Four-Corner Concept: CT-Based Assessment of Fracture Patterns in Distal Radius

Operative treatment using plate fixation is an important adjunct in the treatment of distal radius fractures, although the evidence for its superiority over other modalities remains limited. We propose a new concept for fractures of the distal radius, based on the three-column model of the distal radius, and on the expanding knowledge about the different fracture patterns obtained by evaluation of the distal radius by computed tomographic (CT) scan. All fracture types can be characterized by subdividing the wrist joint into four corners, each with its own characteristics in terms of mobility, stability, and transfer of forces in the intact distal radius. Recognition of the specific fracture types based on this four-corner concept enables a tailored approach to treatment.

[Distal radius fractures: new concepts as basis for surgical treatment]

New advances in the biomechanics and pathomechanics of distal radius fractures as well as new generations of plates and improved surgical approaches now make possible the stable management and early functional rehabilitation not only of simple but also of complicated distal radius fractures according to the principles for articular and juxta-articular fractures. Especially for complex articular fractures, the fracture patterns are so heterogeneous that an individual surgical treatment strategy must be developed for each case. The preoperative clarification of articular fractures with computed tomography is particularly useful for planning surgery. Mental exposition with the three-column model and pathomechanics is an important prerequisite for understanding this type of injury and the appropriate choice of operative technique. A decisive factor for success is the subtle surgical procedure in approaching and handling the fine plates.

[Management of complex distal radius fractures]

Complex injuries of the distal radius can be associated with articular comminution, severe soft tissue injury, large metaphyseal and/or diaphyseal bone defects, carpal ligament tears or its combinations. We recommend a standardized three step approach for the management of these severe injuries: external fixation as an emergency procedure; treatment of soft tissue damage and further diagnostics as needed; definitive adapted operative therapy after thorough analysis of the specific injury.

[Dorsal double plating for fractures of the distal radius--a biomechanical concept and clinical experience]

This article describes the anatomical and biomechanical rationale for stable internal fixation of distal radius fractures using a dorsal approach. The three column biomechanical model is illustrated. Advances in the understanding of the anatomy, the biomechanical model of the three columns and our clinical experience with dorsal double plating have lead to the development of a new set of precontoured 2.4 mm Titanium plates with the option for head locking screws.

Neue Prinzipien der operativen Behandlung von distalen Radiusfrakturen – winkelstabile Implantate

Das Ziel der Behandlung von distalen Radiusfrakturen ist die vollständige Wiederherstellung der Funktion des Handgelenks. Voraussetzungen dazu sind die Wiederherstellung der Anatomie und die frühfunktionelle Nachbehandlung entsprechend den Behandlungsgrundsätzen anderer artikulärer und juxtaartikulärer Frakturen. Ein besseres Verständnis der anatomischen Gegebenheiten und neue biomechanische Modelle haben zur Entwicklung neuer Implantate und Operationstechniken geführt. Das LCP-Konzept mit winkelstabil verankerten Plattenschrauben hat auch in der osteosynthetischen Versorgung der distalen Radiusfraktur wesentliche Fortschritte gebracht.

Neue Stabilisierungskonzepte bei proximalen Humerusfrakturen

Bessere Bildgebung, neuere Erkenntnisse über die Perfusionsverhältnisse am proximalen Humerus und entsprechend adaptierte Osteosynthesetechnik sowie Implantate mit sicherer Verankerung auch im osteoporotischen Knochen bedeuten einen Fortschritt bei der Behandlung proximaler Humerusfrakturen. Die Probleme der Kopfnekrose, des Implantatversagens im osteoporotischen Knochen und die mäßigen funktionellen Resultate sollten dadurch günstig beeinflusst werden. Adäquate Bildgebung, gelegentlich ergänzt durch Schnittbildverfahren, sind Voraussetzung für die Wahl eines dem Patienten und dem Frakturmuster adaptierten Verfahrens. Sie erlaubt eine zuverlässige präoperative Planung. Das angewandte Stabilisierungsprinzip ist Ausdruck chirurgischer Präferenz. Es erfordert aber unterschiedliche Nachbehandlungsmodalitäten. Letztere sollten in Zusammenarbeit mit dem Operateur anhand klinischer und standardisierter radiologischer Kontrollen nach drei respektive sechs und zwölf Wochen dem Heilungsverlauf entsprechend adaptiert werden.

Fractures of the distal radius treated by internal fixation and early function

Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50° to 70° apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients.

Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one.

Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients

Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50 degrees to 70 degrees apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients. Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one. Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study

Three different plating techniques were used on experimentally produced dorsally displaced distal radius fractures in cadavers and were tested in 4-point bending: a AO 3.5-mm T plate (group 1), two 2. 0-mm titanium plates 60 degrees to each other (group 2), and the AO pi plate (group 3). A metaphyseal defect was simulated by a dorsally open wedge osteotomy. The tests show that the 2-mm double-plating technique has superior stiffness and statistically equivalent bending and bone gap to failure compared with the AO 3.5-mm T plate or the pi plate when applied to the unstable distal radius fracture model. (J Hand Surg 2000; 25A:29-33.

A new ultrasound-based method for the assessment of torsional differences following closed intramedullary nailing of femoral fractures

OBJECTIVE

A torsional difference of more than 15 degrees is found in up to 30% of patients following closed intramedullary nailing of femoral fractures. The diagnosis is usually established postoperatively by computed tomography. A torsional deformity of more than 15 degrees should be corrected by early derotation. In order to enable an intraoperative control and possible correction to avoid a second operation for the patient, a new ultrasound-based method suitable for the intraoperative setting has been developed, using the anterior condylar line as a distal reference line.

DESIGN AND PATIENTS

In a prospective study the torsional difference after closed intramedullary nailing of femoral fractures was measured postoperatively by ultrasound in 32 patients and compared with standard CT readings.

RESULTS

Torsional differences measured by ultrasound and CT showed a high correlation (r = 0.8) and a median difference of less than +/-3 degrees.

CONCLUSIONS

By the introduction of the anterior condylar line as a distal reference line femoral torsion can accurately be assessed by ultrasound in a position required for intraoperative control and possible correction.

Long-term results of the external fixation of distal radius fractures

OBJECTIVE

To evaluate the long-term results of external fixation of distal radius fractures.

METHODS

A retrospective follow-up study (median follow-up, 5.3 years) of 49 patients with 50 distal radius fractures treated with an external fixator was carried out. An external fixator (Minifixator, Stratec Medical, Waldenburg, Switzerland) was used. The operative procedure is described in detail. A personal evaluation including clinical and radiologic assessment of both wrists was performed.

RESULTS

The functional results, including the parameters strength, daily activities, range of motion, and presence of pain, as well as an anatomic score, the presence of osteoarthritis, the quality of reduction, and complications were recorded. Functional and anatomic results indicated excellent to good ratings in more than 80% of the cases.

CONCLUSION

The external fixator is a versatile tool in the treatment of intra-articular and extra-articular fractures of the distal radius. The rate of algodystrophy (reflex sympathetic dystrophy) was 6%, and wrist stiffness was not found in our series.

FRACTURES OF THE DISTAL END OF THE RADIUS TREATED BY INTERNAL FIXATION AND EARLY FUNCTION

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency.

Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the ‘lateral’ and the ‘intermediate’ columns of the wrist at an angle of 50° to 70°. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all.

Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency. Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the 'lateral' and the 'intermediate' columns of the wrist at an angle of 50 degrees to 70 degrees. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all.