Prospective study of comminuted articular distal radius fractures stabilized by volar plating in the elderly

Clinical and Radiographic Outcomes Following Volar-Locked Plating Versus Dorsal Bridge Plating for Distal Radius Factures

Purpose

Distal radius fractures (DRFs) indicated for operative intervention are most commonly treated with volar-locked plating (VLP); however, dorsal bridge plating (DBP) has been used as an alternative fixation method. The purpose of this study was to use a propensity score to match and compare the radiographic and clinical outcomes of patients undergoing isolated VLP or DBP for DRFs.

Methods

We performed a retrospective, propensity score-matched analysis of patients undergoing isolated VLP or DBP treatment for isolated DRFs from 2015 to 2022 at a single level-1 trauma center. Patients were propensity score-matched by a total of eight demographic and comorbidity factors, AO Foundation/Orthopedic Trauma Association classification, and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Our primary outcomes included postoperative complications, wrist and forearm range of motion (ROM), grip strength, and radiographic measurements, including radial height, radial inclination, volar tilt, and articular step-off.

Results

Overall, 415 DBP and 2075 VLP were successfully propensity score-matched and included in this study. Grip strength and ROM measurements at the 6-month follow-up, including wrist flexion, wrist extension, forearm pronation, forearm supination, radial deviation, and ulnar deviation, were increased in the VLP compared with DBP (P < .05). Complication rates among both the groups were relatively low; however, the rates of malunion and nonunion were significantly higher among the DBP group (P < .05). Radial height, radial inclination, and articular step-off were improved in the VLP group compared with the DBP group (P < .05); however, volar tilt was similar between groups. PROMIS upper extremity and physical function were significantly higher among the VLP group (P < .05). No significant difference was noted in PROMIS pain interference between the groups.

Conclusions

When compared with DBP, patients undergoing VLP are more likely to have improved clinical and radiographic outcomes. Although improvement in wrist and forearm ROM and radiographic parameters is statistically significant, it may not be clinically relevant.

Type of study/level of evidence

Therapeutic III.

Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician

BACKGROUND

Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction.

OBJECTIVE

This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting.

DISCUSSION

Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA.

CONCLUSIONS

Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

Role for Wrist Hemiarthroplasty in Acute Irreparable Distal Radius Fracture in the Elderly

Volar locking plates for distal radius fracture (DRF) in the elderly may show complications in the most comminuted osteoporotic cases. The authors provide criteria for DRF in elderly that may not be amenable to volar plating ("irreparable DRF") and review the current results of a preliminary series of wrist hemiarthroplasty for these injuries. Between 2011 and 2019, 28 wrists with acute irreparable intra-articular DRF were treated with wrist hemiarthroplasty (96% female, mean age 79 years). A total of 17 wrists with a mean follow-up of 32 months were reviewed. At follow-up, mean visual analog scale (VAS) pain was 1/10, mean forearm rotation arc was 148°.

Efficacy of cast immobilization versus surgical treatment for distal radius fractures in adults: a systematic review and meta-analysis

This articl e includes high-quality randomized controlled trials in recent years and updates the past meta-analysis. It has been proved that cast immobilization can achieve similar functional results, reduce economic burden in the long-term compared with surgery, and provide a basis for doctors to make treatment choices.

PURPOSE

The efficacy of conservative and surgical treatment of distal radius fractures (DRFs) in adults is still controversial. Recently, some high-quality randomized controlled trials (RCTs) evaluated the efficacy of both treatments. We hypothesized that treatment of DRFs with closed reduction and cast immobilization would achieve functional outcomes similar to surgery.

METHODS

This study is a systematic review and summary of RCTs comparing conservative and surgical management of DRFs from 2005 to March 2022. Patients were evaluated for functional and imaging outcomes and complications.

RESULTS

A total of 11 studies [1-11] included 1775 cases of DRFs. At 1-year follow-up, the cast group had lower mean differences (MDs) in DASH scores than the surgery group by - 2.55 (95% CI =  - 5.02 to - 0.09, P = 0.04); with an MD of 1.63 (95% CI = 1.08-2.45, P = 0.02), while the surgery group had a lesser complication rate than the cast group.

CONCLUSIONS

At 1-year follow-up, the lower DASH scores of the cast group showed advantages of this treatment, but the complication rate was higher than that of the surgery group. There was no massive distinction in other scoring methods.

Perioperative Morbidities in Distal Radius Fractures Treated Using Locking Plates in the Super-Elderly Population: A Retrospective Study

Purpose

Currently, there is no consensus on the treatment of distal radius fractures in the super-elderly population. The aim of this study was to evaluate the perioperative morbidities and the need for rehabilitation care after a distal radius fracture treated with locking plates among patients aged 85 years or older.

Methods

A retrospective study was conducted in all patients aged 85 years or older who underwent open surgical treatment using a locking plate for an isolated distal radius fracture from January 2013 to December 2018 at a level 1 trauma center. The occurrence of minor complications (tendinopathy, neuropathy, carpal tunnel syndrome, and infection), major complications (complex regional pain syndrome, nonunion, loss of reduction, intra-articular screw, and hardware failure), and the need for revision surgery were recorded. The need and timing of rehabilitation were also documented. A nested case-control study was performed to evaluate predictive factors associated with the need for inpatient rehabilitation.

Results

The majority of fractures were AO type A, numbering 88 (55.7%), followed by 64 type C (40.5%), and then 6 type B (3.8%). The overall complication rate among the 158 included patients was 17% (n = 26), with 12 (7.6%) having minor complications and 14 (8.9%) having major complications. Inpatient rehabilitation was required for one-third of the patients (n = 59), and 11 (7%) were definitively discharged to a nursing home. The place of residence before the fracture, American Society of Anesthesiologist score, and the type of anesthesia were associated with a need for inpatient rehabilitation.

Conclusions

Overall, this study suggests that perioperative morbidity of distal radius fractures treated using a locking plate is acceptable even in the super-elderly population. Nevertheless, given the frequent requirement for rehabilitation, the impact of age cannot be ignored.

Type of Study/level of evidence

Therapeutic IV.

Corrective Osteotomy with Volar and Dorsal Fixation for Malunion of Intra-Articular Fracture of the Distal Radius: A Retrospective Study

OBJECTIVES

Although corrective osteotomy with volar or dorsal plate fixation can treat malunion of distal radius fractures, each has its own disadvantages. Little is currently known on whether dorsal fixation combined with volar fixation may further improve recovery. This study aimed to evaluate the clinical value of corrective osteotomy combined with volar and dorsal plate fixation in patients with malunion of intra-articular fractures of the distal radius.

METHODS

Seventeen patients with malunion of intra-articular fractures of the distal radius treated with corrective osteotomy with volar and dorsal plate fixation from 1 January 2016 to 31 November 2018 were retrospectively analyzed. The enrolled patients included seven males and 10 females with an average age of 54.9 years (range: 36-70 years). The radiographic parameters, including the radial length, the radial inclination angle, the ulnar variance, and the volar tilt, as well as clinical outcomes, including wrist and forearm range of motion (ROM), grip strength, the Mayo Modified Wrist Score (MMWS), and the disabilities of the Arm, Shoulder, and Hand (DASH) score, were examined at 3 months and 18 months after operation and compared with the preoperative state. The paired t-test was used for statistical analysis.

RESULTS

After corrective osteotomy combined with volar and dorsal plate fixation, all included patients were followed up for 18 months, and there was no surgical site infection. Patients reported postoperative pain due to the irritation of extensor tendon (two cases) and wrist arthritis (two cases). The radial length increased from 1.34 ± 2.34 mm to 9.25 ± 2.65 mm and 9.03 ± 2.47 mm at 3 months and 18 months postoperatively (t = 8.257, 7.954, all p < 0.05). The radial inclination angle increased from 6.45° ± 0.76° to 19.35° ± 3.43° and 19.03° ± 3.63° at 3 and 18 months (t = 12.517, 12.122, all p < 0.05). The ulnar variance decreased from 5.11 ± 0.23 mm to 1.32 ± 0.31 mm and 1.54 ± 0.62 mm at 3 and 18 months (t = 4.214, 4.895, all p < 0.05). The volar tilt was corrected from 4.47° ± 3.46° to 15.51° ± 2.72° and 14.12° ± 2.41°, respectively (t = 11.247, 10.432, all p < 0.05). Moreover, wrist ROM increased from 42.53° ± 8.99° to 98.70° ± 7.61° and 101.24° ± 7.66° (t = 41.433, 46.627, all p < 0.05), while forearm ROM was increased from 94.82° ± 6.54° to 134.47° ± 5.06° and 137.24° ± 5.52°, respectively (t = 31.507, 32.584, all p < 0.05). Similarly, grip strength, MMWS, and DASH were also remarkably improved. There were no significant differences in the wrist and forearm ROM, grip strength, MMWS, and DASH scores between follow-up at 3 and 18 months (all p > 0.05).

CONCLUSIONS

Corrective osteotomy with volar and dorsal fixation can improve recovery of volar tilt, relieve wrist pain, restore wrist and forearm function, and increase grip strength of patients with malunion of intra-articular fractures of the distal radius.

Detection of Five Types of HPV Genotypes Causing Anogenital Warts (Condyloma Acuminatum) Using PCR-Tm Analysis Technology

Objectives

Condyloma acuminatum (CA) is a common sexually transmitted disease caused by human papillomavirus (HPV) infection. We established a high-throughput, simple, low-cost, and accurate HPV-typing assay (polymerase chain reaction-melting temperature [PCR-Tm] analysis) to detect HPV in CA.

Materials and Methods

We detected 280 cervical scraping samples, including positive samples of HPV-6 (26), HPV-11 (12), HPV-16 (22), HPV-42 (18), HPV-43 (25), HPV-multiple (19), HPV- other type (58), and HPV-negative samples (100). All samples were compared by PCR-Tm analysis and a flow fluorescence hybridization assay. Sequencing was used to confirm the results of the PCR-Tm analysis.

Results

PCR-Tm analysis was specific for each genotype (HPV-6, HPV-11, HPV-16, HPV-42, and HPV-43). The sensitivity of the PCR-Tm analysis assay for each genotype was 10³, 10³, 10³, 10³, and 10² copies/reaction, respectively. Most of the 158 samples, including 58 HPV-other type positive and 100 HPV-negative samples tested by the flow fluorescence hybridization assay, were tested negative by PCR-Tm analysis. For the 122 remaining samples, 26 HPV-6, 12 HPV-11, 22 HPV-16, 18 HPV-42, 25 HPV-43, and 19 multiple HPV infections were detected through PCR-Tm analysis. In total, 25 HPV-6, 12 HPV-11, 21 HPV-16, 18 HPV-42, 25 HPV-43, and only 10 multiple HPV infections were detected by the flow fluorescence hybridization assay. The kappa coefficient for the analysis of PCR-Tm analysis and flow fluorescence hybridization assay was 0.940 (P < 0.0001), and the 95% confidence interval of the kappa coefficient was 90.3–97.7%.

Conclusion

PCR-Tm analysis enabled the detection of HPV-6, HPV-11, HPV-16, HPV-42, and HPV-43, including single and multiple infections.

Radiological, Clinical and Functional Outcomes of Combined Dorsal and Volar Locking Plate Osteosynthesis for Complex Distal Radius Fractures

PURPOSE

The purpose of this study was to assess the short- to mid-term radiologic, clinical, and functional outcomes of patients treated with combined dorsal and volar locking plating for internal fixation of complex, comminuted, intra-articular, distal radius fractures.

METHODS

We performed a retrospective review of 34 patients treated with combined dorsal and volar locking plates for the internal fixation of complex, comminuted, intra-articular distal radius fractures. Radiographic and clinical parameters were recorded at a mean of 48 months after surgery. Activities of daily living and quality of life were assessed by the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation questionnaires.

RESULTS

Compared with the contralateral wrist, the treated wrist regained 73% of flexion, 81% of extension, 86% of ulnar deviation, 90% of radial deviation, 98% of pronation, 99% of supination, and 93% of grip strength. Mean Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 11 (range, 0-78) and 11 (range, 0-77), respectively. Radial height and radial inclination were restored anatomically in 24% and 41% of patients, respectively, while volar tilt and ulnar variance were restored in 68% of patients.

CONCLUSION

The overall functional and radiologic outcome of patients with comminuted intra-articular complex distal radius fractures treated with the combined dorsovolar plate osteosynthesis was good to excellent.

LEVEL OF EVIDENCE

Therapeutic IV.

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies

STUDY DESIGN

This was a systematic review with a meta-analysis.

INTRODUCTION

Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery.

PURPOSE

We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF.

METHODS

Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications.

RESULTS

This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss.

CONCLUSION

Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Perioperative management of distal radius fractures

Fractures of the distal radius are the most common upper limb fracture and account for over a sixth of all fractures seen in emergency departments. Although most of these fractures are managed non-operatively, a significant number of complex injuries undergo operative management. This educational review of up to date guidelines discusses the perioperative management of distal radius fractures and provides readers with continuing professional development activities.

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.

Predicting epiphyseal screw length in anterior plating of distal radial fractures

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

Evaluating the necessity of bone augmentation for distal radius fracture fixed with a volar locking plate: a retrospective study

Background

Multiple approaches for fixation of distal radius fractures exist; nonetheless, there is no consensus on the optimal treatment for these injuries. Although using volar locking plates has become increasingly common as a surgical intervention, the usefulness of bone augmentation remains debatable. Therefore, this study aimed to evaluate the necessity of bone augmentation for distal radius fractures fixed with a volar locking plate.

Methods

This retrospective study enrolled patients with a single distal radius fracture treated with a volar locking plate between January 2014 and December 2016. Overall, 105 fractures were included and divided into two groups (non-bone augmentation: group 1, n = 88; bone augmentation: group 2, n = 17). Images were reviewed, and dorsal cortex collapse, volar tilting, and radial height and inclination were measured immediately after surgery and at the 6-month follow-up.

Results

Both groups exhibited significant differences in dorsal collapse (p < 0.001 and p = 0.001, respectively) and radial height shortening (p < 0.001 and p = 0.039, respectively); volar tilting and radial inclination did not differ significantly. There was no difference in the degree of dorsal collapse (p = 0.715) and radial height shortening (p = 0.651) between the two groups. Of the 105 fractures, 54 were identified as comminuted type according to the AO classification (A3, C2, and C3), and similar radiographic outcomes were noted.

Conclusions

Volar locking plates for the treatment of distal radius fractures with or without bone augmentation do not affect the radiographic outcomes. In comminuted fractures, additional bone augmentation is unnecessary if intraoperative anatomical reduction and fixation are performed when possible.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.