Characteristics of two different locking compression plates in the volar fixation of complex articular distal radius fractures

Objectives

To investigate the differences of open reduction and internal fixation (ORIF) of complex AO Type C distal radius fractures between two different models of a single implant type.

Methods

A total of 136 patients who received either a 2.4 mm (n = 61) or 3.5 mm (n = 75) distal radius locking compression plate (LCP DR) using a volar approach were followed over two years. The main outcome measurements included motion, grip strength, pain, and the scores of Gartland and Werley, the Short-Form 36 (SF-36) and the Disabilities of the Arm, Shoulder, and Hand (DASH). Differences between the treatment groups were evaluated using regression analysis and the likelihood ratio test with significance based on the Bonferroni corrected p-value of < 0.003.

Results

The groups were similar with respect to baseline and injury characteristics as well as general surgical details. The risk of experiencing a complication after ORIF with a LCP DR 2.4 mm was 18% (n = 11) compared with 11% (n = 8) after receiving a LCP DR 3.5 mm (p = 0.45). Wrist function was also similar between the cohorts based on the mean ranges of movement (all p > 0.052) and grip strength measurements relative to the contralateral healthy side (p = 0.583). In addition, DASH and SF-36 component scores as well as pain were not significantly different between the treatment groups throughout the two-year period (all p ≥ 0.005). No patient from either treatment group had a step-off > 2 mm.

Conclusions

Differences in plate design do not influence the overall final outcome of fracture fixation using LCP.

A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness

BACKGROUND

Both dynamic and static progressive (turnbuckle) splints are used to help stretch a contracted elbow capsule to regain motion after elbow trauma. There are advocates of each method, but no comparative data. This prospective randomized controlled trial tested the null hypothesis that there is no difference in improvement of motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores between static progressive and dynamic splinting.

METHODS

Sixty-six patients with posttraumatic elbow stiffness were enrolled in a prospective randomized trial: thirty-five in the static progressive and thirty-one in the dynamic cohort. Elbow function was measured at enrollment and at three, six, and twelve months later. Patients completed the DASH questionnaire at enrollment and at the six and twelve-month evaluation. Three patients asked to be switched to static progressive splinting. The analysis was done according to intention-to-treat principles and with use of mean imputation for missing data.

RESULTS

There were no significant differences in flexion arc at any time point. Improvement in the arc of flexion (dynamic versus static) averaged 29° versus 28° at three months (p = 0.87), 40° versus 39° at six months (p = 0.72), and 47° versus 49° at twelve months after splinting was initiated (p = 0.71). The average DASH score (dynamic versus static) was 50 versus 45 points at enrollment (p = 0.52), 32 versus 25 points at six months (p < 0.05), and 28 versus 26 points at twelve months after enrollment (p = 0.61).

CONCLUSIONS

Posttraumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six to twelve months, and patience is warranted. There were no significant differences in improvement in motion between static progressive and dynamic splinting protocols, and the choice of splinting method can be determined by the patients and their physicians.

Fixation of osteoporotic fractures in the upper limb with a locking compression plate

Locking Compression Plate (LCP) has the advantageous feature that screws can be locked in the plate leaving an angular stable construct. There is no need to have contact between the plate and the bone to achieve stability resulting from friction of the plate-bone-construct. Therefore the plate does not need to be contoured exactly to the bone and the healing bone's periosteal blood supply is not affected. The LCP is used as a bridging plate to gain relative stability in multi-fragmentary, diaphyseal or metaphyseal fractures. Depending on the fracture, the combination hole can also allow the LCP to achieve absolute stability similar to conventional fixation techniques. Osteoporotic fractures have significant impact on morbidity and mortality. Proximal humeral and distal radius fractures are typical examples. These osteoporotic and often comminuted fractures are ideal settings/indications for LCP utilization in the upper extremity. However, the data quality is due to mostly small study populations not so powerful. Unquestionably there has been a clear and fashionable trend to choose operative treatment for these fractures, because the angular stability allows stable fixation and early functional mobilization.

Current concepts review - fractures in the region of the elbow

Elbow injuries continue to rise with increased athletic activity and life expectancy. Knowledge of anatomy and biomechanics of this sophisticated joint, various injury patterns, and the implication of injury to the static and dynamic stabilizers will result in improvement in specific diagnosis, and therapy. The surgical treatment of trauma to the adult elbow has evolved rapidly in recent years and many useful concepts and techniques have been established. This paper reviews the published scientific data and current opinion available to guide patient care.

Osseous and ligamentous scaphoid anatomy: Part I. A systematic literature review highlighting controversies

PURPOSE

The interpretation of scaphoid anatomy and kinematics is confusing and controversial. This results from a lack of consensus on the anatomy of the ligaments attaching to the scaphoid and an overwhelming variety of substantially different anatomic descriptions and classification systems of the wrist joint in the literature. The present study systemically reviews the consistencies or inconsistencies of the various scaphoid ligament descriptions and aims to clarify and unify different concepts and classification systems.

METHODS

We performed a systematic search of the medical literature from 1950 to 2010. We included all descriptive reports of the anatomy or morphology of the scaphoid, ligaments, or both. With the aim to describe the best available evidence, we considered all anatomical descriptions but emphasized a selection of the most frequently cited articles.

RESULTS

The literature search resulted in 555 potentially eligible descriptive reports, 58 of which met the inclusion criteria and were included in the review. Variations in the anatomic descriptions appear to be mostly due to the difficulty of identifying individual interdigitating ligaments or bundles by macroscopic dissections, as well as the interindividual variability in ligament anatomy. The most important areas of controversy in the scaphoid ligament attachments include the radial collateral ligament, dorsal radiocarpal ligament, dorsal intercarpal ligament, volar scaphotriquetral ligament, and scaphotrapezium-trapezoid ligament.

CONCLUSIONS

None of the scaphoid ligaments other than the scaphocapitate ligament have been described consistently. Future research is required to verify the ligament attachments that currently have the most controversial descriptions, while addressing the interindividual variability of ligament insertions and morphology.

CLINICAL RELEVANCE

Thorough knowledge of the anatomy will enhance our understanding of the kinematics of the scaphoid.

Operative Treatment of Elbow Stiffness

Introduction

Open elbow contracture release is the mainstay for the operative treatment of posttraumatic elbow stiffness.

Step 1 Skin Incision

Use either a posterior skin incision and raise medial and lateral skin flaps or use more direct individual medial and lateral skin incisions.

Step 2 Protect or Release Peripheral Nerves

Release the ulnar nerve using a small incision and in situ release when a lateral muscle interval (between the extensor carpi radialis brevis and extensor digitorum communis muscles) is preferred for the contracture release; use a larger incision with subcutaneous anterior transposition when a medial muscle interval (50:50 split of the flexor pronator mass) is used.

Step 3 Develop Muscle Intervals for Exposure of the Joint

Choose a lateral (extensor carpi radialis brevis/extensor digitorum communis) or medial (50:50 split of the flexor pronator mass) muscle interval to expose the elbow capsule.

Step 4 Resect Bone Contracted Capsule and Implants Restricting Motion

Remove the structures that hinder motion: implants, heterotopic bone, and contracted capsule.

Step 5 Tenolysis/Muscle Elevation

When the triceps and the brachialis muscles are adherent to the distal third of the humerus, release them using an elevator.

Step 6 Manipulate Elbow Consider Implant Removal

Take care not to push so hard that you fracture the bone at a stress riser created by removal of bone or implants.

Step 7 Wound Closure

Close the muscle intervals and skin.

Step 8 Postoperative Management

The key after surgery is frequent, active, patient-assisted elbow flexion, extension, and forearm rotation stretches.

Results

A case series of patients with elbow contracture release documented an average improvement in the arc of elbow flexion of between 21° and 66°.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

Background

With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.

Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.

Discussion

The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.

In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.

Summary

It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.

The role of stem cells in fracture healing and nonunion

Nonunion and large bone defects present a therapeutic challenge to the surgeon and are often associated with significant morbidity. These defects are expensive to both the health care system and society. However, several surgical procedures have been developed to maximise patient satisfaction and minimise health-care-associated and socioeconomic costs. Integrating recent evidence into the diamond concept leads to one simple conclusion that not only provides us with answers to the "open questions" but also simplifies our entire understanding of bone healing. It has been shown that a combination of neo-osteogenesis and neovascularisation will restore tissue deficits, and that the optimal approach includes a biomaterial scaffold, cell biology techniques, a growth factor and optimisation of the mechanical environment. Further prospective, controlled, randomised clinical studies will determine the effectiveness and economic benefits of treatment with mesenchymal stem cells, not in comparison to other conventional surgical approaches but in direct conjunction with them.

Nonunion of operatively treated capitellum and trochlear fractures

PURPOSE

To test the hypothesis that comminuted fractures of the capitellum and trochlea with posterior comminution (Dubberley type 3B) have a greater risk of nonunion than other types of capitellum and trochlea fractures.

METHODS

We observed 30 patients with operatively treated fractures of the capitellum and trochlea for an average of 34 months (range, 12-75 mo). We compared 18 fractures with comminution of the capitellum and trochlea and posterior comminution (type 3B according to Dubberley and colleagues) with 12 fractures consisting of single large anterior fracture fragments with (6 patients; Dubberley type 2B) or without (6 patients; Dubberley type 2A) posterior comminution.

RESULTS

Of 18 patients, 8 with type 3B fractures were noted to have nonunion. No patients with type 2 fractures had a nonunion.

CONCLUSIONS

Fractures of the capitellum and trochlea are prone to nonunion when they create multiple articular fragments and there is posterior comminution (Dubberley type 3B).

Comparison of angle stable plate fixation approaches for distal radius fractures

INTRODUCTION

The aim of the study was to compare radiological and functional outcomes between volar and dorsal surgical fixation of distal radius fractures using low-profile, fixed-angle implants.

PATIENTS AND METHODS

A total of 305 distal radius fracture patients were treated with Synthes locking compression plate (LCP) 2.4- or 3.5-mm fixation using either a volar (n=266) or dorsal (n=39) approach. The patients were examined at 6 months, 1 and 2 years for radiological assessment of fracture healing, alignment, reduction and arthritis, as well as the determination of various functional outcome scores.

RESULTS

Both groups were comparable with respect to baseline and injury characteristics. The complication rate was higher for the volar approach (15%). No significant differences were observed for Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form (36) Health Survey (SF-36) scores, pain, arthritis grade, grip strength and radiological measurements. However, a significantly better functional outcome represented by a low mean Gartland and Werley score was observed for the volar approach after 6 and 12 months. Significantly higher percentages of dorsal extension, palmar flexion, ulnar deviation and supination angle (relative to the mean contralateral healthy wrist) were also reported for volar approach patients at the 6-month follow-up.

CONCLUSIONS

Volar internal fixation of distal radius fractures with LCP DR implants can result in earlier and better functional outcome compared with the dorsal approach, yet is associated with a higher incidence of complications. After 2 years, these differences are no longer observed between the two surgical methods.

Successful reconstruction for complex malunions and nonunions of the tibia and femur

BACKGROUND

Information regarding the long-term outcomes of the treatment of lower-extremity fracture malunion and nonunion is lacking.

METHODS

Twenty-nine secondarily referred patients with complex malunion or nonunion of the tibia or femur, treated by a single surgeon, were followed for a median of twenty years (range, twelve to thirty-five years) after injury. The patients were referred at a median of twenty months (range, 1.5 to 360 months) postinjury and had undergone a median of three prior surgical procedures (range, zero to twenty-eight). At the time of final follow-up, patient-based outcomes, patient satisfaction, and pain were evaluated.

RESULTS

All twenty-nine patients had healing following treatment of the complex malunion or nonunion of the tibia or femur and were able to bear full weight and walk one block or more. The Lower Extremity Functional Scale (LEFS) outcome tool revealed that twenty patients (69%) experienced moderate-to-severe difficulties in carrying out activities because of their lower-limb disability. The median Short Form-36 (SF-36) score was 67, with a median physical component score of 61 and a median mental component score of 71, indicating substantial impact on physical health status when compared with the norm.

CONCLUSIONS

Reconstruction can be a worthwhile endeavor and should be considered for all patients with complex malunion or nonunion of the tibia or femur.

Current concepts review: carpal injuries - fractures, ligaments, dislocations

An overview about current concepts in treating carpal injuries is presented. These injuries are more commonly seen in young, active individuals after a fall on an outstretched hand. Conventional radiographs and a thorough examination are important. The scaphoid is the most affected bone. Scaphoid fractures can be classified in accordance to OTA, AO, and other classification systems, but mostly to Herbert. It can be treated non-operatively if undisplaced, however a percutaneous internal fixation can be discussed to achieve earlier return to work and shorter time to union, but hazarding the consequences of an operation. Unstable, proximal pole, or delayed diagnosed scaphoid fractures should be treated surgically. Nonunion is seen in 5 - 40% of scaphoid fractures depending mainly on displacement and localization of the fracture. The gold standard in non-osteoarthritic scaphoid nonunion is debridement of the nonunion site, bone grafting, realignment, stable fixation and rehabilitation. The treatment of scaphoid-nonunion advanced collapse is more complex. Proximal row carpectomy or arthrodesis (four-corner or complete wrist) can be mandatory. Other carpal bone fractures are rare. Perilunate dislocations are also uncommon but can be disabling. They usually originate in high-energy trauma. The Mayfield stages help to understand the injury pattern. Open reduction through both volar and dorsal approaches, repair of the volar capsule as well as volar and dorsal ligaments, and internal fixation is commonly the standard treatment. However osteoarthritis and carpal instability are often encountered.

Traumatic laceration of the long head of the biceps brachii from a displaced surgical neck fracture of the humerus: case report

This case report identifies a traumatic laceration of the long head of the biceps brachii associated with a displaced surgical neck fracture of the humerus in a 37-year-old woman who sustained a fall while skiing. At the time of surgery, the tendon was found sharply divided and repaired primarily. The fracture was fixed with a proximal humeral blade plate. Followup revealed nearly full glenohumeral motion and a functional biceps muscle by 4 months.

Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: a randomized controlled trial

Background

Malunion is the most common complication of distal radius fracture. It has previously been demonstrated that there is a correlation between the quality of anatomical correction and overall wrist function. However, surgical correction can be difficult because of the often complex anatomy associated with this condition. Computer assisted surgical planning, combined with patient-specific surgical guides, has the potential to improve pre-operative understanding of patient anatomy as well as intra-operative accuracy. For patients with malunion of the distal radius fracture, this technology could significantly improve clinical outcomes that largely depend on the quality of restoration of normal anatomy. Therefore, the objective of this study is to compare patient outcomes after corrective osteotomy for distal radius malunion with and without preoperative computer-assisted planning and peri-operative patient-specific surgical guides.

Methods/Design

This study is a multi-center randomized controlled trial of conventional planning versus computer-assisted planning for surgical correction of distal radius malunion. Adult patients with extra-articular malunion of the distal radius will be invited to enroll in our study. After providing informed consent, subjects will be randomized to two groups: one group will receive corrective surgery with conventional preoperative planning, while the other will receive corrective surgery with computer-assisted pre-operative planning and peri-operative patient specific surgical guides. In the computer-assisted planning group, a CT scan of the affected forearm as well as the normal, contralateral forearm will be obtained. The images will be used to construct a 3D anatomical model of the defect and patient-specific surgical guides will be manufactured. Outcome will be measured by DASH and PRWE scores, grip strength, radiographic measurements, and patient satisfaction at 3, 6, and 12 months postoperatively.

Discussion

Computer-assisted surgical planning, combined with patient-specific surgical guides, is a powerful new technology that has the potential to improve the accuracy and consistency of orthopaedic surgery. To date, the role of this technology in upper extremity surgery has not been adequately investigated, and it is unclear whether its use provides any significant clinical benefit over traditional preoperative imaging protocols. Our study will represent the first randomized controlled trial investigating the use of computer assisted surgery in corrective osteotomy for distal radius malunions.

Trial registration

NCT01193010

Stable fixation of osteoporotic fractures and nonunions in the upper limb - life before the "locking plate"

I have had a wonderful opportunity over the past 30 years to surgically reconstruct many complex fractures and non- unions in the upper limb in the elderly patient with underlying osteoporosis and prior to the development of the "locked plate". This article will present a number of specific techniques using standard LC-DCP and screw in a variety of applications to provide stable internal fixation. These include the use of long plates; creating a "waved plate" initially described by Blatter and Weber; double plating; 3.5 mm intramedullary plate combined with a larger plate on the cortex; custom and machi- ned blade plates as well as enhancement of screw fixation with bone cement and/ or Norian SRS cement.

Health status after open elbow contracture release

BACKGROUND

Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability.

METHODS

Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness.

RESULTS

One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score).

CONCLUSIONS

Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.

Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction

PURPOSE

This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension.

METHODS

Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system.

RESULTS

An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95 degrees in the ankylosis cohort and 93 degrees in the partial HO cohort. Forearm rotation averaged 131 degrees versus 134 degrees ; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively.

CONCLUSIONS

After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Predictors of pain intensity and disability after minor hand surgery

PURPOSE

To test the null hypothesis that there is no relationship between coping mechanisms and depression measured before surgery, and pain intensity and disability after surgery, as assessed at the time of suture removal.

METHODS

A total of 120 patients (39 electing surgery for carpal tunnel syndrome, 65 for trigger finger, and 16 for a benign tumor) completed questionnaires measuring depression, pain self-efficacy (confidence that one can perform various activities despite pain), pain anxiety (fear and anxiety in response to pain sensations), and pain catastrophizing (maladaptive cognitive activities such as pain-related rumination, magnification, and helplessness) before surgery. Before the surgery and at the time of suture removal (10 to 14 days after surgery) participants completed the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and a numerical pain intensity rating scale.

RESULTS

At the time of suture removal, there was a significant correlation between pain intensity and depression (r = 0.45, p<.001), pain catastrophizing (r = 0.41, p<.001), pain anxiety (r = 0.32, p<.01), and self-efficacy (r = -0.29, p<.01). Disability correlated with self-efficacy (r = -0.34; p<.001) and depression (r = 0.49; p<.001), but not with pain anxiety and catastrophizing (p>.05). In multivariate analyses, depression was the sole predictor of both disability and pain intensity and accounted for 26% of the variance in DASH scores and 25% of the variance in pain intensity, after removing the influence of preoperative DASH and diagnosis, which accounted for 14% variance.

CONCLUSIONS

Psychosocial factors, especially depression, explain a notable proportion of the variation in pain intensity and disability after minor hand surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Pain and swelling after radiofrequency treatment of proximal phalanx osteoid osteoma: case report

Bony tumors in the hand and wrist are uncommon conditions. The objective of this article was to describe an impressive soft-tissue reaction with pain after radiofrequency ablation was used to treat a proximal phalangeal osteoid osteoma in the hand. We feel radiofrequency ablation should be cautiously used in the treatment of these lesions out of concern for similar complications.

Long-term outcomes of corrective osteotomy for the treatment of distal radius malunion

Corrective osteotomy is an established but challenging treatment for distal radius malunion. Short- and intermediate-term results have been previously published while long-term results have not. The long-term results of 22 patients treated with corrective osteotomy for symptomatic distal radius malunion are presented (range 6-24 years, mean 13 years). All patients completed the DASH questionnaire and the modified Gartland and Werley, and Green and O'Brien scores postoperatively. Wrist alignment was assessed through standard wrist radiographs. Average wrist flexion-extension was 72.5% of the contralateral limb. Grip strength averaged 71%. The DASH score averaged 16 points corresponding to mild perceived disability. Results were categorized as fair on both the Gartland and Werley score (average 9 points) and the modified Green and O'Brien score (average 67 points). Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. The outcome presented may be a reflection of the use of stricter evaluation instruments or reflect the development of post-traumatic arthritis.

Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique

BACKGROUND

In the past decade, there has been a trend toward open reduction and internal fixation of unstable distal radial fractures. There are now more than thirty different implant designs specific for the fixation of distal radial fractures. A multicenter prospective study of a case series was conducted to determine the efficacy of the operative management of distal radial fractures stabilized with 2.4-mm locking plates.

METHODS

One hundred and fifty patients were entered into the study over a two-year period. The mean age of these patients was fifty-one years, and the cohort included eighty-eight women and sixty-two men. Eighty-six patients sustained a low-energy injury. Seventy-one percent of the fractures in the series were intra-articular and were Type C according to the Müller-AO Comprehensive Classification. The follow-up evaluations, which were conducted at six weeks, six months, one year, and two years, included assessments of pain, motion, grip strength, and standard radiographs. Gartland and Werley scores were recorded at six months and one and two years, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded at one and two years.

RESULTS

One hundred and twenty-five patients (83%) had a complete follow-up at six months; 121 (81%), at one year; and 117 (78%), at two years. Significant improvements in motion, grip strength, and patient satisfaction were observed between six months and one year, but further improvements were not seen at the two-year follow-up examination. The mean DASH score changed from a preinjury baseline of 2 points to 8 points at one year and 7 points at two years (p < 0.0001). The mean Gartland and Werley score improved significantly from 4 points at six months to 2 points at two years. Of the 102 intra-articular fractures examined in the immediate postoperative period, twenty had a step-off of <or=2 mm and seven had a step-off of >2 mm. Of the seventy-one intra-articular fractures seen at two years, sixty-one had no step-off, five had a step-off of <or=2 mm, and five had a step-off of >2 mm. Twenty-seven percent of the patients showed an increase of at least one grade in radiographic signs of arthritis at two years. There were twenty-eight complications, twenty of which were considered minor. Tendon inflammation occurred in nine patients. There were two tendon ruptures, one of which was due to a prominent dorsal screw tip placed through a volar plate and one of which was due to a prominent volar plate. Loss of reduction occurred in two patients, and screw loosening occurred in two patients.

CONCLUSIONS

Internal fixation of displaced distal radial fractures with implants featuring locking screw fixation can result in good-to-excellent outcomes with a limited number of complications.

A novel non-bridging external fixator construct versus volar angular stable plating for the fixation of intra-articular fractures of the distal radius--a biomechanical study

Non-bridging external fixation has recently been introduced as an alternative to volar angular stable plating for the fixation of unstable intra-articular distal radial fractures. The purpose of this study was to biomechanically compare a new non-bridging external fixator construct to volar angular stable plate fixation in a dorsally comminuted intra-articular fracture model of the distal radius.

MATERIALS AND METHODS

Five pairs of fresh frozen human cadaveric radii were randomly supplied with either a non-bridging external fixator or a stainless steel volar locking plate. A three-fragmental AO 23-C2.1 fracture was created by removing a 15 degrees dorsal wedge with remaining volar cortical contact and by an intra-articular osteotomy lateral to the lister-tubercle. Physiological load transfer via the wrist was simulated by means of a custom-made seesaw. For biomechanical testing, the bones were loaded in cyclic axial compression. Starting at 100N, the load was monotonically increased at 0.025 degrees N per cycle until failure of the construct. Motion of the lunate and scaphoid fragments with respect to the radial diaphysis was acquired by optical three-dimensional (3D) motion tracking. Plastic wedge deformation was determined after 2000, 4000 and 6000 cycles.

RESULTS

The amplitude of wedge motion at the beginning of the test as a measure for construct stiffness was significantly lower for the fixator group (P=0.003, power=0.99). Plastic wedge deformation after 2000, 4000 and 6000 cycles was found significantly lower for the external fixator (repeated measures analysis of variance (ANOVA), P=0.009, power=0.86). Displacement of the intra-articular gap was found below 0.6mm (mean) for both groups (P>0.05).

CONCLUSION

The study revealed superior biomechanical properties of the proposed non-bridging external fixation compared to volar locked plating in an unstable intra-articular fracture model with volar cortical support. However, both fixation techniques seem to apply sufficient stabilisation to restore and retain anatomy after fracture of the most distal part of the radius and should be individually chosen according to distinct criteria.