Die palmare winkelstabile Plattenosteosynthese bei Extensionsfrakturen des distalen Radius

[Distal radius fracture-tactic and approach]

OBJECTIVE

The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare.

INDICATIONS

Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement.

CONTRAINDICATIONS

The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation.

SURGICAL TECHNIQUE

The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen.

POSTOPERATIVE MANAGEMENT

In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization.

RESULTS

Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year

INTRODUCTION

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year.

METHODS

A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20 months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.

RESULTS

Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = - 0.18, p = 0.04) and Mayo Score (r = - 0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2 mm) and acceptable (< 2 mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65 years of age.

CONCLUSIONS

Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2 mm) was not associated with a worse clinical important outcome. Age (< 65/> 65 years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Corrective osteotomy after malunited distal radius fractures

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

Inducing life-like distal radius fractures in human cadaveric specimens: a tool for enhanced surgical training

INTRODUCTION

Surgical education consists often times of a discrepancy between necessary amount of provided operative teaching and amount of organizational and ward duties. Operative education is often cut to a minimum. As public awareness toward surgical competence raises, so must the educational system. Courses that provide pre-fractured cadaveric specimens can facilitate surgical teaching realistically, prior to operating on living patients. The aim of this study is to introduce a realistic distal radius fracture simulation setup.

MATERIALS AND METHODS

12 cadaveric specimens (3 male, 9 female) were fixed onto a custom drop-test-bench in the hyperextension of the wrist. The forearm was cut midway between elbow and carpus. The distal part of the forearm was potted, and the specimen was exposed to a high energetic impulse. CT imaging was performed after fracture simulation to detect the exact fracture patterns. We used the AO/ASIF recommendations and four-corner concept to classify the achieved fractures by two independent trauma surgeons.

RESULTS

All cadaveric specimens could be successfully fractured. 11 fractures were classified as type 23C3.2 and one was classified as type 23C3.3, as additional fracture of diaphysis occurred. Subclassification according to the four-corner concept showed all fractures to be type C. A concomitant ulnar styloid fracture was observed in 4 cases. Furthermore, all cases showed at least one fragment involving the sigmoid notch. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age (p value 0.402), as well as HU and required kinetic energy (p value 0.063).

CONCLUSION

A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic distal radius fractures in cadaveric specimens with intact soft tissue. Furthermore, these pre-fractured specimens can be utilized in surgical education to provide a teaching experience as realistic as possible without harming living patients.

[Palmar radioscapholunate arthrodesis with distal scaphoidectomy]

OBJECTIVE

Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint.

INDICATIONS

Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II.

CONTRAINDICATIONS

Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis.

SURGICAL TECHNIQUE

The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K‑wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws.

POSTOPERATIVE MANAGEMENT

Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks.

RESULTS

Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Pain Perception following Initial Closed Reduction in the Preoperative Care of Unstable, Dorsally Displaced Distal Radius Fractures

Introduction Closed reduction and cast immobilization is a common practice as initial treatment for distal radius fractures. This study examines the pain perception that accompanies this approach. Materials and Methods Thirty dorsally displaced distal radius fractures were reduced and casted under finger-trap traction with intravenous analgesics. Patients rated their pain perception on visual analog scale prior to presentation, during reduction, during casting, and for every day until surgery. Closed reduction improved palmar tilt from -26.3 to -10.8 degrees. Surgery improved palmar tilt from -10.8 to +6.1 degrees. Closed reduction improved radial inclination from 15.5 to 19.1 degrees. Surgery improved radial inclination from 19.1 to 21.6 degrees. Mean pain perception was 5.8 at presentation. Reduction increased pain to 7.5 ( p < 0.001), whereas casting was less painful (3.7; p < 0.001). At the evening following casting and the following days until surgery, mean pain was still as high as 4.1, 4.2, 4.1, 3.6, 3.9, 2.8, 3.0, and 3.0, with some patients experiencing more pain than initially. Conclusion Reduction generates significant pain with only minor relief during cast immobilization. The indication for closed reduction prior to cast application is therefore questionable.

Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width

INTRODUCTION

The standard therapy of intra-articular and extra-articular distal radius fractures consists of open reduction and stabilization using palmar osteosynthesis with an angularly stable plate. The integrity of the flexor pollicis longus tendon (FPLT) may be mechanically affected by the plate, with rupture rates between 1 and 12% reported in the literature, occurring during a postoperative time period from 4 to 120 months. The aim of this study was to investigate the position of the tendon in relation to the distal edge of the plate using high-resolution ultrasonic imaging.

MATERIALS AND METHODS

Nineteen patients undergoing osteosynthesis for distal radius fracture in 2015 with the Medartis^® APTUS^® FPL plate were included in this study. Of these, seven dropped out for various reasons. Therefore,  twelve patients with a median age of 52 years (range 24-82 years) were included in the final analysis. High-frequency ultrasound was performed within a median of 28 (range 10-52) weeks by an experienced radiology specialist to locate the FPLT position in two separate wrist positions: (1) wrist held in 0° position and fingers extended and (2) wrist held in 45° of dorsal extension and actively flexed fingers II to V (functional position). For analysis, we used the axial ultrasound videos. Postoperative X-rays and CT scans were included for the analysis, especially the soft-tissue CT scan window for the exact localization of the FPLT.  Dynamic ultrasound scanning was used to localize the FPLT in relation to the plate in 0° and functional position of the hand. Using CT scanning, the position of the plate relative to the bone was determined. In this way, we were able to correlate the functional FPLT position with the osseous structures of the distal radius.

RESULTS

In all cases, the FPLT was positioned closer to the volar distal edge of the FPL plate in functional position than in 0° position. In four cases, the FPLT did not touch the plate at all and was shown to shift diagonally from radio-volar in ulno-dorsal direction during wrist movement from 0° to functional position, similarly to the sliding of the tendon in the assumed physiological motion sequence. In these cases, in the functional position the center of the FPLT was positioned slightly ulnarly of the center of the distal radius (i.e., less than 50% of the distal radius width measured from the radial border of DRUJ), and positioned more ulnarly than in all other cases (i.e., in which the FPLT came into contact with the plate). In the remaining two-thirds of the cases (eight patients), the FPLT touched the plate during wrist movement from 0° to functional position, shifted in dorsal direction and slid into the plate indentation, irrespective of whether the tendon entered the indentation from the radial or the ulnar side, and independent of the ulnoradial position of the plate. No signs of tendinopathy of the FPLT were found in any of the cases.

CONCLUSION

The results show that the indentation of the Medartis^® APTUS^® FPL plate reduces the tendon-plate contact and ideally even prevents it entirely. In particular, ulnar positioning of the plate lowers the risk of tendon-plate contact. If the FPLT touches the plate, the tendon pulls into the plate indentation, thus lowering the contact. Consequently, the Soong criteria are not applicable when a FPL plate is used.

Early complications and radiological outcome after distal radius fractures stabilized by volar angular stable locking plate

INTRODUCTION

Distal radius fractures (DRF) are the most common fractures of the upper extremities. The incidence is expected to continue rising in the next years due to the increased life expectancy. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF with a complication rate of 8-39% reported in the literature. Main aim of this study was to investigate the incidence of complications after DRF stabilization using palmar angular stable locking plate.

METHODS

A retrospective medical records review conducted from January 2013 to December 2016 included a total of 392 patients with DRF, that were stabilized using palmar angular stable locking plate and showed a minimum follow-up of 3 months. The group comprised 259 female and 133 male patients with a mean follow-up interval of 11 months (range 3-52 months). All recorded complications were documented. Range of motion (ROM) in extension, flexion, supination, pronation, radial- and ulnar deviation of the last follow-up was noted. Age was divided into younger than 65 years (< 65 years) and older than 65 years (≥ 65 years). The primary, immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off.

RESULTS

A total of 51 (13%) early and 17 late (4%) complications were recorded in 392 patients. The most common complications included carpal tunnel syndrome (3%), complex regional pain syndrome (3%) and loss of reduction (2%). Of the 68 complications, only 25 (6%) were directly related to the plate. 73% of all complications occurred in AO type C fractures. Patients without complications showed a significantly better ROM in extension, flexion, pronation and supination than patients with complications. No significant differences in incidence of complications, ROM or loss of reduction could be found between patients over and under 65 years of age. Gender and type of immobilization showed no significant influence on the complication rate.

CONCLUSIONS

Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment. In the majority of the cases a good clinical and radiological outcome with no complications was documented. Gender and type of immobilization had no impact on the complication rate and an age over 65 years is not associated with an increased risk for complications or restricted ROM.

Pronator quadratus repair with a part of the brachioradialis muscle insertion in volar plate fixation of distal radius fractures: a prospective randomised trial

INTRODUCTION

Stable pronator quadratus repair following volar plate fixation of distal radius fractures with complete plate coverage is difficult.

MATERIALS AND METHODS

This study compares a modified pronator quadratus repair technique involving the brachioradialis muscle insertion (test group) with a conventional radial incision through the muscle without pronator quadratus repair (standard group). This prospective randomised study included 16 patients in the test group and 12 in the standard group; all were available for clinical, radiographic and ultrasound examination at a mean follow-up of 15 months.

RESULTS

Pronator quadratus repair was feasible in all test group patients, and complete coverage of the distal plate was achieved in 11. No differences in functional outcome were observed between the groups.

CONCLUSION

Pronator quadratus repair with a part of the brachioradialis muscle insertion is a reliable technique for coverage of a volar plate by slight distal transposition. In the repair of distal radius fractures, this may better protect the finger flexor tendons against irritation and/or rupture. That likelihood should now be studied.

[The proximal radioulnar joint in consideration of the distal radioulnar joint]

The movement of the forearm follows a complex interplay of three main components: the proximal and distal radioulnar joint and the interosseous membrane. Injuries to one or even all components have a huge impact on the integrity of this system. The Essex-Lopresti lesion presented a high challenge in clinical diagnostics as well as therapy. Reconstructions of the length and stability are essential for a satisfactory postoperative outcome. If a reconstruction of the radial head by osteosynthesis is not possible, a radial head prosthesis should be implanted in the case of longitudinal instability - avoiding overlapping and/or oversizing. The reconstruction of the interosseous membrane should be considered, as well as the assessment of the distal radioulnar joint and/or the triangular fibrocartilage complex. Various reconstruction options are available in this regard.

Re-fracture of Distal Radius and Hardware Repair in the Setting of Trauma

Distal radius fractures are one of the most common fractures in the elderly. Falls and motor vehicle collisions lead to increased risk for this type of fracture. A seventy-three year-old female had a previous history of distal radius fracture with repair by open reduction and internal fixation. She was involved in a motor vehicle collision that re-fractured the distal radius. The plate was bent and required removal, which is a very rare but potentially serious complication. Surgery was done to fix the open reduction and internal fixation with volar locking plates while removing damaged hardware. Only a select few cases have reported hardware failure as a cause of complications. Among those cases, high-energy activities and maintained stress on the hardware were likely causes. Distal radius fractures are the most common upper extremity fracture in the elderly. We highlight a unique case of re-fracture in the setting of trauma with prior hardware failure and describe the strategy for hardware repair.

Complications following open reduction and internal fixation versus external fixation in treating unstable distal radius fractures: Grading the evidence through a meta-analysis

BACKGROUND

The common fixation techniques for unstable distal radius fractures include open reduction and internal fixation (ORIF) with plates and closed reduction and external fixation (EF). There is controversy over the choice of surgical approach in treating unstable distal radius fractures.

HYPOTHESIS

This meta-analysis was performed to compare complication rates in patients treated with ORIF or EF for unstable distal radius fractures and to develop GRADE (grading of recommendations, assessment, development, and evaluation)-based recommendations for using the procedures to treat unstable distal radius fractures.

MATERIALS AND METHODS

A systematic search of all the studies published was conducted using the Pubmed, ScienceDirect, Embase, BIOSIS, Springer, Cochrane Library databases. The randomized controlled trials (RCTs) that compared ORIF with EF in treating adult patients with unstable distal radius fractures and provided data regarding the complication were identified. The demographic characteristics and adverse events were manually extracted from all of the included studies. RevMan 5.1 was used for data analysis. PRISMA guidelines were followed.

RESULTS

Sixteen studies that included a total of 1280 patients met the inclusion criteria. Compared with ORIF, EF results in higher incidence of total complications, infection and malunion. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system.

DISCUSSION

This meta-analysis indicates that ORIF and EF are both effective procedures for treating unstable distal radius fractures. ORIF may be superior to EF in the treatment of unstable distal radius fractures. Because of the low quality evidence currently available, high-quality RCTs are required.

LEVEL OF EVIDENCE

Level II: low-powered prospective randomized trial meta-analysis.

[Distal radius fracture of the adult : Diagnostics and therapy]

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

Spontaneous radioscapholunate fusion after septic arthritis of the wrist: a case report

Bacterial septic arthritis rarely occurs in the upper extremities. Yet, early diagnosis and treatment is important, as a delay in diagnosis results in pain, impaired hand function, and degenerative joint disease. Radioscapholunate (RSL) arthrodesis is a well-established procedure for treating inflammatory arthritis and osteoarthritis (primary or posttraumatic), primarily to achieve pain relief. The wrist deformity correction offers an alternative option to total wrist arthrodesis. Indications for a RSL arthrodesis are osteoarthritis of the radiolunate and radioscaphoid joint with a concomitant intact midcarpal joint. We present a case study of spontaneous RSL fusion post wrist infection caused by a dog bite.