor and extensor tendon problems, median nerve neuropathy, and screw diplacement into the radiocarpal joint are surgeon related and are avoidable with proper education. More randomized prospective studies are needed to prove superiority of any fixation method to another.

A randomised clinical study comparing palmar and dorsal fixed-angle plates for the internal fixation of AO C-type fractures of the distal radius in the elderly

Current surgical treatments for distal radial fractures include dorsal and palmar plate fixation. We report results of a randomised study comparing these methods for AO C1-3 fractures. The emphasis was placed on the early postoperative functional recovery within the first 6 months as this interval is of decisive importance for elderly patients. Thirty patients with unilateral AO C1-3 fractures were enroled, 15 were treated with a palmar plate and 15 received a dorsal Pi-plate. Results were assessed 6 weeks, 3 months and 6 months postoperatively focusing on functional recovery. The palmar plate group demonstrated significantly better results in range of motion, grip strength and pain.

Acute vascular injury associated with fracture of the distal radius: a report of 6 cases

OBJECTIVES

To highlight the potential for vascular injury with fracture of the distal radius.

DESIGN

Retrospective case series.

SETTING

The practices of several orthopaedic hand surgeons.

PATIENTS/PARTICIPANTS

Six patients with arterial injury as a consequence of fracture of the distal radius: 2 partial lacerations of the radial artery, 2 complete arterial lacerations (1 radial and 1 ulnar), 1 thrombosed radial artery, and 1 thrombosed ulnar artery. There were 4 men and 2 women with an average age of 42 years (range 26-70 years). Three of the fractures were open, and 3 had an associated distal ulnar fracture.

INTERVENTION

Volar open reduction and internal fixation of the distal radius fracture. Ligation or no treatment for 3 arterial injuries and repair or vein graft reconstruction (1 patient) for 3 injuries.

MAIN OUTCOME MEASUREMENTS

Vascular status of the hand.

RESULTS

At an average follow-up of 9 months (range 5-16 months), all patients had a well-vascularized hand, normal capillary refill, and no complaints of vascular dysfunction.

CONCLUSIONS

Vascular complications, once thought rare in association with fracture of the distal radius, may be more frequently recognized as volar exposures are increasingly used. Because most single artery injuries in the wrist and forearm are not associated with ischemia, identification of these injuries is unlikely to affect the functional result or outcome. In the unusual patient with a dysvascular hand after distal radius fracture, arterial reconstruction may be necessary.

Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius

PURPOSE

To determine whether a volar radial (Henry) exposure to the distal radius is associated with less median nerve dysfunction than a direct volar exposure of the distal radius through the carpal tunnel that has been abandoned due to median nerve problems.

METHODS

Over an 18-month period, all patients with distal radius fractures treated with volar locking plate osteosynthesis were consecutively integrated into this therapeutic study. A direct volar midline approach ulnar to the flexor tendons and median nerve including prophylactic carpal tunnel release (CTR) was routinely performed from July 2003 to December 2004 (CTR group). Due to median nerve problems, this approach was abandoned and a distal part of the classical Henry approach (HRY) through the flexor carpi radialis (FCR) tendon sheath was performed for volar locking plate osteosynthesis in a second period from April 2005 to May 2006 (HRY group). In this group, the carpal tunnel was released only in selected cases. Data were collected prospectively for both groups. Analysis included clinical examination, the Patient-Rated Wrist Evaluation, and radiological follow-up up to 1 year after surgery.

RESULTS

Eighty-three patients entered the CTR group during the initial series. Thirty-one patients showed median nerve dysfunction 6 weeks after surgery. In the second period of observation, 91 patients entered the HRY group. The carpal tunnel was therapeutically decompressed in 18 patients, leaving the carpal tunnel untouched in 91 patients. Temporary median nerve paraesthesia was seen in 4 patients without CTR in the HRY group 6 weeks after surgery. After 1 year, persistent median nerve irritation was observed in 4 patients of the CTR group and none of the HRY group. Grip strength, range of motion, and Patient-Rated Wrist Evaluation were similar after 1 year.

CONCLUSIONS

The direct volar approach to the distal radius with routine CTR should be abandoned because it was associated with an increased rate of temporary and persistent median nerve irritation compared to the distal part of the classic Henry approach in our series.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Distal radius fractures: current concepts

Despite the frequency of distal radius fractures, studies in the existing literature have not been able to determine the optimal surgical strategies for various fracture patterns. Numerous clinical articles have been written, but most are level IV case series or expert opinion reviews. Good biomechanics studies have been published that suggest advantages of certain fixation methods over others. Transference of these expectations to clinical reality, however, requires well-controlled patient trials. In large part, this has not happened. This article reviews the theoretical pros and cons of different surgical strategies used for adult distal radius fractures, and then looks at randomized controlled trials that have been published in the last 5 years.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Immediate mobilisation following corrective osteotomy of distal radius malunions with cancellous graft and volar fixed angle plates

The purpose of the study was to examine the reliability with which a specific technique of corrective osteotomy of malunions of the distal radius combined with early mobilisation could both restore the normal anatomic parameters of the radius and achieve a functional range of motion with good strength. Corrective osteotomy of the distal radius was performed through a volar approach using a fixed angle volar plate and cancellous bone graft from the iliac crest in 19 patients of mean age 50 years with initial malunions with a mean dorsal tilt of 36 degrees and 7 mm of ulnar variance. An immediate mobilisation programme was started. All healed at a mean of less than 12 weeks (including two heavy smoking patients who required repeat cancellous bone grafting to achieve final union) to achieve a total arc of wrist motion around 120 degrees, forearm rotation of 158 degrees and grip strength which was 80% of contralateral. This treatment strategy was judged to be straightforward and effective.

Volar fixed-angle plating of the distal radius

The treatment of unstable distal radius fractures continues to improve as better methods of skeletal fixation and soft-tissue management are developed. Apart from closed reduction and percutaneous pinning of simpler fracture patterns, the three main methods of management are external fixation, dorsal plating, and volar fixed-angle plating. Specific advantages of volar fixed-angle plating include stable fixed-angle support that permits early active wrist rehabilitation, direct fracture reduction, and fewer soft-tissue and tendon problems. Volar fixed-angle plating also avoids the complications often associated with external fixation and dorsal plating. Biomechanical data indicate that, when loaded to failure, volar fixed-angle plates have significant strength advantages over dorsal plating. Volar fixed-angle plating is advantageous in elderly osteopenic patients and for high-energy comminuted fractures and malunions requiring osteotomy.

Volar fixed-angle fixation of distal radius fractures: the DVR plate

Volar fixed-angle fixation of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. The DVR plate is a new fixation implant that was introduced specifically for the purpose of managing both dorsal and volar displaced fractures from the volar aspect. Experience gained applying volar fixed-angle fixation to clinically complex cases led to the description of a new surgical approach and to refinement in design of the implant. The need to reduce fractures with significant articular displacement and the need to debride dorsal organized hematoma or callus in old fractures led to the development of an extended form of the flexor carpi radialis approach that provides improved dorsal exposure by mobilizing the proximal radius out of the way and allows the use of the fracture plane for intrafocal exposure. The use of this implant in severely osteoporotic bone and in those fractures presenting severe articular fragmentation or displacement led to the improvement of its design. The plate's ability to stabilize the distal radius was optimized by taking full advantage of the principles of subchondral support and buttress fixation.

The 45 degrees pronated oblique view for volar fixed-angle plating of distal radius fractures

Distinctive to volar fixed-angle plating of the distal radius, the optimal position of the distal fixed-angle support is in the subchondral bone immediately proximal to the articular surface. Standard intraoperative radiographic imaging of the distal radius during placement of a volar fixed-angle plate does not provide adequate visualization of the subchondral bone-distal support interface. A 45 degrees pronated oblique view is described to address this specific issue of whether volar hardware placed at the immediate subchondral bone level has effectively avoided the radiocarpal joint. This is a quite important radiographic consideration when pursuing the strategy of volar fixed-angle plating of distal radius fractures.