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

Treatment of Distal Radial Fractures with an Intramedullary Nail

Introduction

This paper will describe the surgical technique for the treatment of unstable distal radial fractures with use of the MICRONAIL Intramedullary Distal Radius System (Wright Medical Technology, Arlington, Tennessee).

Step 1 Closed Reduction and Pinning

The fracture must be adequately reduced and pinned prior to nail insertion.

Step 2 Perform Exposure and Enter Canal

Protect the branches of the superficial radial sensory nerve at all times.

Step 3 Insert Nail and Distal Locking Screws

Insert the nail to a depth to place the most distal screw just proximal to the radiocarpal joint line; confirm fluoroscopically that the screw does not penetrate the articular surface.

Step 4 Insert Proximal Interlocking Screws and Close

Confirm that the proximal interlocking screws are bicortical for adequate fixation but are not too long.

Step 5 Postoperative Management

Use of a splint is followed by active and then passive range-of-motion exercises.

Results

We reported a prospective analysis of patients treated for an unstable distal radial fracture with an intramedullary nail.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

The dorsal horizon view: detecting screw protrusion at the distal radius

PURPOSE

Extensor tendon injury after osteosynthesis of distal radius fractures is a well-documented complication. It has been shown to be associated with screw protrusion through the dorsal cortex, or plunging of the drill bit into the overlying tendon. It is difficult to determine screw length and protrusion using the standard anteroposterior and lateral intraoperative fluoroscopic images because of the triangular configuration of the distal radius and Lister tubercle. In fractures with a coronal split, it may be necessary to lag the dorsal fragment, necessitating longer screws and risking screw protrusion beyond the dorsal cortex. For these fractures, we use a radiographic view aimed along the long axis of the radius to detect screw protrusion.

METHODS

This was a retrospective case series involving 15 distal radius fractures. To obtain the dorsal horizon view, the wrist is hyperflexed and the beam of the image intensifier is aimed along the long axis of the radius. We evaluated 15 distal radius fractures with a coronal split component, where the dorsal horizon view was used to detect dorsal cortex screw protrusion. This view was used intraoperatively following the use of the standard views. We evaluated records and imaging to ascertain whether the use of this radiograph led to a change in intraoperative screw selection.

RESULTS

Of the 15 cases, we changed screw selection as a result of the additional view in 4 patients. In 3 of these cases, the screw length was long, which was not apparent on standard intraoperative fluoroscopic views.

CONCLUSIONS

The use of the dorsal horizon view is a useful adjunct to prevent screw protrusion beyond the dorsal cortex when performing osteosynthesis of the distal radius.

Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius

PURPOSE

To evaluate whether there was a difference in complication rates in our patients treated with external fixation versus volar plating of distal radius fractures. We also looked for a difference in radiographic results; in the clinical outcomes of flexion, extension, supination, pronation, and grip strength; and in scores on the visual analog scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

METHODS

We reviewed 115 patients with comminuted intrarticular distal radius fractures. Of those patients, 59 were treated with external fixation and 56 with volar plate fixation. Postoperative radiographs, range of motion, and grip strength were measured; DASH and VAS pain questionnaires were administered; and complications were documented.

RESULTS

The external fixation group had a significantly higher overall complication rate. In the volar plate group, there were more tendon and median nerve complications, but this difference was not significant. Radiographically, the external fixator group demonstrated radial shortening of 0.7 mm, whereas the volar plate group demonstrated 0.3 mm of radial shortening during the postoperative period. There were no significant differences between the groups in the measurement of scapholunate angle or palmar tilt. The mean DASH score at final follow-up was 32 in the external fixation group and 17 in the volar plate group, which was statistically significant. The final VAS scores were statistically different at 3.1 for the external fixation group and 1.1 for the volar plate group. On physical examination, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.

CONCLUSIONS

In the patients we studied, volar plate fixation has an overall decreased incidence of complications and significantly better motion in flexion-extension and supination-pronation compared to external fixation. Volar plate fixation also has less radial shortening than the external fixation group, yet the absolute difference in magnitude of ulnar variance was only 1.4 mm, calling into question the clinical significance of this difference. Patients with volar plating also have better pain and functional outcomes and better grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

SURGICAL TREATMENT OF DISTAL RADIUS FRACTURES WITH A VOLAR LOCKED PLATE: CORRELATION OF CLINICAL AND RADIOGRAPHIC RESULTS

Objectives: To analyze and correlate the clinical and radiographic results from patients with distal radius fractures who underwent surgical treatment with a fixed-angle volar locked plate. Methods: Sixty-four patients with distal radius fractures were evaluated. They all underwent surgical treatment with a volar locked plate for the distal radius, with a minimum of six months of postoperative follow-up. They underwent a physical examination that measured range of motion and grip strength, answered the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and underwent radiographic examination. Results: In the physical examination on the patients, all the range-of-motion measurements were reduced. Grip strength measured in kgf was on average 85.8% of the strength on the unaffected side. The mean DASH score was 15.99. A significant relationship was found between lower DASH scores and losses of extension and grip strength. On the radiographs, the mean values in relation to the unfractured side were 84.0% for radial inclination, 85.4% for radial length and 86.8% for volar deviation of the radius. Loss of radial length was correlated with losses of extension and grip strength.

Prospective study of distal radial fractures treated with an intramedullary nail

BACKGROUND

Intramedullary nailing for the treatment of unstable distal radial fractures is reported to provide stable fixation with minimal soft-tissue complications, but there is a paucity of data documenting the results of this technique. The purpose of this study was to prospectively determine the functional outcomes of treatment of unstable distal radial fractures with an intramedullary nail.

METHODS

Patients aged fifty years and older with a dorsally displaced unstable distal radial fracture--an extra-articular or simple intra-articular fracture--that was amenable to closed or percutaneous reduction were offered treatment with intramedullary nail fixation (MICRONAIL). Thirty-one patients were enrolled in the study, and twenty-nine patients with a mean age of sixty-seven years (range, fifty-one to eighty-five years) were available for one-year follow-up. According to the AO classification, there was one type-A2, twenty-four type-A3, and four type-C2 distal radial fractures. The patients were evaluated at six weeks, three months, six months, and one year after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, grip strength, a modified Mayo wrist score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

At the final one-year follow-up evaluation, the active range of motion of the injured wrist relative to that on the uninjured side averaged 95% of flexion, 95% of extension, 93% of ulnar deviation, 91% of radial deviation, 99% of pronation, and 99% of supination. The mean grip strength was 96% of that on the uninjured side. According to the modified Mayo wrist score, there were twenty excellent and nine good results. The mean DASH score was 4.8 points. The final radiographic measurements demonstrated, on average, 25° of radial inclination, 11° of volar tilt, 10 mm of radial length, and +1 mm of ulnar variance. Loss of reduction occurred in two patients. One patient developed transient superficial radial sensory neuritis, which resolved within two months.

CONCLUSIONS

Intramedullary nailing can be a safe and effective treatment with minimal complications for dorsally displaced unstable extra-articular or simple intra-articular distal radial fractures.

Surgical exposures of the radius and ulna

The forearm contains many muscles, nerves, and vascular structures that change position on forearm rotation. Exposure of the radial shaft is best achieved with the Henry (volar) or Thompson (dorsal) approach. The volar flexor carpi radialis approaches are used increasingly for exposure of the distal radius. Although the dorsal approach is a safe utilitarian option with many applications, its use for managing fracture of the distal radius has waned. Potential complications associated with radial exposure include injury to the superficial branch of the radial nerve, the lateral antebrachial cutaneous nerve, and the cephalic vein. Dorsal and ulnar proximal radial exposures are associated with increased risk of injury to the posterior interosseous nerve. With surgical exposure of the ulna, care is required to avoid injuring the dorsal cutaneous branch of the ulnar nerve.

Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study

PURPOSE

Dorsal plating of distal radius fractures with traditional 2.5-mm-thick plates is associated with extensor tendon complications. Consequently, volar locking plates have gained widespread acceptance. A new generation of 1.2- to 1.5-mm, low-profile dorsal plates was designed to minimize tendon irritation. This study examines the complication rates of low-profile dorsal plates compared with volar locking plates.

METHODS

We identified patients with distal radius fractures treated between September 2002 and June 2006 by low-profile dorsal or volar locking plates. Information pertaining to 7 categories of complications (hardware discomfort and pain, tendon irritation/rupture, failure of reduction, infection, complex regional pain syndrome, stiffness, and neuropathy/hypersensitivity) was collected. Complications were defined as any postoperative plating complications requiring additional surgical intervention, whereas those that only caused patient discomfort were considered secondary problems.

RESULTS

We included 100 patients, comprising 104 plating cases (57 dorsal, 47 volar), in this study. Overall length of follow-up was 44 ± 21 months (range, 12-80 mo). A total of 18 patients (8 dorsal, 10 volar) experienced complications, whereas 47 (25 dorsal, 22 volar) had secondary reports. Three dorsal and 4 volar patients had complete plate removals. Three dorsal and no volar plates had screw removals only. One volar plate (no dorsal plates) had a major tendon rupture (flexor pollicis longus); 3 dorsal and 3 volar plates resulted in tendon irritation complications, and 4 dorsal and 3 volar plates had secondary problems from tendon irritation. None of the above measures approached statistical significance. Volar cases were associated with significantly more neuropathic complications than dorsal cases.

CONCLUSIONS

Dorsal low-profile plates are not associated with significantly more tendon irritation or rupture complications. However, volar plating is associated with a higher rate of neuropathic complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Internal versus external fixation for unstable distal radius fractures: an up-to-date meta-analysis

PURPOSE

Our aim was to compare the effect of internal vs external fixation for unstable distal radius fractures regarding postoperative complications, clinical results and radiological outcomes.

METHODS

We selected PubMed; Cochrane Library; EMBASE; BIOSIS; Ovid and the relevant English orthopaedic journals and pooled data from ten eligible randomised controlled trials containing 738 patients to conduct a subgroup analysis according to different periods of follow-up. Our aim was to summarise the best available evidence.

RESULTS

Results showed that compared with external fixation, internal fixation led to significantly fewer total surgical complications [95% confidence interval (CI) 0.39-0.81, P = 0.002] and reduced the incidence of pin-track infections (95% CI 0.08-0.46, P = 0.0002) after a one year follow-up. For clinical results, grip strength (95% CI 1.59-8.25, P = 0.004), supination (95% CI 13.99-48.83, P = 0.0004) and pronation (95% CI 5.61-26.09, P = 0.002) were superior in the internal fixation group six weeks postoperatively, and the same results were obtained three months postoperatively for grip strength (95% CI 3.21-13.47, P = 0.001) and supination (95% CI 3.61-16.01, P = 0.002). Meanwhile, the Disabilities of the Arm, Shoulder and Hand (DASH) score was superior in the internal fixation group at three months (95% CI -20.62 to -2.07, P = 0.02) and after one year (95% CI -14.37 to -2.32, P = 0.007) follow-up.

CONCLUSIONS

We suggest that the final results are significant and there is some evidence supporting the use of open reduction and internal fixation.

Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixed-angle plating

BACKGROUND

Extensor tendon irritation and attritional tendon ruptures are well-recognized complications, secondary to dorsal screw penetration following volar plating of the distal radius. Lateral and oblique views of the wrist have limited ability to detect such penetration, particularly at the ulnar side of the Lister's tubercle. In this report, we conducted an intraoperative fluoroscopic study to determine dorsal screw penetration in various positions of the wrist/forearm and compared the standard radiographic views (lateral, supination, and pronation views) with dorsal tangential view of the wrist.

MATERIALS AND METHOD

Standard lateral, oblique (in pronation and supination), and dorsal tangential views were obtained in 27 consecutive patients undergoing fixation a distal radius fractures using a volar plate. The number of penetrating screws in each dorsal compartment (second, third, fourth) was recorded in each view. Dorsal tangential view was obtained using a mini C-arm intraoperatively and sending the beam parallel to the dorsal aspect of the wrist in transverse plane.

RESULTS

Of the 125 distal screws, 8 screws were seen to be penetrating the dorsal cortex in lateral and oblique views, whereas 11 screws were detected in dorsal tangential view.

CONCLUSION

The screw penetration to the third dorsal compartment was missed in standard views, but visualized in dorsal tangential view. We recommend the use of dorsal tangential view in addition to standard lateral and oblique views during volar plating of the distal radius.

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

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

Dorsal and volar 2.4-mm titanium locking plate fixation for AO type C3 dorsally comminuted distal radius fractures

PURPOSE

In this retrospective, nonrandomized, single-surgeon study, we evaluated the clinical outcomes of dorsal and volar locking plate fixation for AO type C3 dorsally comminuted distal radius fractures.

METHODS

We treated 41 consecutive patients who had sustained AO C3 dorsally comminuted fractures of the distal radius with 2.4-mm titanium locking plates between 2006 and 2008. Patients in group 1 (n = 22) were treated with dorsal locking plates, and those in group 2 (n = 19) with volar locking plates. We evaluated clinical outcomes at an average of 37 months and performed statistical analysis using the Mann-Whitney U test and Fisher's exact test.

RESULTS

No significant difference was noted between the 2 groups in terms of radial inclination, volar tilt, and ulnar variance. At the 3- and 6-month follow-up, group 1 showed better clinical results with respect to wrist extension, grip strength, and Gartland and Werley score, whereas group 2 showed better wrist flexion during this period. The range of motion and grip strength progressively leveled out between the 2 groups, and no significant differences were observed at the 9- and 12-month assessments. One patient in group 1 had short-term complex regional pain syndrome, and 4 patients in group 2 had temporary median nerve numbness.

CONCLUSIONS

Treatment with dorsal or volar locking plates can provide satisfactory radiographic and functional outcomes for AO type C3 dorsal comminuted distal radius fractures. The dorsal plate group showed an earlier recovery of wrist extension, grip strength, and functional score at the 3- and 6-month follow-up owing to direct reduction as well as fragmental-specific fixation of the dorsal fracture fragments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience

BACKGROUND

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction.

RESULTS

Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10 days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction.

DISCUSSION

The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.

Screw prominences related to palmar locking plating of distal radius

Fixation of unstable distal radius fractures with palmar locking plates provides a stable reduction and early return of function, but complications arising from unrecognized dorsally prominent screws penetrating the extensor compartments are increasingly reported. Standard radiographs and fluoroscopy may not adequately visualize screw lengths, owing to the complex shape of the dorsum of the distal radius. We examined 46 distal radius fractures treated with palmar locking plates by ultrasound. Of the total 230 locking screws, 59 protruded from the dorsal cortical surface by 0.5 mm or more (range 0.5-6.1 mm). The first extensor compartment was violated by one screw, the second compartment by 22 screws, the third compartment by 15 screws, and the fourth compartment by 21 screws. Asymptomatic tenosynovitis was detected in four and symptomatic tenosynovitis in 14 of the 59 prominent screws. Ultrasound imaging may be useful in cases where intra-articular and/or comminuted fractures require distal plate placement and engagement of screws in the dorsal cortex.

Biomechanical properties of volar hybrid and locked plate fixation in distal radius fractures

PURPOSE

We compare the biomechanical properties of a volar hybrid construct to an all-locking construct in an osteoporotic and normal comminuted distal radius fracture model.

METHODS

Groups of 28 normal, 28 osteoporotic, and 28 over-drilled osteoporotic left distal radius synthetic bones were used. The normal group consisted of synthetic bone with a standard foam core. The osteoporotic group consisted of synthetic bone with decreased foam core density. The over-drilled osteoporotic group consisted of synthetic bone with decreased foam core density and holes drilled with a 2.3 mm drill, instead of the standard 2.0 mm drill, to simulate the lack of purchase in osteoporotic bone. Within each group, 14 synthetic bones were plated with a volar locking plate using an all-locking screw construct, and 14 synthetic bones were plated with a volar locking plate using a hybrid screw construct (ie, both locking and nonlocking screws). A 1-cm dorsal wedge osteotomy was created with the apex 2 cm from the volar surface of the lunate facet. Each specimen was mounted to a materials testing machine, using a custom-built, standardized axial compression jig. Axial compression was delivered at 1 N/s over 3 cycles from 20 N to 100 N to establish stiffness. Each sample was stressed to failure at 1 mm/s until 5 mm of permanent deformation occurred.

RESULTS

Our results show no difference in construct stiffness and load at failure between the all-locking and hybrid constructs in the normal, osteoporotic, or over-drilled osteoporotic synthetic bone models. All specimens failed by plate bending at the osteotomy site with loss of height.

CLINICAL RELEVANCE

Although volar locking plates are commonly used for the treatment of distal radius fractures, the ideal screw configuration has not been determined. Hybrid fixation has comparable biomechanical properties to all locking constructs in the fixation of metaphyseal fractures about the knee and shoulder and might also have a role in the fixation of distal radius fractures.

Surgical approaches to the distal radius

INTRODUCTION

Fractures of the distal radius are among the most common fractures seen. They encompass a myriad of presentations and fracture patterns that often benefit from various open reduction and internal fixation techniques-including volar plating, dorsal plating, radial plating, intramedullary nailing, and fragment-specific fixation. In order to obtain optimal reduction of these fractures, surgeons require a thorough understanding of the anatomy and various surgical exposures.

ANATOMY

The distal radius is surrounded by a soft tissue envelope rich in vascularity and cutaneous innervation. The osseous surface consists of two articular surfaces and three cortical sides covered almost entirely by soft tissue.

SURGICAL APPROACHES

Approaches to the distal radius can be broadly divided into volar, radial, and dorsal. Visualization of the articular surface can be accomplished best arthroscopically. Arthroscopy can be performed alone or in conjunction with other open approaches to the distal radius.

SUMMARY

This article will review the pertinent anatomy and various surgical approaches in order to facilitate the surgeon's ability to safely expose a distal radius fracture.

Should unstable extra-articular distal radial fractures be treated with fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial

Fractures of the distal radius are commonly treated with cast immobilisation; however, those potentially unstable injuries with dorsal comminution may need operative intervention. This intervention is usually with manipulation and Kirschner wires but advances in locking-plate technology have enabled surgeons to achieve anatomical reconstruction of complex fracture patterns, even in poor-quality osteoporotic bone.To ascertain if fixed-angle volar-locked plates confer a significant benefit over manipulation and Kirschner-wire stabilisation, we prospectively randomised 56 adult patients with isolated, closed,unilateral, unstable extra-articular fractures into two treatment groups, one fixed with K-wires and the other fixed with a volar locking plate.Functional outcomes were assessed using Gartland and Werley and Disabilities of the Arm, Shoulder and Hand (DASH) scores. These were statistically better in the plate group at 3 and 6 months.Radiological assessment showed statistically better results at 6 weeks, 3 months and 6 months, postoperatively.In the plate group, there was no significant loss of fracture reduction.

Wrist function recovers more rapidly after volar locked plating than after external fixation but the outcomes are similar after 1 year

BACKGROUND AND PURPOSE

Promising results have been reported after volar locked plating of unstable dorsally displaced distal radius fractures. We investigated whether volar locked plating results in better patient-perceived, objective functional and radiographic outcomes compared to the less invasive external fixation.

PATIENTS AND METHODS

63 patients under 70 years of age, with an unstable extra-articular or non-comminuted intra-articular dorsally displaced distal radius fracture, were randomized to volar locked plating (n = 33) or bridging external fixation. Patient-perceived outcome was assessed with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) questionnaire.

RESULTS

At 3 and 6 months, the volar plate group had better DASH and PRWE scores but at 12 months the scores were similar. Objective function, measured as grip strength and range of movement, was superior in the volar plate group but the differences diminished and were small at 12 months. Axial length and volar tilt were retained slightly better in the volar plate group.

INTERPRETATION

Volar plate fixation is more advantageous than external fixation, in the early rehabilitation period.

Comparative Analysis of the Complication Profile following Palmar Plating versus External Fixation of Fractures of the Distal Radius

Background

Much attention has been given recently to the complication profile of volar plate fixation of distal radial fractures. The purpose of this investigation was to compare complication rates among patients with distal radial fractures treated with volar plating versus those treated with external fixation.

Methods

Two parallel series of patients with comminuted intra-articular distal radius fractures were reviewed. 59 patients were treated with external fixation and 56 patients with volar plate fixation. Postoperative radiographs, range of motion, grip strength, DASH scores, and VAS pain questionnaires were analyzed, and complications were described.

Results

The external fixation group had a significantly higher overall complication rate (p = 0.021) than the volar plate fixation group. In the volar plate group, there were more tendon complications and median nerve pathology. Radial shortening was greater in the external fixation group when compared to the volar plate fixation group. DASH scores and VAS scores were significantly higher in the external fixation group. Clinically, the patients in the volar plate fixation group had significantly greater arcs of motion in pronation-supination (p < 0.0001) and flexion-extension (p = 0.002) with a trend towards better grip strength (p = 0.0062).

Conclusions

Volar plate fixation for fractures of the distal radius provides an overall decreased incidence of complications, significantly less radial shortening, and significantly greater postoperative wrist motion when compared to external fixation. Volar plate fixation is also associated with lower VAS scores when compared to external fixation as well as DASH scores that approach statistical significance.

Level of evidence

III (retrospective comparative study).

Biomechanical comparison of locking versus nonlocking volar and dorsal T-plates for fixation of dorsally comminuted distal radius fractures

OBJECTIVES

The purpose of this study was to gain insight into the effect of plate location and screw type for fixation of extra-articular distal radius fractures with dorsal comminution (Orthopaedic Trauma Association Type 23-A3.2).

METHODS

Sixteen pairs of cadaver radii were randomized to four plating configurations: dorsal locking, dorsal nonlocking, volar locking, and volar nonlocking. A standard 1-cm dorsal wedge osteotomy was used. Cyclic axial loads were applied for 5000 cycles. Stiffness and fragment displacement were recorded at 500 cycle-intervals. Pre- and postcyclic loading radiographs were analyzed. An axial load to failure test followed and construct stiffness and failure strength recorded. Biomechanical data were analyzed using a two-way analysis of variance (P < 0.05). Failure modes were descriptively interpreted.

RESULTS

Cyclic testing data revealed no difference between constructs at any interval. Within all construct groups, displacement that occurred did so within the first 500 cycles of testing. Pre- and postcyclic loading radiographic analysis showed no differences in construct deformation. Load to failure testing revealed no differences between groups, whereas volar constructs approached significance (P = 0.08) for increased failure strength. Dorsal constructs failed primarily by fragment subsidence and fragmentation, whereas volar constructs failed by plate bending.

CONCLUSIONS

No difference in all measured biomechanical parameters supports equivalence between constructs and surgeon discretion in determining operative method. Minimal fragment displacement and construct deformation during physiological testing support previous data that early postoperative motion can be recommended. Fragment displacement that occurs does so in the early periods of motion.

Anatomical and radiological study applied to distal radius surgery

PURPOSE

The purpose of this study was to determine, during anterior plating of the distal radius, the length of a screw above which there is a risk for the extensor tendons and the optimal shape of an anterior plate. It was also to determine the projection of the axis of the distal third of the radius on the distal articular surface in case of wrist arthroplasty in order to simplify the procedure.

METHODS

We studied 74 dry radii from adult cadavers. Each one underwent a CT scan. We measured the thickness of each radius at the dorsal tubercle level, at the second compartment level and at the third compartment level. We calculated the metaphyseal-epiphyseal angles of the lateral column and of the intermediate column (Rikli and Regazzoni in J Bone Joint Surg (Br) 78(4):588-592, 1996). We also calculated the projection of the longitudinal axis of the most distal 7 cm of the radius on the distal carpal surface of the radius.

RESULTS

Mean thickness at the dorsal tubercle level was 22.1 mm (18-26.1). The mean slope of the lateral column was 155° (143-167) while that of the intermediate column was 145° (134-153). We have found a statistically significant difference (p < 0.0001) between these two slopes. The axis of the distal radius was projected on the posterior-lateral quadrant of the distal articular surface.

CONCLUSIONS

The emergence of new implants needs a precise evaluation of a fractured, an arthritic or a reconstructed distal radius. The double slope of the distal radius complicates the manufacturing of an "anatomical" plate. The optimal shape is between these two slopes. Moreover, ancillaries for wrist replacement are still approximations, which means that it is important to know the projection of the radial axis on the articular surface of the distal radius.

DISTAL RADIAL FRACTURES IN PATIENTS OVER 60 YEARS OLD: ORTHOGONAL PLATES VERSUS VOLAR PLATE

Objective: To compare the results from surgical treatment between volar plates with angular stability and orthogonal plates in unstable distal radius fractures, in patients aged over 60 years. Methods: The patients were divided into two groups that were treated with volar plates or orthogonal plates. Clinical and radiographic results were analyzed prospectively. Results: The study groups presented similar clinical and radiographic results six months after the operation. However, three months after the surgery, the volar plate group had superior results. Conclusion: Both group presented good functional results. Surgical treatment enabled early rehabilitation. The orthogonal plate technique required a longer learning curve, presented more complications and worse initial results.

Management of distal radius fractures: treatment protocol and functional results

Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment is controversial and still debated in the literature. For a correct management of these lesions many authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint mobilisation. We report our experience in the daily management of these lesions. The fractures are evaluated considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture stability. The best treatment option must be decided in accordance to the type of fracture, the extent of metaphyseal comminution, the quality of the bone and the medical condition of the patient.

Minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study

INTRODUCTION

Rupture of extensor pollicis longus (EPL) tendon is a recognised complication following volar plate fixation of distal radius fractures, usually from attrition caused by prominent screws. We sought to identify the screw holes in some of the most commonly used plates which may precipitate tendon injury.

SUBJECTS AND METHODS

Three fixed-angle volar locking plates were sequentially positioned into 18 cadaveric arms. A wire was passed through each of the holes in the plates using a locking guide and the dorsal relationships noted.

RESULTS

Each plate had specific 'high-risk' holes which directed the wire towards the EPL groove. The central screw holes appeared mostly implicated in EPL injury.

CONCLUSIONS

Awareness of 'high-risk' holes and appropriate minor alterations in surgical technique may consequently decrease the incidence of EPL irritation and rupture.

Extension fractures of the distal radius in patients older than 50: a prospective randomized study comparing fixation using mixed pins or a palmar fixed-angle plate

We randomized 103 patients over the age of 50 with an unstable closed intra- or extra-articular dorsally displaced distal radius fracture to have either palmar fixed-angle plating (n=50) or 'mixed pinning' (n=53) and compared the clinical and radiological outcomes at 3, 6, 12 and 26 weeks after surgery in a prospective study. Postoperative palmar tilt was significantly better in those stabilized with K-wires, but loss of reduction was statistically less in those stabilized with a plate. At 26 weeks, functional results, assessed by DASH and Herzberg scores, were better in those fixed with a plate.

Palmar multidirectional fixed-angle plate fixation in distal radius fractures: do intraarticular fractures have a worse outcome than extraarticular fractures?

INTRODUCTION

The results and complications using a palmar plate system with the possibility of multidirectional fixed-angle screw fixation (Aptus® Radius 2.5 mm by Medartis®) for the treatment of unstable distal radius fractures were evaluated in a single cohort study including 62 patients.

PATIENTS

Patients with extra- and intraarticular fractures were evaluated separately. The mean follow-up was 14.7 months. Active wrist motion averaged 60.1° extension, 52.0° flexion, 86.3° pronation, and 84.6° supination. Grip strength averaged 89% of the contralateral wrist.

RESULTS

There was no loss of the initial reduction with bony union in all cases. The mean DASH-score was 12.6 points. Postoperative complications included two extensor pollicis longus tendon ruptures, two median nerve compression syndromes, one complex regional pain syndrome, and one postoperative haematoma. In our series the results of the intraarticular fracture group were similar to the extraarticular fracture group. The complication rate, however, was substantially higher in the intraarticular fracture group.

CONCLUSION

We conclude that palmar plating with multidirectional fixed-angle screw insertion is an effective and useful treatment option, especially for complex intraarticular distal radius fractures.

Influence of screw diameter and number on reduction loss after plating of distal radius fractures

BACKGROUND

The current options for plate-screw combinations in volar locking distal radius plates used for the treatment of distal radius fractures are either plates with a single distal screw row or plates with multiple distal screw rows. Additionally, the screws themselves may have either fixed angle locking or polyaxial locking mechanisms. To date, there is no evidence or consensus regarding the optimal plate-screw combination. The aim of this study was to assess the biomechanical behaviour of different plate-screw combinations with respect to total distal screw number, number of distal screw rows and screw projection surface area of the most distal row.

METHODS

Biomechanical study to assess six different plating configurations in five different volar locking plate models in a Sawbone distal radius fracture model. The specimens were loaded with 800 Newton loads for 2.000 cycles at 1 Hz. After cyclic loading, load-to-failure testing was performed.

RESULTS

  With cyclical testing, there was a significant and positive correlation between rigidity and a greater projection area of the most distal screws. Dorsal tilting was significantly more pronounced in plate models with a lesser projection area of the most distal screws and a smaller number of distal screws. With load-to-failure testing, there was a significant increase in rigidity with increasing screw projection area of the most distal row and total number of distal screws.

CONCLUSIONS

Additional distal screw rows in volar locking distal radius plates might not add substantially to resistance against loss of reduction in the post-operative period.

The role of locking technology in the hand

Locked fixed-angle plating in the hand and wrist helps to optimize outcomes following surgical fixation of select acute fractures and complex reconstructions. Select indications include unstable distal ulna head/neck fractures, periarticular metacarpal and phalangeal fractures, comminuted/multifragmentary diaphyseal fractures with bone loss (ie, combined injuries of the hand), osteopenic/pathologic fractures, nonunions and corrective osteotomy fixation, and small joint arthrodesis. Locked plating techniques in the hand should not be seen as a panacea for wrist and digital acute trauma and delayed reconstructions. An understanding of the biomechanics of fixed-angle plating and proper technical application of locking constructs will optimize outcomes and minimize complications. As clinical experience with locking technology in hand trauma broadens, new indications and applications will emerge. Currently, several systems are available. The specific implants share common features in their protocols for insertion, but unique differences in their design (ie, individual locking mechanisms, uniaxial vs polyaxial locking capability, metallurgy, and plate profiles) must be appreciated and considered preoperatively.

Intramedullary fixation of distal radius fractures

Intramedullary fixation is the latest in a variety of techniques that have been developed to manage distal radius fractures. Intramedullary nailing of these fractures combines the soft-tissue advantages of a less invasive surgical approach with the biomechanical advantages of locking screw technology. These features may enable an accelerated postoperative rehabilitation and quicker return to function. Disadvantages associated with the intramedullary technique include the necessity of a closed or percutaneous reduction and the inability of the implant to adequately stabilize intraarticular or highly comminuted fractures. Consequently, intramedullary implants are primarily indicated for fixation of extra-articular or simple intraarticular split patterns and should not be employed for management of volar or dorsal shear fractures. Preliminary clinical data is emerging in the form of short-term follow-up studies with limited numbers of study participants.

Distal radius fracture arthroscopic intraarticular displacement measurement after open reduction and internal fixation from a volar approach

BACKGROUND

The purpose of this study was to assess articular surface reduction arthroscopically after volar locked-plate fixation of distal radius fractures (DRFs) via fluoroscopyguided open reduction/internal fixation. We also aimed to develop preoperative radiographic criteria to help assist in determining which DRFs may need arthroscopic evaluation.

METHODS

A total of 31 consecutive patients with DRF were prospectively enrolled. Posteroanterior (PA) and lateral radiographs as well as axial, coronal, and sagittal CT scans were obtained just after attempted reduction of the DRF. The widest articular displacement at the radiocarpal joint surface of the distal radius (preopD) was then measured using a digital radiography imaging system. The DRF was reduced under fluoroscopy, and a volar locked plate was applied. The degree of residual articular displacement was then measured arthroscopically, and the maximum displacement (postopD) was measured with a calibrated probe.

RESULTS

Of the 31 patients, 7 had an arthroscopically assessed maximum postopD of > or = 2 mm after internal fixation. The correlation coefficients between each preopD and postopD of all radiographs and CTs were statistically significant. The cutoff values were 0.5 mm for PA radiographs, 2.10 mm for lateral radiographs, 2.15 mm for axial CT scans, 3.15 mm for coronal CT scans, and 1.20 mm for sagittal CT scans. All cutoff values for PA and lateral radiographs and for axial, coronal, and sagittal CT scans were unsuitable as screening criteria for arthroscopic reduction of DRF because of their low sensitivities and specificities. The cutoff value of the new preopD (the sum of the preopDs determined by lateral radiography and coronal CT scan) was 5.80 mm, and its sensitivity and specificity were 100% and 83.3%, respectively.

CONCLUSIONS

Because a new preopD cutoff value of 5.80 mm is a good indicator for residual articular displacement after internal fixation of >2 mm, it is also a good indicator for the need for arthroscopic evaluation after internal fixation.

Number and locations of screw fixation for volar fixed-angle plating of distal radius fractures: biomechanical study

PURPOSE

To compare the biomechanical properties of different numbers and locations of screws in a multidirectional volar fixed-angle plate in a distal radius osteotomy cadaver model.

METHODS

We created an extra-articular fracture in 16 pairs of fresh-frozen human cadaver radiuses. The 32 specimens were randomized into 4 groups. All fractures were fixated with a multidirectional volar fixed-angle plate. We tested 4 different screw-placement options in the distal fragment. The distal fragment was fixed with 4 locking screws in the distal row of the plate in group a, and with 4 locking screws alternately in the distal and proximal rows in group b. In group c, 3 locking screws were used in the proximal row; in group d, 7 locking screws were used, filling all screw holes in the distal and proximal rows of the plate. The proximal fragment was fixed with 3 screws. The specimens were loaded with 80 N under dorsal and volar bending and with 250 N axial loading. Finally, load to failure tests were performed.

RESULTS

Group d had the highest mean stiffness, 429 N/mm under axial compression, and was statistically significantly stiffer than the other groups. Group b had a mean stiffness of 208 N/mm, followed by group a, with 177 N/mm. Group c showed only a mean stiffness of 83 N/mm under axial compression. There were no statistically significant differences under dorsal and volar bending.

CONCLUSIONS

In this model of distal radial fractures, there was a difference regarding the stiffness and the placement of screws in the distal rows of a volar fixed-angle plate. Inserting screws in all available holes in the distal fragment offered the highest stability. Using only the proximal row with 3 screws created an unstable situation. Based on these findings, we recommend placing at least 4 screws in the distal fragment and assigning at least 2 screws to the distal row of the multidirectional screw-holes.

Lateral tilt wrist radiograph using the contralateral hand to position the wrist after volar plating of distal radius fractures

PURPOSE

Lateral tilt (radially inclined) radiographs are useful after volar locked plate fixation of distal radius fractures to assess the radiocarpal joint, subchondral bone congruity, and volar tilt. The purpose of our study was to define the reliability of our positioning method using the patient's opposite hand to position the injured wrist to obtain an inclined lateral radiograph with good visualization of the subchondral bone.

METHODS

A retrospective review identified adult patients who had a unilateral distal radius fracture treated with a volar locked plate and who had an initial postoperative lateral tilt radiograph using the contralateral hand to position the injured wrist. Intraoperative fluoroscopic images were reviewed to confirm the ability to see the extra-articular placement of all hardware. The inclined lateral wrist radiograph was obtained by positioning the injured wrist at a height determined by the contralateral hand being placed under the ulnar wrist crease. The wrist was then supported there with firm blocks in all cases. The radiographic beam was directed perpendicular to the horizontal cassette. Two reviewers (authors) then blindly reviewed postoperative radiographs to determine whether the radiocarpal joint and subchondral bone were visualized and whether any screws or pegs appeared to cross the radiocarpal joint. An acceptable lateral tilt radiograph was defined as good visualization of the subchondral bone while allowing only the most radial peg to appear to cross the joint. We also placed 15 normal volunteers into the lateral tilt position, using their opposite hand, to measure the inclined forearm angle.

RESULTS

A total of 24 wrists (24 patients) were identified and 23 patients had lateral tilt radiographs with acceptable visualization of the subchondral bone. The concordance of the subchondral bone visualization was 100% (95% confidence interval, 85.5% to 100%). The mean angle with lateral tilt positioning was 18 degrees from horizontal (range, 15 degrees to 23 degrees; standard deviation, 2.4 degrees).

CONCLUSIONS

Using the contralateral hand to position the lateral inclined view, our lateral tilt position produced radiographs with reliable visualization of the distal radius subchondral bone in 96% of our cases. Visualization of the subchondral bone in the region of the radial aspect of the scaphoid fossa requires more tilt than is achieved with this technique.

A biomechanical comparison of a biodegradable volar locked plate with two titanium volar locked plates in a distal radius fracture model

BACKGROUND

Volar plating is commonly used in the management of distal radius fractures; bioresorbable plates have attractive features. We compared a bioresorbable plate with a latest generation and an established locked titanium plate.

METHODS

Twenty-four fresh-frozen radii (12 pairs) were assigned to three mean bone mineral density-matched groups of eight radii each. A standardized extraarticular distal radius fracture was created and plated using one implant type per group. Postplating stiffness and displacement were studied in a first axial-loading test (15 cycles at 250 N). Next, biodegradation was simulated by 4 weeks' immersion in phosphate-buffered saline, followed by a second axial test. Finally, the specimens underwent cyclic loading (2,400 cycles at 250 N).

RESULTS

It is clear from the initial test that the LCP plate was significantly stiffer and displaced less than the bioresorbable plate. The outcome of the postimmersion tests is that one bioresorbable plate failed early on after 4 weeks' immersion, and the remaining bioresorbable plates and the T plates did not differ significantly. Cyclic tests conclude that the LCP plate was significantly superior to the other systems. One T plate and four of the bioresorbable plates failed, but none of the LCP plates failed. In the bioresorbable constructs, stability, time to failure, and bone mineral density were significantly correlated.

CONCLUSIONS

The LCP plate was biomechanically superior and may be generally recommended for the volar plating of distal radius fractures. Except one plate failure, the bioresorbable plate was similar to the T plate in the quasi-static tests and should, therefore, be considered for clinical studies, with patient selection confined, initially, only to candidates with good bone stock quality.

Delayed rupture of flexor tendons caused by protrusion of a screw head of a volar plate for distal radius fracture: a case report

We report a rare occurrence of attritional rupture of flexor tendons caused by protrusion of the screw head of the volar radius plate. The cause of the protrusion was plate placement on the prominent distal volar lip of the radius and secondary loss of the original reduction due to using a non-locking osteosynthesis system for the treatment of displaced intra-articular fracture of the distal radius.

Quality of life after volar plate fixation of articular fractures of the distal part of the radius

BACKGROUND

Outcome measurement following surgery is increasingly the focus of attention in current health-care debates because of the rising costs of medical care and the large variety of operative options. The purpose of the present study was to correlate quality of life after volar locked plate fixation of unstable intra-articular distal radial fractures with functional and radiographic results as well as with quality-of-life data from population norms.

METHODS

Fifty-four consecutive patients with intra-articular distal radial fractures and a mean age of sixty-three years were managed with a volar locked plate system. Range of motion, grip strength, and radiographs were assessed at a mean of six years postoperatively. The wrist-scoring systems of Gartland and Werley and Castaing were adopted for the assessment of objective outcomes. The Disabilities of the Arm, Shoulder and Hand and Short Form-36 questionnaires were completed as subjective outcome measures, and the results were compared with United States and Austrian population norms.

RESULTS

Functional improvement continued for two years postoperatively. At the time of the latest follow-up, >90% of all patients had achieved good or excellent results according to the scoring systems of Gartland and Werley and Castaing. The results of the Short Form-36 questionnaire were similar to the United States and Austrian population norms. The mean Disabilities of the Arm, Shoulder and Hand score was 5 points at two years, and it increased to 13 points at six years. The twenty patients with radiocarpal arthritis had significantly poorer results in the physical component summary measure of the Short Form-36 questionnaire (p = 0.012).

CONCLUSIONS

The results of the present single-center study show that, following distal radial fracture fixation, wrist arthritis may affect the patient's subjective well-being, as documented with the Short Form-36, without influencing the functional outcome. Well-designed longitudinal clinical trials are needed to confirm the findings of the present investigation in terms of quality of life after surgical treatment of intra-articular distal radial fractures.

Comparison between locking and non-locking plates for fixation of metacarpal fractures in an animal model

PURPOSE

The use of locking plates increases the primary load to failure, thereby reducing the rate of implant-related failure. The good clinical and biomechanical results of locking plates in long bones might be applicable to treatment of metacarpal fractures. The purpose of this study was to determine strength and stiffness of locking plates in a metacarpal fracture model with mono- and bicortical screw fixation in comparison to non-locking plate mono- and bicortical screw fixation, with both types of plates placed at the dorsal side of the bone.

METHODS

Fresh second metacarpals from domestic pigs (n=40) were randomized in 4 equal groups. Short, oblique, mid-shaft fractures were generated, using a standardized 3-point bending method. Fractures were plated with non-locking, titanium, 1-mm-thick monocortical (group 1, n=10) or bicortical (group 2, n =10) plates (Leibinger-Stryker; Stryker Corp, Freiburg, Germany). Newly designed locking titanium plates with the same width and thickness (Leibinger-Stryker) were used in the same manner for groups 3 (monocortical) and 4 (bicortical). The metacarpals were then tested to load to failure in a cantilever bending mode.

RESULTS

Bicortical, non-locking fixation (group 2, 359 +/- 90 N) had a higher load to failure than monocortical non-locking fixation (group 1, 250 +/- 56 N) in testing the maximum load to failure (p < .01). There was no significant difference in stiffness between group 1 (46 +/- 12 N/mm) and group 2 (56 +/- 21 N/mm). The difference in maximum load to failure between monocortical (group 3, 440 +/- 85N) and bicortical (group 4, 378 +/- 116 N) locking plate stabilization was not significant. Also, there was no significant difference in stiffness between monocortical (group 3, 83 +/- 35 N/mm) and bicortical locking plates (group 4, 70 +/- 31 N/mm). Comparing non-locking (group 1) and locking plates in a monocortical fixation technique (group 3) demonstrated significant differences in maximum load to failure (group 1, 250 +/- 56 N; group 3, 440 +/- 85 N) and stiffness (group 1, 46 +/- 12 N/mm; group 3, 83 +/- 35 N/mm). The stability of monocortical locking plates was stronger, although not statistically significant, than the non-locking bicortical plates (load to failure, 440 +/- 85 N vs 359 +/- 90 N; stiffness, 83 +/- 35 N/mm vs 56 +/- 21 N/mm).

CONCLUSIONS

The new generation of locking plates can be used to achieve a higher stability for fixation of metacarpal fractures. Monocortical, stable fixation can minimize flexor tendon interference and probably reduce bone and soft tissue trauma.

Biomechanical comparison of dorsal nail plate versus screw and K-wire construct for extra-articular distal radius fractures in a cadaver bone model

PURPOSE

The purpose of the study was to compare the biomechanical stability of distal radius fracture fixation with 2 new implants, the DNP (Hand Innovations LLC, Miami, FL), a dorsal locked hybrid of nail and plate, and the XSCREW (Zimmer, Freiburg, Germany), an implant combining a cannulated screw and K-wires, in a cadaver bone distal radius fracture model.

METHODS

Eight pairs of fresh-frozen cadaver radii were used. To simulate an extra-articular distal radius fracture, a 5-mm volar open wedge osteotomy was made. Axial loads of 10 to 100 N and torque loads of -1.5 to 1.5 Nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. One thousand cycles in torque and failure tests were performed.

RESULTS

With a median of 136.0 N/mm, the axial stiffness of XSCREW-fixed specimens was higher than that of DNP-fixed specimens, with a median of 69.5 N/mm, but differences were not statistically significant. With a median of 0.163 Nm/ degrees , the torque stiffness of XSCREW-fixed specimens was significantly higher than that of DNP-fixed specimens, with a median of 0.068 Nm/ degrees . The XSCREW-group reached 33% of the axial stiffness and 49% of the torque stiffness of the intact radii, and the DNP-group reached 14% of the axial stiffness and 20% of the torque stiffness of the intact radii.

CONCLUSIONS

In this human cadaver bone biomechanical study, the XSCREW provided more stability than the DNP in torque stiffness but not in axial stiffness.

The use of kinematic and parametric information to highlight lack of movement and compensation in the upper extremities during activities of daily living

A problem that is common to the study of upper limb kinematics and gait analysis is the translation of the evidence from kinematic measurements into easily interpretable information on the status of the patient, such as the amount of compensation or lack of motion. In this study parameters that can be helpful in the rapid and clear identification of limited wrist motion and compensation were derived from kinematic data. A group of six subjects (group A) with no hand impairment, average age 32.5 ys SD 10.7 ys, and another group of five subjects (group B), average age 34.2 ys SD 16.8 ys, having suffered from distal radius fracture were tested during a cyclic activity of daily living. The activity simulated page turning. Thorax, shoulder, elbow and wrist angles were measured during this task using a motion capture system. Corresponding angle ranges were also calculated. The active range of motion (AROM) found for Group B was generally lower than that of Group A, particularly for elbow supination and wrist movements, with wrist flexion/extension statistically smaller for group B (P=0.02). Additional parameters that took into account lack of movements at the wrist and compensation from shoulder elevation, rotation and elbow pronation/supination proved to be more useful at identifying those subjects of group B outside the normative range and can provide clinicians with a rapid and efficient tool that can shorten the analysis process and help make more informed decisions on therapeutic treatments.

Single-incision extensile volar approach to the distal radius and concurrent carpal tunnel release: cadaveric study

PURPOSE

To determine whether a single-incision extensile approach to the distal radius used for open reduction internal fixation and a concomitant radial sided carpal tunnel (CT) release safely and effectively decompresses the carpal tunnel.

METHODS

Five pairs of cadaveric forearms were mounted to a tabletop with a cable pulley system attached to the long finger. Each paired specimen was randomized to volar plating via either the flexor carpi radialis approach (control group) or the extensile volar exposure (combined flexor carpi radialis and radial-sided carpal tunnel release). Before and after the respective exposure and plating, increased CT pressures were created with 2.27, 4.54, and 6.81 kg of distraction. We used a paired t-test to compare the change in CT pressure at each level of distraction before and after intervention for the 2 groups, with significance set at p </= .05. A dissection of each exposure was performed with attention given to the radial aspect of the transverse carpal ligament (TCL) and any possible iatrogenic injuries.

RESULTS

Carpal tunnel pressure increased with increasing distraction. We noted a statistically significant reduction in CT pressure after the extensile exposure and plating with 4.54 (p = .023) and 6.81 (p < .001) kg of distraction, respectively. No significant reduction in mean CT pressure for the control group specimens occurred at any level of distraction force. The average length of the radial TCL was 22 mm (range, 18-31 mm); the average distance between the recurrent motor branch and distal TCL was 11 mm (range, 8-15 mm). No iatrogenic tendon or nerve injury occurred with the extensile volar exposure.

CONCLUSIONS

Carpal tunnel pressure is safely reduced and the distal radius is adequately exposed for fixation with the extensile volar approach.

Complications of distal radius fractures

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

Locked volar plating for unstable distal radial fractures: clinical and radiological outcomes

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

External fixation versus "pi" plate for distal radius fractures

BACKGROUND

Fractures of the distal radius are among the most common fractures in orthopedic practice. The purpose of our study was to explore the advantages and disadvantages of two methods of treatment for this type of fracture.

METHODS

One hundred thirteen fractures of the distal radius have been operated; 49 fractures were treated with an external fixator and 64 fractures by internal fixation using a "pi" plate. The mean follow-up was 12 months. Clinical evaluation was performed using the modified Gartland and Werley's Functional Scoring System. Radiographic evaluation was performed using the modified Lidstrom Radiographic Scoring System.

RESULTS

Clinical results were similar between the two groups of patients (p = 0.46). Radiographic parameters were superior in the group of patients treated with open reduction and internal fixation (p = 0.028).

CONCLUSIONS

Final functional results are comparable between external fixation and dorsal "pi" plating.

The role of locking technology in the upper extremity

The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.

A retrospective pilot study comparing the number of therapy visits required to regain functional wrist and forearm range of motion following volar plating of a distal radius fracture

PURPOSE

The purpose of this retrospective study was to compare the number of therapy visits and amount of time required to achieve functional motion in patients who underwent open reduction and internal fixation of the distal radius.

METHODS

Fourteen patients started early range of motion (ROM) and nine patients started ROM exercises after six weeks. Group comparisons were performed regarding age, Upper Limb Functional Index scores across time points, forearm and wrist ROM measurements across time points, grip strength, days until goal attainment, and number of visits attended.

RESULTS

A statistically significant difference (F=6.48, p<0.005) (95% confidence interval [CI] -14.52 to -6.34) was present between groups when comparing the number of therapy visits. A statistically significant difference (F= 2.35, p<0.005) (95% CI -49.72 to -24.49) was present between groups when comparing the number of days each group took to attain functional ROM of the wrist and forearm.

LEVEL OF EVIDENCE

3.

Flexor tendon problems after volar plate fixation of distal radius fractures

Four cases of flexor tendon problems which developed after volar plate fixation of distal radius fractures are presented. All cases were associated with close contact of the screws or distal edge of the plate with the flexor tendons. Poor bone stock or multiple bone fragments allowing loosening of the plate or non-locking screws cause the hardware to irritate the flexor tendons and ultimately lead to rupture. The flexor tendons involved include the flexor carpi radialis, flexor pollicis longus and flexor digitorum superficialis, and flexor digitorum profundus to the index and long fingers.

Radiographic evaluation of the distal radius using two novel biplanar "pitch-and-roll" views: a preliminary cadaveric study

This study's objective was to compare the use of two biplanar angled radiographs versus standard posterioanterior (PA) and lateral radiographs in determining preservation of the articular space with regard to pin placement in the distal radius. Various combinations of inclination (pitch) and clockwise/counterclockwise rotation (roll) were used to determine the best view of the distal radius articular surface. Optimum visualization of the articular surface presented at 12 degrees inclination plus 15 degrees counterclockwise rotation for the PA view and 22 degrees inclination and 15 degrees counterclockwise rotation for the lateral view. Ten cadaveric forearms were dissected, and ten Kirschner wires (K-wires) were placed at specific surfaces of the distal radius. Each K-wire was countersunk 2 mm below the chondral surface so all K-wires resided within the subchondral bone. Each forearm was radiographed in four views; PA, lateral, pitch-and-roll PA (PR-PA), and pitch-and-roll lateral (PR-lateral). Four blinded reviewers evaluated the radiographs and marked whether they were certain, relatively certain, or uncertain that the K-wires did not penetrate into the articular space. Reviewers demonstrated significantly less uncertainty about intraarticular penetration (p < 0.005) with both the PR-PA and PR-lateral views compared with standard PA and lateral views. The biconcave nature of the distal radius makes it extremely difficult to visualize placement of hardware with respect to the articular surface using standard radiographs. The use of PR-PA and PR-lateral views significantly improves the surgeon's ability to judge the position of hardware in the distal radius compared to standard radiographic views, thus allowing for more meaningful clinical decision in post-operative radiographs.