Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report

The influence of surgeon age on distal radius fracture treatment in the United States: a population-based study

PURPOSE

This study attempted to determine the extent to which surgeon age influences treatment patterns for distal radius fractures (DRFs). We hypothesized that younger surgeons perform open reduction internal fixation (ORIF) for DRFs among elderly individuals more frequently than older surgeons, who employ a wider range of treatment modalities.

METHODS

We identified 61,314 Medicare beneficiaries who experienced DRFs and the 12,823 surgeons who performed ORIF, external fixation, pinning, or closed reduction on them during 2007. We examined the effect of surgeon age on DRF treatment pattern, controlling for patient characteristics and other surgeon factors using multinomial logistic regression. We then stratified our analysis by American Society for Surgery of the Hand membership to more closely examine the influence of surgeon specialization on the association between surgeon age and DRF treatment.

RESULTS

Surgeons aged 40 years and younger were more likely to perform ORIF and less likely to choose external fixation and percutaneous pinning to treat DRFs, compared with older surgeons. Surgeon specialization mitigated this relationship, and American Society for Surgery of the Hand members were more likely to choose ORIF compared with nonmembers. However, surgeon age remained a significant predictor of treatment choice after controlling for other factors and surgeon specialization.

CONCLUSIONS

Younger surgeons are more likely to perform ORIF for DRFs among Medicare beneficiaries over 65 years of age. Given the lack of evidence supporting any single treatment option for DRF, understanding the factors that drive dissemination of operative techniques may provide insight into treatment disparities within the Medicare population.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Polyaxial versus uniaxial volar locking plate for distal radial fractures

PURPOSE

To compare the penetration of the distal screws in relation to the thickness of the distal metaphysis in the polyaxial versus uniaxial volar locking plates.

METHODS

Records of 78 patients aged 16 to 79 years who underwent open reduction and internal fixation for distal radial fractures (n=81) were reviewed. All fracture subtypes were included. 20 men and 22 women aged 18 to 79 (mean, 50) years were treated with the uniaxial locking plate, whereas 15 men and 21 women aged 16 to 79 (mean, 51) years were treated with the polyaxial locking plate. The choice of plate was determined by the operating surgeon based on familiarity and perceived advantages of the 2 plates. Penetration of the distal locking screws in relation to the volar-dorsal thickness of the distal radial metaphysis was measured, and the percentage of subchondral bone unsupported by the screws calculated.

RESULTS

The mean percentage of unsupported subchondral bone was significantly lower in the polyaxial than uniaxial volar locking plate group (12% vs. 23%, p<0.001). No patient had screw over-penetration.

CONCLUSION

The polyaxial volar locking plate system enabled deeper insertion of distal screws into the subchondral bone, and thus providing better buttress for the fracture fragments.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention

STUDY DESIGN

Descriptive cross-sectional design.

INTRODUCTION

Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research.

PURPOSE OF THE STUDY

The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF.

METHODS

Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status.

RESULTS

Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable.

CONCLUSIONS

Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients.

LEVEL OF EVIDENCE

2c.

Complications after volar locking plate fixation of distal radius fractures

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate fixation in a busy teaching hospital. The purpose of the study was to assess whether complication rates after volar locking plate use in general, routine trauma practice were higher than published literature from expert users. A retrospective review was carried out of patients treated with a volar locking plate between January 2009 and December 2010. The series included 206 procedures in 204 patients (77 males and 127 females) with mean age of 55 years (range 16-94). Surgery was performed by 18 different consultant surgeons and 11 registrars. A total of 22 complications were observed in 20 patients with an overall complication rate of 9.7%. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Four (1.9%) patients required re-operation for metalwork problems; four patients developed complex regional pain syndrome (CRPS). Three fracture reduction problems were noted. A total of 16 further operations were carried out for complications. The overall complication rate was low even when surgery was done by many surgeons, suggesting that this is a safe and reproducible technique. This study provides information which can be used to counsel patients about risks, including those of tendon and metalwork problems. This allows patients to make an informed decision. Surgeons must have specific strategies to avoid these complications and remain vigilant so that these can be identified and managed early.

Comparison of palmar fixed-angle plate fixation with K-wire fixation of distal radius fractures (AO A2, A3, C1) in elderly patients

The objective of this prospective, randomized, controlled trial was to compare the results of two operative techniques used for the treatment of unstable distal radius fractures in elderly patients classified as AO types A2, A3, and C1. Patients were treated with either fixed-angle volar plates or K-wires using a combined Kapandji and Willenegger technique. The functional results were determined after 3, 6, and 12 months. We included 40 patients aged over 65 years. Twenty-one patients were treated with plate fixation and 19 with K-wire fixation. The functional results, after 1 year, were nearly the same in both treatment groups, suggesting that either method is suitable for the treatment of unstable distal radius fractures of AO types A2, A3, and C1 in elderly patients. Sixteen of 21 patients with plate fixation and 17 of 19 patients with K-wire fixation present good results as assessed by the Castaing score. The median DASH score was three in both groups after 1 year. The patients with plate fixation were able to resume activities of daily living 4 weeks earlier. The most common complication was an intermediate post-traumatic median nerve irritation. Both methods are suitable for the treatment of elderly patients with unstable distal radius fractures of AO types A2, A3, and C1. If early functional post-operative care is important, palmar fixed-angle plate fixation is an ideal treatment approach. Otherwise, K-wire fixation is an effective, minimally invasive method with comparable clinical results.

Biomechanical comparison of volar locked plate constructs using smooth and threaded locking pegs

The goal of this study was to determine whether there is any biomechanical difference in terms of construct strength with axial loading between volar fixed-angle locking plates with threaded locking vs smooth locking pegs. The control group comprised 7 cadaveric specimens with threaded locking pegs, and the test group comprised 7 cadaveric specimens from the same donor with smooth locking pegs. The DVR plate (Biomet, Warsaw, Indiana) was applied to the volar surface. A 15-mm dorsal wedge osteotomy was created near the level of Lister's tubercle. The radii were potted in polymethylmethacrylate for biomechanical testing. The loading protocol consisted of 3 parts: ramp loading, cyclic loading, and failure loading. The outcome measures of stiffness and failure were used to test the plates fixed with threaded and smooth locking pegs. When comparing each cycle, the difference in mean stiffness between threaded and smooth locking pegs was as follows: 122 N/mm, -9.09 N/mm, -14.7 N/mm, 49.4 N/mm, 57.4 N/mm, 71.9 N/mm, 52.3 N/mm, 35.8 N/mm. The difference in mean failure load between the threaded and smooth locking pegs was -11.3 N. There was no difference in stiffness throughout all cycles. Failure analysis showed no significant difference between the smooth (962 N) and threaded (951 N) locking pegs. The difference in stiffness between the 2 constructs (smooth minus threaded locking pegs) in ramp loading ranged from -122 to 15 N/mm. The results of this study showed no significant differences in stiffness and failure load between constructs consisting of threaded locking pegs or smooth locking pegs in the distal rows of the DVR distal radius volar locking plate. Based on the results of this study, there may be no benefit to using threaded locking pegs vs smooth locking pegs when treating distal radius fractures with a volar locking plate.

Fixation of distal ulna fractures associated with distal radius fractures using intrafocal pin plate

Background Unstable distal ulna fractures in the setting of distal radius fractures can present a challenging problem, especially in the elderly population. Operative fixation of the subcapital distal ulna fracture may help to provide a stable ulnar buttress for attempting to reduce the distal radius fracture. Traditional fixation techniques of the distal ulna may prove unsatisfactory in the setting of osteoporosis and comminution. Description The intrafocal pin plate is placed through a small incision distally and uses the curve of the plate to obtain multiple points of fixation within the intramedullary canal. The overhang of the distal aspect of the plate helps to reduce the fracture. The plate is secured using unicortical locking screws in the ulnar head. Patients and Methods The most ideal fracture pattern for this fixation technique is a subcapital distal ulna fracture that is unstable and associated with a distal radius fracture. This technique is contraindicated in ulnar head fractures, segmental fractures with proximal extension, and open fractures with gross contamination as well as in the setting of active infection. Results This technique has provided a stable ulnar buttress and aided in the reduction of grossly unstable distal radius fractures. All of these patients have gone on to union, and we have not experienced a need for plate removal due to pain or soft tissue irritation. Conclusions We have found the intrafocal pin plate to provide both a stable ulnar buttress as well as intramedullary fixation to aid in the fixation of distal radius fractures associated with unstable distal ulna subcapital fractures.

Are there any differences in various polyaxial locking systems? A mechanical study of different locking screws in multidirectional angular stable distal radius plates

Numerous angular stable plates for the distal radius exist, and technically based comparisons of the polyaxial locking interfaces are lacking. The aim of this mechanical study was to investigate three different locking interfaces of angular stable volar plates by cantilever bending: VA-LCP Two-Column Distal Radius Plates 2.4 mm (Synthes® GmbH, Oberdorf, Switzerland), IXOS® P4 (Martin, Tuttlingen, Germany) and VariAX™ (Stryker®, Duisburg, Germany). We assessed the strength of 0°, 5°, 10° and 15° screw locking angles and tested the bending strength from 10° to 5° angles by cyclic loading until breakage. The final setup repeated the above assessments by inclusion of four locking screws. The single screw-plate interfaces of the VA-LCP showed the highest bending moment at an angle of 0° and 5°, the IXOS® P4 at an angle of 10° and 15° and the VariAX™ when changing the insertion angle from 10° into 5°. The strength of polyaxial locking interfaces and mechanism of failure proved to be different among the examined plates.

The effect of acute distal radioulnar joint laxity on outcome after volar plate fixation of distal radius fractures

OBJECTIVES

The objective of this study was to determine whether intraoperative laxity of the distal radioulnar joint (DRUJ) is associated with adverse postoperative outcomes after volar plate fixation of a distal radius fracture (DRF) and 4 weeks of immobilization.

DESIGNS

Prospective study with clinical and radiographic assessment.

SETTING

Level 1 trauma center.

PATIENTS

One hundred consecutive patients were treated by volar locking plate fixation at our institution for an unstable DRF from April 2007 to November 2009. Of these patients, 84 patients with a minimum follow-up of 12 months were enrolled in this study.

INTERVENTION

Intraoperative DRUJ laxity was evaluated using a radioulnar stress test after fixation of DRF using volar locking plate and splint immobilization of the forearm for 1 month in patients with intraoperative DRUJ laxity. Patients were allocated to an unstable group or stable group according to the presence of intraoperative DRUJ laxity.

MAIN OUTCOME MEASUREMENTS

Our primary outcome measure was disabilities of arm, shoulder, and hand score and the secondary outcome measures were wrist motion, grip strength, modified Mayo wrist score, visual analogue scale for wrist pain, and ongoing pain in the DRUJ.

RESULTS

Nineteen of the 84 study subjects were allocated to the unstable group and 65 to the stable group. No significant differences were observed between 2 groups in wrist range of motion, grip strength, modified Mayo wrist score, disabilities of arm, shoulder, and hand score, visual analogue scale score, and ongoing pain in the DRUJ at 1 year postoperatively.

CONCLUSIONS

In our series of patients treated with volar locking plate and immobilization of the forearm for 1 month in patients with intraoperative laxity of the DRUJ, laxity did not affect impairment, pain, or disability 1 year after fracture. However, the role of postoperative immobilization of the forearm is debatable and merits additional study.

LEVEL OF EVIDENCE

Prognostic level I.

Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events

OBJECTIVES

Determining the rate of specific adverse events after volar plating performed for distal radius fractures.

DESIGN

Retrospective.

SETTING

University level I trauma center.

PATIENTS

We searched the electronic database of all surgical procedures performed in our department using the following keywords: distal radius fracture, wrist fracture, and plate fixation. We identified 315 patients, 12 of whom were lost at follow-up.

INTERVENTION

Volar plate fixation for the treatment of distal radius fractures.

MAIN OUTCOME MEASUREMENTS

At an average follow-up of 5 years, 303 patients were evaluated through medical records and clinical and radiographic assessment for specific adverse events after volar plate fixation.

RESULTS

Adverse events were observed in 18 patients (5.9%). Implant-related adverse events, including tendon impairments, intra-articular screws, and screw loosening, were observed in 15 patients (5.0%). Extensor tendon impairments were represented by 5 cases of extensor tenosynovitis and 3 cases of rupture of the extensor pollicis longus due to screws protruding dorsally. Flexor impairments were represented by 2 cases of tenosynovitis and 2 cases of flexor pollicis longus rupture. Screw penetration into the radioulnar joint was observed in 1 case. Loss of reduction was identified in 3 cases. One patient had a deep postoperative infection treated with operative debridement. One patient experienced injury to the median nerve during routine implant removal unrelated to tendon issues.

CONCLUSIONS

The majority of adverse events after volar plate fixation were due to technical errors in implant placement. In our cohort, tendon impairments were the most frequently observed; among these, extensor tendon impairments were the most represented (50% of all adverse events). All 12 tendon-related adverse events were due to technical shortcomings with implant placement.

LEVEL OF EVIDENCE

Therapeutic level IV.

The 100 top-cited classic papers in hand surgery

The number of citations that a published article has received reflects the importance that paper has on that area of practice. In hand surgery, it is unknown which journal articles are cited most frequently. The purpose of this study was to identify and analyze the characteristics of the top 100 papers in the field of hand surgery. The 100 most cited papers were identified in the following journals; the Journal of Hand Surgery (American volume), the Journal of Hand Surgery (European volume), the Journal of Hand Surgery (British and European volume), The Scandinavian Journal of Plastic and Reconstructive and Hand Surgery, Hand Clinics, and the Journal of Plastic Surgery and Hand Surgery. The articles were ranked in order of the number of citations received. These classic 100 papers were analyzed for article type, their journal distribution, as well as geographic and institutional origin.

Corrective osteotomy of the distal radius following failed internal fixation

INTRODUCTION

The purpose of this study was to quantify the clinical and radiographic outcomes after corrective osteotomy for malunions of the distal radius following failed internal fixation.

MATERIALS AND METHODS

Results of 18 patients (8 women, 10 men; mean age 41 years) are presented an average of 7 years after osteotomy of a malunited distal radius fracture. We assessed active range of motion, grip strength, radiographic alignment, pain and disability. Subjective and objective data were summarized using the modified Mayo Wrist Score and the point-score system of Fernandez.

RESULTS

Wrist motion, pain and deformity improved with the operation in all cases. The modified Mayo Wrist Score averaged 79 points. The scale of Fernandez indicated ten good, two fair and six poor results.

CONCLUSIONS

The results of this study suggest that the operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment.

Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study

PURPOSE

To determine whether volar locking plates are superior to external fixation with adjuvant pins in the treatment of unstable distal radius fractures.

METHODS

A total of 111 unstable distal radius fractures were randomized to treatment with external fixation (EF) using adjuvant pins or with a volar locking plate (VLP). The mean age of the patients was 54 years (range, 20-84 y). Seven patients were lost to follow-up. At 1 year, 104 patients were assessed with a visual analog scale pain score, Mayo wrist score, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH), range of motion, and radiological evaluation. The QuickDASH score at 52 weeks was the primary outcome measure.

RESULTS

The operative time in the EF group was 77 minutes, compared with 88 minutes in the VLP group. At 52 weeks, patients with VLPs had a higher Mayo wrist score (90 vs. 85), better supination (89° vs. 85°), and less radial shortening (+1.4 mm vs. +2.2 mm). There were more patients with pain over the ulnar styloid in the EF group (16 vs 6 patients). For AO type C2/C3, the patients with VLPs had better supination (90° vs. 76°) and less ulnar shortening (+1.1 mm vs. +2.8 mm). The complication rate was 30% in the EF group, compared with 29% in the VLP group. Eight (15%) plates were removed due to complications. The QuickDASH score was not significantly different between the groups.

CONCLUSIONS

Although we did not find a significant difference between the groups for the QuickDASH score, we believe that our results support the use of VLPs for the treatment of unstable distal radius fractures. A serious concern is that some patients will have to have their plates removed; therefore, improving the surgical technique is important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Volar plate fixation of intra-articular distal radius fractures: a retrospective study

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

EXTENSOR POLLICIS LONGUS TENDON RUPTURES AFTER THE USE OF VOLAR LOCKING PLATES FOR DISTAL RADIUS FRACTURES

Currently, volar locking plates are commonly used to treat distal radius fractures (DRF) because of their stable biomechanical construct and because they cause less soft tissue disturbance and allow early mobilisation of the wrist. Complications such as rupture of tendons have been reported to occur with use of volar locking plates. We describe six cases of rupture of extensor pollicis longus (EPL) tendons after the use of volar locking plates. EPL tendon injuries occurred in 2.1% (6/286) of cases after DRF surgery. The causes of EPL rupture after DRF surgery were protrusion of the head tip and insufficient reduction of the dorsal roof fragment of the distal radius. These were considered iatrogenic problems. The cause of EPL rupture was unknown in three cases. We should be extremely careful when determining optimum screw length and reducing displaced dorsal roof fragments to prevent damaging the EPL tendons.

Functional consequence of distal brachioradialis tendon release: a biomechanical study

PURPOSE

Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, this common procedure has the potential to decrease elbow flexion strength. To determine the potential morbidity associated with brachioradialis release, we measured the change in elbow torque as a function of incremental release of the brachioradialis insertion footprint.

METHODS

In 5 upper extremity cadaveric specimens, we systematically released the brachioradialis tendon from the radius and measured the resultant effect on brachioradialis elbow flexion torque. We defined release distance as the distance between the release point and the tip of the radial styloid.

RESULTS

Brachioradialis elbow flexion torque dropped to 95%, 90%, and 86% of its original value at release distances of 27, 46, and 52 mm, respectively. Importantly, brachioradialis torque remained above 80% of its original value at release distances up to 7 cm.

CONCLUSIONS

Our data demonstrate that release of the brachioradialis tendon from its insertion has minor effects on its ability to transmit force to the distal radius.

CLINICAL RELEVANCE

These data imply that release of the distal brachioradialis tendon during distal radius open reduction internal fixation can be performed without meaningful functional consequences to elbow flexion torque. Even at large release distances, overall elbow flexion torque loss after brachioradialis release would be expected to be less than 5% because of the much larger contributions of the biceps and brachialis. Use of the brachioradialis as a tendon transfer donor should not be limited by concerns of elbow flexion loss, and the tendon could be considered as an autograft donor.

Fixation of distal radius fractures in adults: a review

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

A new volar plate DiPhos-RM for fixation of distal radius fracture: preliminary report

We analyzed the efficiency of a new plate DiPhos-RM in CFR-PEEK [carbon-fiber-reinforced poly (etheretherketone)] for the volar fixation of distal radius fractures. The new plate's composition has the advantage of x-ray absolute transparency, therefore allowing to monitor the healing of the fracture. The desired combination of high strength and low rigidity is obtained through the use of the polymer composites CFR-PEEK. In this preliminary study (from March 2012 to June 2012), 10 cases of intra-articular distal radius fractures were treated with DiPhos-RM produced by Lima Corporate (Italy). The fractures were classified according to the AO classification, 4 fractures were type C1, 3 type C2, and 3 were A2. A preoperative computed tomography scan was carried out in all patients. One patient also underwent a postoperative computed tomography scan. Grip strength, range of motion, and DASH score were evaluated at follow-up. There were no cases of hardware failure. Specifically, no loss of position or alignment of fixed-angle locking screws or breakage of the plate were observed. Radiographic union was present at an average of 6 weeks (range, 5 to 8 wk). The overall preliminary experience with this new plate is favorable. The new plate is easy to apply and provides the surgeon dual options of fixed-angle or variable-angle screws. It was rigid enough to maintain the reduction also in AO type C articular fractures.

Volar plating for distal radius fractures--do not trust the image intensifier when judging distal subchondral screw length

BACKGROUND

The use of the volar plate to treat distal radius fractures is increasing but despite the theoretical advantages of a volar approach there have been reports of extensor tendon ruptures due to prominent screw tips protruding past the dorsal cortex. The valley in the intermediate column between Lister tubercle and the sigmoid notch of the distal radius makes it difficult to rely on fluoroscopy to judge screw length. Our aim was to quantify the dimensions of this valley and to demonstrate the danger of relying on intraoperative image intensification fluoroscopy to determine lengths of distal screws.

METHODS AND RESULTS

We measured the depth of this valley in the intermediate column of the distal radius in 33 patients with computed tomographic (9 patients) or magnetic resonance image (24 patients) scans of the wrist. There was a consistent valley in all images examined [average 1.8 mm (95% confidence interval, 1.6-2.0 mm)]. Thirty-nine percent of wrists had a valley depth of at least 2 mm.

CONCLUSIONS

Standard lateral views or rotation of the forearm to obtain oblique views does not identify prominent screw tips; and whatever the rotation of the forearm, screw tips protruding beyond dorsal cortex may look as if it is within the bone when in fact it is out. When drilling we suggest noting the depth at which the drill bit just penetrates dorsal cortex and routinely downsize the distal screw length by 2 mm. We caution against relying on flourosocopy when judging the length of the distal subchondral screws.

Radiographic outcomes of volar locked plating for distal radius fractures

PURPOSE

To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures.

METHODS

We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type.

RESULTS

At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome.

CONCLUSIONS

Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Fragment-specific fixation for complex intra-articular fractures of the distal radius: results of a prospective single-centre trial

The goal was to evaluate the efficacy of 2.4 mm column-specific plating for intra-articular distal radius fractures. In total, 105 patients with AO type C distal radius fractures were operated on using the locking distal radius system, Synthes. Follow-up assessments including clinical (wrist and forearm range of motion, grip strength), radiological (articular step, radial length and inclination, volar tilt, and ulnar variance), and functional scores (Disabilities of the Arm, Shoulder, and Hand; Patient Rated Wrist Evaluation) were made at regular intervals until 1 year. Union was obtained in all patients. Articular surface was anatomically reconstructed in 74 patients (70.5%). Clinical and functional evaluation showed significant continuous improvements over the first year. C1 fractures had a better chance of anatomical reduction compared with C2 and C3 fractures. Fracture type, quality of reduction, and presence of degenerative changes did not show a significant effect on functional outcome scores. Column-specific fixation of the distal radius can achieve satisfactory results in complex intra-articular fractures.

Distal ulna hook plate fixation for unstable distal ulna fracture associated with distal radius fracture

The significance of distal ulna fractures is often undermined, which can result in inadequate treatment compared with fractures of the radius, the ulna's larger counterpart. However, little guidance exists in the current literature on how to manage distal ulna head or neck fractures and intra-articular ulna head fractures. Therefore, the purpose of this retrospective study was to evaluate the outcomes of distal ulna hook plate fixation for the treatment of an unstable distal ulna fracture associated with a distal radius fracture. Twenty-five patients with unstable distal ulna fractures who underwent stable fixation for an associated distal radius fracture were included in the study. All patients achieved satisfactory reduction and bony union. Average final motion was as follows: wrist flexion, 72° (range, 60°-85°); extension, 69° (range, 65°-80°); pronation, 77° (range, 55°-95°); supination, 82° (range, 65°-90°); ulnar deviation, 35° (range, 15°-50°); and radial deviation, 24° (range, 10°-40°). Average postoperative grip strength was 28 kg (range, 22-30 kg) and was 91% (range, 71%-100%) in the cases in which the dominant hand was injured and 80% (range, 65%-100%) in the cases in which the nondominant hand was injured. Average postoperative modified Mayo wrist score and Disabilities of the Arm, Shoulder and Hand score was 87 points (range, 65-100 points) and 14 points (range, 0-54 points), respectively. Chronic instability of the distal radioulnar joint was not encountered in any patient. Thus, the study demonstrated that distal ulna hook plate fixation for the treatment of unstable distal ulna fractures can achieve healing with good alignment, satisfactory function, and minimal transient morbidity.

Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: a prospective clinical cohort study

PURPOSE

To assess prospectively the integrity of pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures and to compare the clinical and radiographic outcomes of durable versus failed repairs in 24 subjects. In addition, by grading the degree of PQ injury, an attempt was made to correlate failure of repair with the PQ injury severity.

METHODS

The extent of PQ injury was graded for each fracture. After fracture fixation, the PQ muscle was repaired along its radial and distal borders. Radiopaque hemoclips were attached to each side of the PQ repair, 2 radially and 2 distally. The distance between these markers at time 0 versus x-rays taken at approximately 2 weeks, 6 weeks, and 3 months was recorded. Clip displacement of 1 cm or more compared to time 0 indicated repair failure.

RESULTS

One of 24 repairs (4%) failed at 3 months. No statistical difference was noted between the type of PQ injury and wrist flexion/extension, pronation/supination, and grip strength.

CONCLUSIONS

Pronator quadratus repairs after volar plate fracture fixation are generally durable. They withstand forces that occur at the distal radius during the healing process with a 4% failure rate. No correlation was shown between type of PQ injury and radiographic failure of the repair.

Orthogonal plating of intra-articular distal radius fractures with an associated radial column fracture via a single volar approach

INTRODUCTION

The purpose of this study was to investigate the radiographic and functional outcome of orthogonal plating (two plates at right angles) via a single volar approach for fixation of intra-articular distal radius fractures with an associated radial column fracture.

METHODS

In a retrospective, chart-based review, we identified 14 consecutive patients with an intra-articular distal radial fracture who had been treated with locked volar plate fixation and an additional radial column plate. Radial column plates were LCP Distal Radius Plates 2.4; volar plates were LCP Distal Radius Plates 2.4 (n=13) or LCP T-plate (n=1). These patients were operated on using the extended volar flexor carpi radialis (FCR) approach as described by Orbay. Radiographic measurements, healing rates, time to union, complications, range of motion, the Gartland and Werley score, and the QuickDASH questionnaire were done in order to evaluate the radiographic and functional outcomes of this technique.

RESULTS

Thirteen of the 14 fractures healed within 7 weeks after surgery. Two implant removals were done. One patient had malposition of the fracture and carpal tunnel symptoms, which required a second surgery. No other complications (e.g., first dorsal compartment problems, radial plate prominence problems and radial sensory nerve problems) were observed. The average length of follow-up was 30 months (range, 12.8 months to 5.4 years). Radiographic results after healing were radial inclination 20°, radial length 11.4mm, tilt 6° volar, ulnar variance -0.5mm, articular gap 0.1mm and step-off 0.1mm. Wrist range of motion was flexion-extension arc 93°, ulnar-radial deviation arc 49° and pronation-supination arc 152°. Nine patients scored 'excellent' on the Gartland and Werley score, while the remaining five patients scored 'good'. The average QuickDASH score was 13.4.

CONCLUSION

Additional fixation of a radial column process in an intra-articular distal radius fracture via the extended FCR approach using a standard volar plate and radial LCP resulted in good/excellent radiographic and functional outcome.

LEVEL OF EVIDENCE

Therapeutic IV.

Volar fixed-angle plating of distal radius fractures: screws versus pegs--a biomechanical study in a cadaveric model

OBJECTIVES

The purpose of this biomechanical study was to determine whether a multidirectional fixed-angle plate with locking screws or with locking pegs in the distal fragment would optimize fixation of Orthopaedic Trauma Association (OTA) type A3 distal radius fractures.

METHODS

Eight pairs of fresh-frozen human distal radii were used. Extra-articular distal radius fractures were created and stabilized with a multidirectional volar fixed-angle plate. The radii were randomized into 2 matched-paired groups. The distal fragment in Group I was stabilized with 7 locking screws. The distal fragment in Group II was fixed with 7 locking pegs. The proximal fragment in both groups was fixed with 3 screws. The specimens were tested under torsion and axial compression during static and cyclic tests. Finally, load-to-failure tests were performed under torsion.

RESULTS

After 1000 cycles, 99% of the median torsional stiffness remained in the group using screws, whereas only 76% of the median stiffness under torsion remained in the group using pegs (P = 0.018). Under axial compression, median stiffness remained at 93% in the group using screws after 1000 cycles compared with a median of 0% in the group using pegs (P = 0.018).

CONCLUSIONS

This biomechanical study showed a statistically significant difference between the locking screw and locking smooth peg configuration with regard to stiffness of the constructs after 1000 cycles. The use of locking screws as opposed to smooth locking pegs for OTA type A3 extra-articular distal radius fractures optimizes construct stability.

Distal radial fracture arthroscopic intraarticular gap and step-off measurement after open reduction and internal fixation with a volar locked plate

PURPOSE

A persistent articular gap and a step-off of ≥1 mm after a distal radial fracture (DRF) may lead to post-traumatic arthritis of the radiocarpal joint. This study aims to arthroscopically assess the reduction in the articular surface in patients requiring volar locked-plate fixation for DRF via fluoroscopy-guided open reduction and internal fixation (ORIF).

METHODS

Seventy consecutive patients with DRF were prospectively enrolled. Posteroanterior and lateral radiographs and axial, coronal, and sagittal computed tomography (CT) scans were obtained before ORIF for DRF. The widest articular gap (pregap) and step-off (prestep-off) at the radiocarpal joint surface of the distal radius were measured on all radiographs and CT images. Total predisplacement was defined as the sum of all pregaps and prestep-offs. The DRF was reduced under fluoroscopic guidance, and a volar locked-plate was applied after fluoroscopic ORIF. The residual maximum articular gap and step-off (postgap and poststep-off) were measured arthroscopically with a calibrated probe. Total incongruity was defined as the sum of postgap and poststep-off. The receiver operating characteristic curve was applied within the pregaps, prestep-offs and total incongruity in order to identify the cutoff values of pregap and prestep-off beyond which total incongruity would exceed 1 mm.

RESULTS

Of the 70 patients, 40 had a postgap of ≥1 mm, and 15 had a poststep-off of ≥1 mm. All pregap and prestep-off cutoff values were judged to be unsuitable as the screening criteria for arthroscopic reduction of DRF because of their low sensitivity and specificity. The cutoff value obtained from total predisplacement was 7.85 mm, and its sensitivity and specificity were 90 and 70 %, respectively.

CONCLUSIONS

Since the cutoff value of 7.85 mm derived from total predisplacement is a good indicator of post-ORIF residual total incongruity of ≥1 mm, it is also a good indicator of the need for arthroscopic reduction.

The extended flexor carpi radialis approach for partially healed malaligned fractures of the distal radius

PURPOSE

The aim of the study is to evaluate the safety and utility of the extended flexor carpi radialis (FCR) exposure and volar locking plate fixation for partially healed malaligned fractures of distal radius.

MATERIALS AND METHODS

Thirty-five patients with a partially healed malaligned fracture of the distal radius had realignment of the fracture using an extended FCR approach (release of the insertion of the brachioradialis and dorsal periosteum) and volar locked plate and screw fixation.

RESULTS

Retrospective review an average of 20 months after the index operation patients identified an average wrist extension of 68°, flexion of 64°, pronation of 84° and supination of 85°. Radial inclination, volar tilt and ulnar variance significantly improved compared to preoperative radiographs. All fractures healed, and there were no infections, implant loosening or breakage or tendon ruptures.

CONCLUSIONS

This study demonstrated that the extended FCR approach is safe and effective as a treatment method for nascent malunions of the distal radius.

External fixation versus internal fixation for unstable distal radius fractures: a systematic review and meta-analysis of comparative clinical trials

OBJECTIVES

There is no consensus on the surgical management of unstable distal radius fractures. In this systematic review and meta-analysis, we pool data from trials comparing external fixation and open reduction and internal fixation (ORIF) for this injury.

DATA SOURCES

We searched electronic databases (including MEDLINE, EMBASE, and SCOPUS) and conference proceedings from 1950 to 2009 in the English literature.

STUDY SELECTION

We pooled data from 12 trials totaling 1011 patients (491 fractures treated with external fixation and 520 with ORIF). All randomized studies of external fixation to ORIF for unstable distal radius fractures were considered, and nonrandomized trials were included if and only if they directly compared external fixation with ORIF.

DATA EXTRACTION

Two authors independently extracted data from all eligible studies, including patient characteristics, sample size, fracture type, length of follow-up, intervention, and outcomes.

DATA SYNTHESIS

Continuous variables were pooled across studies using the method of standard mean differences (SMD) or effect size. ORIF demonstrated significantly better Disabilities of the Arm, Shoulder, and Hand scores (SMD, 0.28; 95% confidence interval, 0.03-0.53; P = 0.03), recovery of forearm supination (SMD, 0.23; 95% CI, 0.08-0.38; P = 0.003), and restoration of volar tilt (SMD, 0.53; 95% CI, 0.34-0.72; P < 0.00001). However, external fixation resulted in significantly better grip strength (SMD, -10.32; 95% CI, -16.36 to -4.28; P = 0.0008), and subgroup analyses of randomized studies showed external fixation yielded better wrist flexion (SMD, -0.38; 95% CI, -0.58 to -0.17; P = 0.0004).

CONCLUSIONS

For surgical fixation of unstable distal radius fractures, ORIF yields significantly better functional outcomes, forearm supination, and restoration of anatomic volar tilt. However, external fixation results in better grip strength, wrist flexion, and remains a viable surgical alternative.

LEVEL OF EVIDENCE

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

OUTCOME OF UNSTABLE DISTAL RADIUS FRACTURES TREATED WITH OPEN REDUCTION AND INTERNAL FIXATION VERSUS EXTERNAL FIXATION

The objective of this study was to compare the clinical results of unstable distal radius fractures treated with ORIF with plate and screws compared to EF. Patients with unstable distal radius fractures treated with ORIF or EF from January 2005 to December 2010 were reviewed in terms of the Modified Mayo Wrist Score, range of motion, pain, grip strength, and radiologic parameters. Results showed that there was no difference in the Modified Mayo Wrist Score between ORIF (17 patients) and EF (11 patients) (p = 0.07). The ORIF group had better wrist flexion, wrist extension, pronation and supination compared to the EF group (p < 0.05). There were no significant differences in terms of radial and ulnar deviation, grip strength, pain and postoperative radiologic parameters (p < 0.05). Better wrist flexion, wrist extension and forearm rotation can be expected in ORIF compared to EF in the management of unstable distal radius fractures.

Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius

PURPOSE

To determine whether use of the dorsal tangential view improves the diagnostic accuracy of intraoperative fluoroscopy compared with conventional views in detecting dorsal screw penetrations during volar distal radius plating.

METHODS

Dorsal cortices of 10 cadaveric distal radii were penetrated in each of the second, third, and fourth dorsal extensor compartments at 0, 1, 2, and 3 mm penetration. We obtained 4 standardized fluoroscopic images of the wrist: lateral, supination, pronation, and dorsal tangential views. Using high-definition digital images, 2 observers blinded to the experimental paradigm determined whether screws were penetrating the dorsal cortex.

RESULTS

For screws that penetrated the floor of the second dorsal compartment, the 45° supination view was 92% sensitive for detecting screw penetration of 2 mm, and 98% for 3 mm. For screws that penetrated the third dorsal compartment, the lateral view was 68% and 80% sensitive in detecting screw penetrations of 1 and 2 mm, respectively. However, the dorsal tangential view showed 95% sensitivity for 1 mm and 98% for 2 mm penetrations. On the floor of the fourth dorsal compartment, pronation and dorsal tangential views were both 88% sensitive for 1 mm screw penetration and 90% and 93% for 2 mm, respectively.

CONCLUSIONS

The standard lateral view of the wrist failed to detect all screw penetrations. The dorsal tangential view increased the accuracy of detecting screw penetrations on the floor of the third dorsal compartment, whereas we needed oblique views to detect screw penetrations on the floors of second and fourth dorsal compartments.

CLINICAL RELEVANCE

Routine clinical use of the dorsal tangential view has the potential to increase accuracy in detecting dorsal screw penetration during volar plating of the distal radius.

The use of bone grafts and substitutes in the treatment of distal radius fractures

The interest in developing biomaterials to augment fracture healing continues to grow. New products promise early return to function with minimal morbidity; however, indications to use these products remain unclear. An ideal bone graft material stimulates bone healing and provides structural stability while being biocompatible, bioresorbable, easy to use, and cost-effective. This article reviews the biology of bone grafts and the clinical evidence in the use of bone graft substitutes for the treatment of distal radius fractures.

Avoiding and treating perioperative complications of distal radius fractures

Numerous methods of treatment are available for the management of distal radius fractures, with modern trends favoring volar fixed-angle distal radius plates. Whatever the method of fixation, recognition, management, and prevention of the known associated complications are essential to achieve a good outcome. This article reviews the common preventable complications that are associated with operative treatment of distal radius fractures, including tendon injuries, inadequate reduction, subsidence or collapse, intra-articular placement of pegs or screws, nerve injuries, complex regional pain syndrome, carpal tunnel syndrome, and compartment syndrome.

PALMAR PLATING FOR AO/ASIF C3.2 FRACTURES OF THE DISTAL RADIUS WITH ARTHROSCOPICALLY ASSISTED REDUCTION

We performed a retrospective study of 15 patients with AO/ASIF C3.2 fracture of the distal radius. All patients were treated with arthroscopically assisted reduction of the radiocarpal joint followed by palmar plating with autologous bone graft, with a follow-up evaluation of 24 months. According to the demerit point system of Gartland and Werley, five patients had excellent results and 10 had good results. Grade 1 arthritic changes were found in 10 patients even though with no step-off on radiographs. In the current study, this combined treatment was challenging and useful for AO/ASIF C3.2 fractures.

OSTEOTOMY OF THE DISTAL RADIUS USING A FIXED-ANGLE VOLAR PLATE

OBJECTIVE

Skewed consolidation of the distal radius, due to sequelae of fractures, may cause functional incapacity, thus leading such patients to present pain, loss of strength and diminished mobility. Based on the excellent results obtained from surgical treatment of unstable fractures of the distal radius through a volar approach and use of rigid fixation with a fixed-angle volar plate, we started to use the same method for osteotomy of the distal radius.

METHODS

A retrospective review was conducted, and 20 patients treated between February 2002 and October 2009 were found. The mean length of follow-up was 43.9 months (range: 12 to 96 months). The surgical indications were persistent pain, deformity and functional limitation subsequent to a dorsally displaced fracture.

RESULTS

The mean preoperative deformity was 27° of dorsal tilt of the distal radius, 87° of ulnar tilt, and 7.3 mm of shortening of the radius. All the osteotomies consolidated and the final mean volar tilt was 6.2°, with ulnar tilt of 69.3° and shortening of 1 mm. The mean mobility of the wrist increased by 19.9° (flexion) and by 24° (extension). Mean forearm supination increased by 23.5° and pronation by 21.7°. Grip strength increased from 13.4 to 34.5 pounds.

CONCLUSION

Use of a fixed-angle volar plate for a volar approach towards osteotomy of the distal radius enables satisfactory correction of the deformities and eliminates the need for removal of the synthesis material caused by tendon complications.

The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates

PURPOSE

Volar plating for distal radius fractures has caused extensor tendon ruptures resulting from dorsal screw prominence. This study was designed to determine the biomechanical impact of placing unicortical distal locking screws and pegs in an extra-articular fracture model.

METHODS

We applied volar-locking distal radius plates to 30 osteoporotic distal radius models. We divided radiuses into 5 groups based on distal locking fixation: bicortical locked screws, 3 lengths of unicortical locked screws (abutting the dorsal cortex [full length], 75% length, and 50% length to dorsal cortex), and unicortical locked pegs. Distal radius osteotomy simulated a dorsally comminuted, extra-articular fracture. We determined each construct's stiffness under physiologic loads (axial compression, dorsal bending, and volar bending) before and after 1,000 cycles of axial conditioning and before axial loading to failure (2 mm of displacement) and subsequent catastrophic failure.

RESULTS

Cyclic conditioning did not alter the constructs' stiffness. Stiffness to volar bending and dorsal bending forces were similar between groups. Final stiffness under axial load was statistically equivalent for all groups: bicortical screws (230 N/mm), full-length unicortical screws (227 N/mm), 75% length unicortical screws (226 N/mm), 50% length unicortical screws (187 N/mm), and unicortical pegs (226 N/mm). Force at 2-mm displacement was significantly less for 50% length unicortical screws (311 N) compared with bicortical screws (460 N), full-length unicortical screws (464 N), 75% length unicortical screws (400 N), and unicortical pegs (356 N). Force to catastrophic fracture was statistically equivalent between groups, but mean values for pegs (749 N) and 50% length unicortical (702 N) screws were 16% to 21% less than means for bicortical (892 N), full-length unicortical (860 N), and 75% length (894 N) unicortical constructs.

CONCLUSIONS

Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation. Unicortical distal fixation for extra-articular distal radius fractures should be entertained to avoid extensor tendon injury because this technique does not appear to compromise initial fixation.

CLINICAL RELEVANCE

Using unicortical fixation during volar distal radius plating may protect extensor tendons without compromising fixation.

The effects of a displaced dorsal rim fracture on outcomes after volar plate fixation of a distal radius fracture

INTRODUCTION

The purpose of this study was to determine whether a displaced dorsal rim fracture has an adverse effect on wrist function after volar plate fixation of a dorsally displaced distal radius fracture (DRF).

MATERIALS AND METHODS

Two matched cohorts of 23 matched patients, one with a displaced dorsal rim fracture >2mm (group 1), and the other without a dorsal rim fracture (group 2) were analysed in this study of volar locking plate fixation for dorsally unstable DRFs. The two cohorts were analysed for differences in wrist function and wrist pain, radiographic parameters and arthritic grades of radiocarpal joints. Displacement of dorsal rim fragments and diameters of the retained articular portions of dorsal rims in group 1 were measured.

RESULTS

No significant difference was found between the two groups in overall wrist function or wrist pain. Mean displacement of dorsal rims in group 1 was 3.0mm and the mean diameter of the retained articular portion of dorsal articular wall was 2.0mm. No significant difference was found between the two groups in terms of any radiographic parameters or the arthritic grading of radiocarpal joints.

CONCLUSION

A displaced dorsal rim fracture does not appear to affect outcomes adversely after volar locking plate fixation of dorsally displaced DRFs.

Locking distal radius plate--early results from India

BACKGROUND

Restoration of wrist function to close to preinjury levels of patients with intra-articular distal end radius fractures is of concern. Open reduction and internal fixation with angular stable screw fixation implants is coming in vogue but little literature evidence supports it. The objectives of this study are to assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced intra-articular distal radial fractures and to assess the patient-related outcome after this procedure.

METHODS

In a prospective study from March 2008 to September 2009, 23 cases of intra-articular distal radius fractures were included in the study. All these fractures underwent open reduction and internal fixation with 2.4 volar locking distal radius plates. Every patient was reviewed with a minimum follow-up of 36 weeks (9 months to 2 years). Radiographs were taken to assess fracture union or for any potential loss of fracture reduction. Functional outcome was assessed with evaluation of range of movements of the wrist and pain as per the Visual Analog Scale.

RESULTS

Radiologic union was noted by the end of 18 weeks in 3 subjects, at the end of 24 weeks in 13 subjects and by 30th week in 6 patients. As for overall functional outcome, 4 patients had excellent outcome, 18 had good outcome, and 1 patient had poor outcome. None of our patients had neurovascular injuries or tendon ruptures during this period.

CONCLUSION

Volar locking plate is a viable option for treating intra-articular distal radius fractures.

Variations in the use of internal fixation for distal radial fracture in the United States medicare population

BACKGROUND

Distal radial fractures affect an estimated 80,000 elderly Americans each year. Although the use of internal fixation for the treatment of distal radial fractures is becoming increasingly common, there have been no population-based studies to explore the dissemination of this technique. The aims of our study were to determine the current use of internal fixation for the treatment of distal radial fractures in the Medicare population and to examine regional variations and other factors that influence use of this treatment. We hypothesized that internal fixation of distal radial fractures would be used less commonly in male and black populations compared with other populations because the prevalence of osteoporosis is lower in these populations, and that use of internal fixation would be correlated with the percentage of the patients who were treated by a hand surgeon in a particular region.

METHODS

We performed an analysis of complete 2007 Medicare data to determine the percentage of distal radial fractures that were treated with internal fixation in each hospital referral region. We then analyzed the association of patient and physician factors with the type of fracture treatment received, both nationally and within each hospital referral region.

RESULTS

We identified 85,924 Medicare beneficiaries with a closed distal radial fracture who met the inclusion criteria, and 17.0% of these patients were treated with internal fixation. Fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio, 0.84; 95% confidence interval, 0.80 to 0.89) and in black patients than in white patients (odds ratio, 0.74; 95% confidence interval, 0.65 to 0.85). Patients were more likely to be treated with internal fixation rather than with another treatment if they were treated by a hand surgeon than if they were treated by an orthopaedic surgeon who was not a hand surgeon (odds ratio, 2.49; 95% confidence interval, 2.29 to 2.70). Use of internal fixation ranged from 4.6% to 42.1% (nearly a ten-fold difference) among hospital referral regions. The percentage of patients treated with internal fixation within a hospital referral region was positively correlated with the percentage of patients in that region who were treated by a hand surgeon (correlation coefficient, 0.34; p < 0.0001).

CONCLUSIONS

The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture.

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.

An economic analysis of outcomes and complications of treating distal radius fractures in the elderly

PURPOSE

There is a lack of scientific data regarding which treatment provides the best outcome for distal radius fractures (DRFs) in the elderly. Currently, casting is used to treat the majority of these fractures, although open reduction and internal fixation (ORIF) has been used increasingly in recent years. Given the recent emphasis on the wise use of medical resources, we conducted a cost-utility analysis to assess which of 4 common DRF treatments (casting, wire fixation, external fixation, or ORIF) optimizes the cost-to-patient preference ratio.

METHODS

We created a decision tree to model the process of choosing a DRF treatment and experiencing a final outcome. Fifty adults aged 65 and older were surveyed in a time trade-off, one-on-one interview to obtain utilities for DRF treatments and possible complications. We gathered Medicare reimbursement rates and calculated the incremental cost-utility ratio for each treatment.

RESULTS

Participants rated DRF treatment relatively high, assigning utility values close to perfect health to all treatments. The ORIF was the most preferred treatment (utility, 0.96), followed by casting (utility, 0.94), wire fixation (utility, 0.94), and external fixation (utility, 0.93). The ORIF was the most expensive treatment (reimbursement, $3,516), whereas casting was the least expensive (reimbursement, $564). The incremental cost-utility ratio for ORIF, when compared to casting, was $15,330 per quality-adjusted life years, which is less than $50,000 per quality-adjusted life year, thereby indicating that, from the societal perspective, ORIF is considered a worthwhile alternative to casting.

CONCLUSIONS

There is a slight preference for the faster return to minimally restricted activity provided by ORIF. Overall, patients show little preference for one DRF treatment over another. Because Medicare patients pay similar out-of-pocket costs regardless of procedure, they are not particularly concerned with procedure costs. Considering the similar long-term outcomes, this study adds to the uncertainty surrounding the choice of DRF treatment in the elderly, further indicating the need for a high-powered, randomized trial.

THE TREATMENT OF DISTAL RADIUS ARTICULAR FRACTURES THROUGH LCP SYSTEM

We analysed LCP efficiency in type B and type C wrist fractures (according to the AO Classification). We treated 58 wrist fractures (19 B-type fractures and 39 C-type fractures) in 35 male and 23 female patients, aged 19 to 87 years. Forty-one cases were followed up for an average period of 13 months. We performed a volar approach on 32 patients, a dorsal approach on five, and a double approach on four (both volar and dorsal). Twenty-six cases were pre-operatively examined with CT. All patients were evaluated using the "Mayo modified wrist score", with an excellent/good result in 76% of patients and a satisfactory/poor result in 24%. The LCP system proved to be adequately reliable and stable to keep the reduction in complex fractures (e.g. the C-type fractures in patients with low bone quality).

A NEW VARIABLE ANGLED LOCKING VOLAR PLATE SYSTEM FOR COLLES' FRACTURE: OUTCOME STUDY AND TIME-COURSE IMPROVEMENT OF OBJECTIVE CLINICAL VARIABLES

Our purposes were to report the radiographic outcomes and complications of patients with Colles' fracture treated with the Nakashima locking volar plate system (variable angled distal screw locking mechanism) prospectively and to report the results of objective clinical variables such as grip strength and range of motion of the wrist prospectively at up to one year. This study consisted of eight men and 32 women for analysis of radiographic parameters (volar tilt, radial inclination and radial length) and complications. Radiographic parameters were measured pre-operatively, immediately post-operatively and at final follow-up visit. The average age at operation was 60.3 years old. Among them, we selected 25 cases (6 men and 19 women) whom we followed up at six weeks, three months, six months and one year post-operatively. The average age at operation in this group was 62 years old. We measured objective clinical variables (grip strength, forearm rotation, wrist extension/flexion) at each visit. Except for volar tilt, radiographic parameters revealed no significant changes between immediately post-operative radiographs and radiographs at final follow-up visit. Complications included loss of reduction in two cases. Objective clinical variables other than pronation measurement showed significant increase at each visit up to one year post-operatively. Satisfactory clinical and radiographic results were obtained by using this system. The variable angled distal fragment plating system appears to be a reliable construct for rigid fixation of Colles' fractures; however, technical errors can occur, as with other fixation systems. We demonstrated that the follow-up of Colles' fracture treated by our volar locking plate less than one year post-operative may be insufficient.

USE OF THE VOLAR FIXED ANGLE PLATE FOR COMMINUTED DISTAL RADIUS FRACTURES AND AUGMENTATION WITH A HYDROXYAPATITE BONE GRAFT SUBSTITUTE

Treatment of distal radius fractures with a volar fixed angle plate achieves sufficient stabilisation and permits early physical exercise. However, secondary displacement after surgery sometimes occurs in elderly patients with a metaphyseal comminution and/or cases in which the subchondral support pegs were not placed immediately below the subchondral zone.

We treated elderly patients suffering from distal radius fractures with metaphyseal comminution, using both volar fixed angle plate with or without augmentation with a hydroxyapatite bone graft substitute to investigate the benefit of augmentation for maintaining a fracture reduction. We evaluated the differences among radiographic parameters including palmar tilt, radial inclination, and ulnar variance on immediate postoperative and final follow-up radiographs to analyse the maintenance of the initial reduction.

There were no significant differences between the two groups in terms of palmar tilt (P = 0.80) and radial inclination (P = 0.17); however, ulnar variance increased significantly in the group treated with a volar fixed angle plate without augmentation (P < 0.05).

It might be useful to use a combination technique of a locking plate system and the hydroxyapatite bone graft substitute as augmentation to treat distal radius comminuted fractures in elderly patients.

Locking palmar plate fixation for dorsally displaced fractures of the distal radius: a preliminary report

We reviewed a series of 62 consecutive patients with dorsally displaced fractures of the distal radius, including 20 extra-articular and 42 intra-articular fractures. All patients were treated with palmar locking plate systems at our institution between 2002 and 2006. After a minimum follow-up time of 12 weeks, the fractures had healed with satisfactory radiographic and functional results. According to the demerit point system of Gartland and Werley, 35 patients were rated excellent, 26 good, and one fair. In the good and fair groups, the demerit points were almost all for ulnar wrist pain. Our results suggest that palmar locking plate systems enable early functional mobilization with good reproducible radiographic and clinical outcomes. Since nine out of 62 patients had residual ulnar wrist pain at the final follow-up evaluation, further investigation of the pathogenesis of ulnar wrist pain is necessary to obtain better functional outcomes.

Treatment of unstable distal radius fractures with the volar locking plate

BACKGROUND

Open reduction and internal fixation using an interlocking plate system has gained popularity for the treatment of dorsally displaced distal radius fractures.

PURPOSE

To evaluate the functional and radiological results of treating unstable distal radius fractures with the volar locking plate.

PATIENTS AND METHODS

A retrospective review was conducted of patients from one institution using the volar locking plate to treat intra-articular and extra-articular distal radius fractures. Unstable distal radius fractures in 15 patients, comprising 3 men and 12 women with a mean age of 64.4 years (34-76 years), were treated with a volar locking compression plate (Acu-Loc distal radius plate system; Acumed, Oregon, USA) and followed up for a minimum of 1 year. Fractures were classified using the AO classification. Radiographic parameters of preoperative, postoperative, and final follow-up radiographs were compared. The time to initiation of active range of motion was determined. Final follow-up range of motion and complications were reported.

RESULTS

At final functional assessment, the scores of 5 patients were excellent, 7 patients good, and 3 patients fair according to Cooney's Clinical Scoring Chart. No non-union or infection occurred. Rupture of the flexor pollicis longus tendon occurred in 1 patient.

CONCLUSION

Treatment of unstable distal radius fractures with a volar locking plate leads to satisfactory results, provided the operative technique is carefully performed to prevent complications.

Evaluation of a polyaxial angle-stable volar plate in a distal radius C-fracture model--a biomechanical study

INTRODUCTION

Polyaxial angle-stable plating is thought to be particularly beneficial in the management of complex intra-articular fractures of the distal radius. The purpose of the present study was to investigate whether the technique provides stability to match that of conventional (fixed-angle) angle-stable constructs.

MATERIAL AND METHODS

In seven pairs of human cadaver radii, an Arbeitsgemeinschaft für Osteosynthese (AO) 23 C2.1 intra-articular fracture was created. One radius of each pair received a juxta-articular 2.4-mm locking compression plate (LCP) Volar Distal Radius Plate, whilst the contralateral one received a 2.4-mm Variable Angle Locking Compression Plate (LCP) Two-Column Volar Distal Radius Plate (both plates: Synthes, Oberdorf, Switzerland). Parameters tested were construct stiffness (static axial loading with 150 N), range of motion and secondary loss of reduction (dynamic 150 N axial loading over 5000 cycles). Stiffness and range of motion were measured both pre- and post-cycling.

RESULTS

The polyaxial constructs were significantly stiffer, both before and after cyclic testing. However, the two-column plates showed a significant loss of stiffness during cyclic testing. The range of motion was significantly greater, both initially and at the end of cyclic testing, in the fixed-angle constructs. The conventional constructs had significantly greater secondary loss of reduction.

CONCLUSION

The polyaxial two-column plate tested in this study provides a biomechanically sound construct for the management of intra-articular fractures of the distal radius.