[Biomechanics of distal radius fractures : Basics principles and GPS treatment strategy for locking plate osteosynthesis]

Computed Tomography and Pathobiomechanical-Based Treatment of Volar Distal Radius Fractures

Today, there are various classifications for distal radius fractures (DRF). However, they are primarily based on plain radiographs and do not provide sufficient information on the best treatment option. There are newer classifications that simultaneously consider the pathobiomechanical basis of the fracture mechanism and analysis of computed tomography images. Main determinants of which type of DRFs occurs are the strength/direction of the applied forces on the carpus and radius, and the position of the wrist relative to the radius during the fall. Reconstruction of the mechanism of injury provides information about which anatomic structures are involved, such as torn ligaments, bone fragments, and the dislocated osteoligamentous units. This article attempts to combine and modify current pathobiomechanically oriented classifications with an improved understanding of the "key fragments" to subsequently offer a treatment approach to stabilize these critical fragments through specific types of internal fixation.

Arthroscopic Management of Intra-articular Ligament Lesions on Distal Radius Fractures

Articular distal radius fractures (DRFs) have increased in incidence in recent years, especially among the economically active population. Most of the treatment approaches are based on plain X- rays, and do not give us any information on how to treat these fractures. In the search for solutions with greater precision in diagnosis, in reducing the joint surface of the fracture, and envolving minimally-invasive techniques, we found arthroscopy as the main tool for these patients. Therefore, an enhanced understanding of the biomechanics of the different types of fracture associated with ligamentous lesions should facilitate the right decision regarding the treatment. The present paper aims at providing a management-oriented concept to diagnose and treat ligamentous lesions associated with intra-articular DRFs based on a arthroscopy-assisted procedure, and showing the objective and patient-reported outcomes and a new classification. The objective and patient-reported outcomes were: the mean range of motion (ROM) was of 94.80% on the non-affected side; the mean score on the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was of 3.6 (range: 1 to 12). The score on the Visual Analog Scale (VAS) was of 1.66 (range: 1 to 3). Complications were observed in 2 (13.33%) patients: extensor tendon synovitis in 1 patient, and a limitation (stiffness) in ROM in 1 patient, both treated with wrist arthroscopy release. The mean time until the return to work was of 6.4 weeks. In patients with unstable intra-articular DRFs associated with ligamentous lesions, the fixation of specific osseous-ligamentous fragments and ligamentous repair/reconstruction by wrist arthroscopy prove to be a safe and reliable treatment. The clinical and functional results predict that the patients can return to work more quickly.

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.

Screw placement is everything: Risk factors for loss of reduction with volar locking distal radius plates

AIM

To determine factors correlated with postoperative radial shortening in patients with distal radius fractures treated with volar locking distal radius plates.

METHODS

A total of 250 patients with a distal radius fracture stabilised with volar locking plates between January 2010 and December 2014 were included in a multicentre retrospective cohort study. We measured the distance of the distal locking screws to the joint line immediately postoperatively and then measured radial shortening after six to eight weeks using the change in ulnar variance.

RESULTS

Multivariate linear regression analysis showed that there was a significant linear association between the distance of the screws from the joint line and radial shortening. No other patient, injury, or treatment-related characteristic significantly influenced radial shortening in multivariate analysis.

CONCLUSION

Distal locking screws should be placed as close as possible to the subchondral joint line to prevent postoperative loss of reduction.

[Distal radius fractures : Current treatment concepts and controversies]

Distal radius fractures represent the most frequent bone fractures in humans. Although the treatment was dominated for decades by conservative measures or closed surgical procedures, such as percutaneous wire osteosynthesis, a paradigm shift was instigated by the introduction and rapid dissemination of volar locking plate osteosynthesis (VLP). The novel procedure was soon proclaimed to be the gold standard and applied for practically all forms of fractures of the distal radius. In addition to clinical mishaps, e.g. failure to address dorsal edge fragments or the occurrence of extensor and flexor tendon irritation, the publication of various prospective randomized studies and meta-analyses led to a certain degree of disillusionment. In comparison to percutaneous wire osteosynthesis, no differences in the clinical result could be established for VLP 1 year postoperatively. It was therefore obvious that not all problems of the distal radius could be solved using the innovative instrument of volar locking plates. This article gives an overview on the current insights and reflects the current expert opinion on the present concepts for the treatment of distal radius fractures. This is illustrated by comprehensive case presentations.