Dorsal plating for distal radius fractures

Volar Intra-articular Extended Window Approach for Intra-articular Distal Radius Fractures

Distal radius fractures are one of the most common injuries seen globally with increasing use of use of volar plating for surgical treatment. Although it is common to directly visualize the articular surface for most other periarticular fractures, during volar plating of the distal radius the joint is typically not visualized. This is due to concern for carpal instability from disruption of the volar carpal ligaments. When direct visualization of the articular surface is deemed necessary, either to reduce articular fragments or to confirm the quality of reduction, current options include a separate dorsal arthrotomy or arthroscopic assistance. However, biomechanical evidence supports safely performing a volar capsulotomy to visualize the articular surface. We describe the Volar Intra-Articular Extended Window approach, which allows direct visualization of the articular surface through the volar approach to treat distal radius fractures.

Combined approach versus single Henry approach for fixation of die-punch distal radius fractures: a retrospective study

BACKGROUND

Distal radius fracture (DRF) is one of the most common orthopaedic-related traumas. DRF patients with die-punch fractures have a higher risk of loss of reduction, poorer functional outcomes, and increased risk of complications even after open reduction and internal fixation (ORIF). According to the three-column theory, the lunate fossa is an important part of the intermediate column for load bearing. When the distal radius fracture involves the lunate fossa, adequate anatomical reduction can have an important impact on the prognosis of wrist function. Herein, we used the combined volar and dorsal approach, and the dorsal approach was used to assist in bone grafting or dorsal plate fixation in reducing fractures. We compare the combined approach versus the Henry approach for the fixation of die-punch distal radius fractures.

METHODS

We reviewed patients who were admitted for surgery for die-punch fractures from January 2016 to June 2021. The patients were followed-up after surgery to measure and evaluate their Gartland-Werley wrist score, wrist range of motion (ROM), and follow-up imaging data.

RESULTS

There were 21 patients in the volar locking plate (VLP) group and 10 patients in the combined approach group. The majority of fractures in the VLP and combined approach groups were AO B and C fractures, respectively. The cause of injury and AO fracture classification showed significant differences between the two groups, and there was no difference in age or sex between the two groups. There was no significant difference in ROM between the two groups, but the VLP group presented a better Gartland-Werley score and volar tilt angle, and the combined group presented better maintenance in radial height and articular congruity.

CONCLUSIONS

Reduction through the combined palmar and dorsal approach supplemented by bone grafting or dorsal plate fixation is an effective method for the treatment of die-punch distal radius fractures, which provides a new option for the treatment of die-punch fractures.

Dorsal Plate Osteosynthesis in Simple and Complex Fractures of the Distal Radius: A Radiological Analysis of 166 Cases

Background  To report the radiologic outcome and rate of complications of open reduction and internal fixation (ORIF) using a dorsal plate fixation of simple and complex distal radius fractures in adult patients. Methods  Patients treated with dorsal ORIF of simple and complex distal radius fractures between December 2008 and April 2013 were included in this single-center retrospective study. Type of fracture, radiographic measurements, and complications were documented. Results  One-hundred and sixty-six patients/fractures were included. Restoration of radial inclination (22° ± 3°) was achieved in 38%. Radial height (14 ± 1 mm) was least likely to be restored to normal values postoperative in 25%. Normal ulnar variance (0.7 ± 1.5 mm) could be observed in 60% and adequate volar tilt (11° ± 5°) was achieved in 50% at final follow-up. We observed one loss of reduction in an AO type C2 fracture and a total of 15 nonimplant-related minor clinical complications. Conclusion  Our radiographic findings after dorsal plating are comparable to those published on volar plating. The changes in radial height and volar tilt could be attributed to projection-related differences in the radiographs and did not signify a loss of reduction in all cases. Clinical Relevance  Dorsal plating of distal radius fractures is safe and remains an important approach in the treatment of complex distal radius fractures. Complications in our study were even less compared to those reported in the literature. Type of Study/Level of Evidence  This is a Type IV study. Level of Experience of Surgeons  The level of experience of surgeons is III-V.

Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Dorsally Displaced Unstable Extra-Articular Distal Radial Fractures: Functional and Radiographic Results from a Randomized Controlled Trial

The use of low-profile dorsal and volar locking plates for distal radial fracture surgery has improved results and lowered the complication rate compared with older plate designs. The purpose of the present randomized controlled trial was to compare patient-reported outcomes as well as radiographic and functional results between patients who underwent stabilization with a volar locking plate or a dorsal locking nail-plate for the treatment of dorsally displaced unstable extra-articular distal radial fractures.

Interpretations of the Term "Watershed Line" Used as Reference for Volar Plating

Objective  The objective of this systematic review is to provide an overview of all interpretations of the definition of the watershed line used in literature. Methods  The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed for this review. A comprehensive search was performed for definitions of the watershed line given in literature. A total of 32 studies giving an explicit interpretation of the definition of the watershed line or anatomical reference for plate positioning in writing and/or imaging were included. Results  In 32 studies, we found eight different landmarks used to refer to the watershed line or correct plate positioning. Five studies used two different soft tissue landmarks. Six different bony landmarks were described in 24 studies. These could further be subdivided into three anatomical interpretations, described in seven studies, in which the term "watershed line" is explained as a distinguishable anatomical line, and two surgical interpretations, described in 15 studies, which are purely reflecting the optimal location of the volar plate. One interpretation of the watershed line described in two studies combined both anatomical and surgical landmarks. Conclusion  The (mis)interpretation of the definition of the term "watershed line" as described by Orbay is subject to the type of landmarks and purpose used: soft tissue or bony landmarks and an anatomical or a surgical purpose. A clear distinction can be made between interpretations using bony landmarks, as the true watershed line is defined and definitions using soft tissue landmarks, which might represent the reference points surgeons use in clinical practice.

The Die Punch Fragment: Analysis of Fragment Geometry and Need for Fixation

Introduction Die punch (DP) fragments are among the most common fracture fragments to lose reduction after volar locked plating of articular distal radius fractures (DRFs). We aimed to report the number of patients in our institution who had a computed tomography (CT)-confirmed DP fragment and who had open reduction and internal fixation (ORIF) through a dorsal approach; to report the length of the radioulnar portion of the DP fragment relative to the total distal radioulnar joint (DRUJ) length; and to identify if an association exists between this length and the choice for a volar versus a dorsal operative approach to the DP fragment.

Materials and Methods We performed measurements on the preoperative CT scans of 94 skeletally mature patients with a DP fragment. We also collected data related to their demographics, injury, and treatment. Of the 94 patients in this study, 84 (89%) had AO type C fractures.

Results Thirteen out of 94 patients (14%) who had ORIF of their DRF with a DP fragment had a separate dorsal incision. The mean proportion of the DP fragment length relative to the total DRUJ length was 0.51 ± 0.19. There was no association between the length of the DP fragment and volar versus dorsal approach.

Conclusion DP fragment size is not an indicator of the need for or use of a dorsal approach in DRF fixation.

Level of Evidence This is a Level IV,—retrospective study.

Distal Radius Volar Plate Design and Volar Prominence to the Watershed Line in Clinical Practice: Comparison of Soong Grading of 2 Common Plates in 400 Patients

PURPOSE

To compare plate positioning in clinical practice of 2 commonly used volar locking plate designs with respect to the watershed line as classified by the Soong grading system.

METHODS

For this retrospective study, we included a total of 400 patients who underwent open reduction and internal fixation between May 2013 and February 2018. Cohort 1 was defined as patients treated with distal volar radius (DVR) plates during this period. Cohort 2 comprised 200 patients who had volar plate fixation with variable angle locking compression plates (LCP) during the same period. Standardized lateral wrist radiographs were categorized into Soong grade 0, 1, or 2.

RESULTS

In cohort 1, 87 plates (43.5%) were not prominent volar to the watershed line, grade 0; 95 plates (47.5%) demonstrated grade 1 prominence; and 18 plates (9.0%) demonstrated grade 2 prominence. In cohort 2, 63 plates (31.5%) were grade 0; 103 plates (51.5%) were grade 1; and 34 plates (17%) had grade 2 prominence on, and volar to, the watershed line. These radiographic results show a greater incidence of volar plate prominence with respect to the watershed line, as defined as Soong grading, in cohort 2.

CONCLUSION

This study shows that the use of the variable angle LCP plate is associated with more prominent volar positioning with respect to the watershed line compared with the DVR plate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Complications of Radial Column Plating of the Distal Radius

Background: Distal radius fractures treated with open reduction and internal fixation are commonly stabilized with a volar locking plate; however, more complex fracture patterns may require supplemental fixation with fragment-specific implants. The objective of this study was to evaluate the outcomes of distal radius fractures treated with radial column plates. Methods: A consecutive series of 61 patients who sustained distal radius fractures underwent radial column plating alone or in conjunction with other implants between August 2006 and January 2014. Thirty-one patients returned for follow-up or returned a mailed questionnaire at an average of 4.1 years. The outcomes measures included Visual Analog Scale (VAS); Disabilities of the Arm, Shoulder and Hand (DASH); and Patient-Rated Wrist Evaluation (PRWE) scores. Results: Sixty-one patients with a mean age of 55 years (range, 20-87) met inclusion criteria and were available for follow-up or chart review at an average of 5.2 years (range, 1.6-9.0 years). Seventeen of 61 (28%) underwent radial column plate removal. Twenty patients returned for final follow-up examination, and 11 completed questionnaires via mail. Subjective scores included a mean postoperative VAS of 0.72, DASH score of 17.2, and PRWE score of 15.7. Hardware sensitivity and wrist stiffness were the most common complications at final follow-up. Conclusions: Radial column plating of the distal radius is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures, but patients should be counseled that there is a 28% chance that hardware removal may be required. Our retrospective review found evidence of few complications and objective scores consistent with return to normal function.

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.

Volar plating in distal radius fractures: A prospective clinical study on efficacy of dorsal tangential views to avoid screw penetration

PURPOSE

The purpose of this prospective cohort study of patients treated with volar plating for distal radius fractures is to evaluate the efficacy (defined as detection rate, or the ability to detect dorsally protruding screws) of additional dorsal tangential views (DTV) after obtaining standard anteroposterior (AP) and elevated lateral views by evaluating the change in intraoperative strategy in 100 patients.

MATERIALS AND METHODS

100 patients aged 18 years and older undergoing volar plating for acute extra- or intra- articular distal radius fractures were prospectively enrolled. Intraoperative fluoroscopy views, including AP, elevated lateral and DTV were obtained. Intraoperative -screw- revision frequency for dorsal screw protrusion, screw position relative to volar plate and to dorsal compartment, and screw lengths were evaluated.

RESULTS

Additional DTV led to a change of intraoperative management in 31 of 100 (31%) of patients. A total of 35 out of 504 screws (6.9%) were changed. Screws in the two most radial screws in the plate were at the highest risk of being revised; 16 (46%) screws in most radial position and nine (26%) screws in the 2nd from radial position were revised. Furthermore, five (14%) screws in both the 2nd from ulnar and most ulnar screw holes were revised after DTV. No screws were revised in the central hole. The median length of revised protruding screws was 22 mm (range, 12-26 mm), and these were changed to a mean length of 20  mm (range, 10-22 mm).

CONCLUSION

In this prospective series of 100 patients, obtaining additional DTV is found to be efficacious as it led to change in intraoperative strategy in one-third of patients. We concur with previous pilot studies that DTV, after obtaining conventional AP and elevated lateral views, is advised to avoid dorsally protruding screws, which could minimise the potential for iatrogenic extensor tendon rupture after volar plating for distal radius fractures. Diagnostic accuracy of DTV is subject of a subsequent prospective cohort study with post-operative CT to serve as the reference standard.

LEVEL OF EVIDENCE

.Prognostic I.

Surgical Strategy and Techniques for Low-Profile Dorsal Plating in Treating Dorsally Displaced Unstable Distal Radius Fractures

Background The low-profile dorsal locking plating (DLP) technique is useful for treating dorsally comminuted intra-articular distal radius fractures; however, due to the complications associated with DLP, the technique is not widely used. Methods A retrospective review of 24 consecutive cases treated with DLP were done. Results All cases were classified into two types by surgical strategy according to the fracture pattern. In type 1, there is a volar fracture line distal to the watershed line in the dorsally displaced fragment, and this type is treated by H-framed DLP. In type 2, the displaced dorsal die-punch fragment is associated with a minimally displaced styloid shearing fracture or a transverse volar fracture line. We found that the die-punch fragment was reduced by the buttress effect of small l-shaped DLP after stabilization of the styloid shearing for the volar segment by cannulated screws from radial styloid processes. At 6 months after surgery, outcomes were good or excellent based on the modified Mayo wrist scores with no serious complications except one case. The mean range of motion of each type was as follows: the palmar flexion was 50, 65 degrees, dorsiflexion was 70, 75 degrees, supination was 85, 85 degrees, and pronation was 80, 80 degrees; in type 1 and 2, respectively. Conclusion DLP is a useful technique for the treatment of selected cases of dorsally displaced, comminuted intra-articular fractures of the distal radius with careful soft tissue coverage.

Dorsal or Volar Plate Fixation of the Distal Radius: Does the Complication Rate Help Us to Choose?

BACKGROUND

Internal fixation with plates is a reliable fixation technique for the treatment of distal radius fractures. An ongoing discussion exists whether volar or dorsal plating is the appropriate technique. In clinical practice, volar plate fixation is usually preferred because of the assumed lower complication frequency. However, recent studies with the newer generation low-profile dorsal plates reported lower complication rates.

PURPOSE

The aim of our study was to evaluate the differences in complication rates between volar and dorsal plate for the treatment of distal radius fractures in adult patients.

PATIENTS AND METHODS

A total of 214 patients with acute distal radius fractures were included in this retrospective study with a minimum 2 years of follow-up. In total, 123 patients were treated with dorsal plate fixation and 91 patients with volar plate fixation. Our primary study outcome was complication rate.

RESULTS

The overall risk for complications was 15.4% in the dorsal group and 14.3% in the volar group (p = 0.81). A total of 19 patients had implant removal due to complications: 11 patients in the dorsal group and 8 patients in the volar group (p = 0.97).

CONCLUSION

There is no preferred plate fixation technique based on these study results. In our opinion, decision for type of plate fixation should be based on fracture type and surgeon's experience with the specific approach and plate types.

LEVEL OF EVIDENCE

Therapeutic level III.

Complications of Distal Radius Fixation

Complications following any form of distal radius fixation remain prevalent. With an armamentarium of fixation options available to practicing surgeons, familiarity with the risks of newer plate technology as it compares with other conventional methods is crucial to optimizing surgical outcome and managing patient expectations. This article presents an updated review on complications following various forms of distal radius fixation.

Hardware-related complications after dorsal plating for displaced distal radius fractures

There has been a trend away from dorsal fixation of distal radius fractures secondary to a historically higher complication rate. However, the literature on low-profile dorsal plates and titanium implants for the treatment of these fractures is limited. The goal of the current study was to evaluate hardware-related complications and removal rates after open reduction and internal fixation of unstable, displaced distal radius fractures using a dorsal approach with a low-profile titanium plate. A single surgeon treated 125 patients with isolated, unstable, dorsally displaced distal radius fractures by open reduction and internal fixation using a low-profile titanium dorsal plating system. A total of 110 patients were followed for a minimum of 1 year, and mean follow-up was 27 months (range, 12-74). Outcomes were assessed radiographically and clinically. Satisfactory alignment was achieved in all cases, and no fracture went on to nonunion. Nine patients (8%) required removal of hardware at an average of 12 months (range, 6-34). Six patients (5%) had evidence of extensor tenosynovitis intraoperatively, but no extensor tendon ruptures were identified. Overall, using the Gartland and Werley score, results were excellent in 82 patients, good in 22 patients, fair in 5 patients, and poor in 1 patient. Six complications accounted for the fair and poor results. The average Disabilities of the Arm, Shoulder and Hand (DASH) score at latest follow-up was 6 (range, 0-25). This series showed that the technique of dorsal plating with a low-profile titanium plate is safe and effective.

Fractures of the distal radius: postmanagement radiographic characterization

OBJECTIVE

The purpose of this article is to describe the management options available for the treatment of the distal radius fracture as well as potential associated complications.

CONCLUSION

There are a wide variety of currently accepted and used treatment options for fractures of the distal radius, ranging from closed reduction with casting to various forms of invasive surgical management. The radiologist must be familiar with these various forms of management to recognize complications when present on follow-up radiographs.

Dorsal locked plate fixation of distal radius fractures

Distal radius fractures are common, and internal fixation for operative management of these injuries is widely accepted. Although use of the volar approach for plate fixation has become more popular, benefits of the dorsal surgical approach include the potential for direct reduction and assessment of articular alignment, evaluation and management of concomitant intrinsic intercarpal ligament injury, and initiation of early range of motion. For certain fracture patterns, dorsal plate fixation is the preferred surgical technique. Improvements in implant design, in particular the use of low-profile dorsal plates, has decreased the rate of complications seen previously with this technique. Here, we provide an overview of the evaluation of patients with distal radius fractures, as well as the surgical indications and contraindications, techniques, and complications after dorsal locked plate fixation of intra-articular distal radius fractures.

Complications following dorsal versus volar plate fixation of distal radius fracture: A meta-analysis

Objectives:

A meta-analysis to compare complication rates following volar or dorsal surgical fixation of distal radius fracture.

Methods:

A detailed search of PubMed®/MEDLINE® was undertaken to identify randomized and nonrandomized controlled trials published before 25 August 2012 that compared volar with dorsal fixation, in patients with distal radius fracture.

Results:

A quantitative meta-analysis of 12 trials (952 patients) was performed. There was no between-group difference in the overall rate of complications. Volar fixation was associated with significant increases in neuropathy (relative risk [RR] 2.19; 95% confidence intervals [CI] 1.27, 3.76) and carpal tunnel syndrome (RR 4.56; 95% CI 1.02, 20.44), and a reduction in tendon irritation, compared with the dorsal approach (RR 0.38; 95% CI 0.17, 0.86).

Conclusions:

Dorsal fixation offers a lower risk of neuropathy and carpal tunnel syndrome than the volar approach, but a higher risk of tendon irritation. Patients with a distal radius fracture can expect similar outcomes after volar or dorsal surgery.

THE TREATMENT OF DISTAL RADIUS ARTICULAR FRACTURES THROUGH LCP SYSTEM

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

Dorsal fixation of intra-articular distal radius fractures using 2.4-mm locking plates

Displaced, unstable intra-articular distal radius fractures are usually treated with reduction and fixation to allow early motion and minimize the potential for development of posttraumatic arthritis. The dorsal surgical approach allows direct visualization of the articular surface to ensure an anatomic reduction. Low profile, locked plates have minimized the unacceptable complication rates previously associated with dorsal plates. This study reviews the historical perspective, indications, technique, complications, and rehabilitation for dorsal, locked plate fixation of intra-articular distal radius fractures. The authors report a strategy for simplifying the fixation of these fractures.

Operative treatment of distal radius fractures

The incidence of distal radius fractures is increasing together with the average age of population. Intra-articular incongruity is the most probable cause of unsatisfactory outcome of distal radius fractures in younger and more active patients. Thus, the main goal in the treatment of distal radius fractures should be restoration of articular congruence. A computed tomography (CT) is recommended to help surgeon in preoperative planning in the treatment of comminuted intra-articular fractures. New implants have been designed to provide stable enough fixation for early mobilisation after surgery and to lower rather high complication rates related to conventional fixation methods such as external fixation and dorsal plating. The most common complications related to volar fixed angle plating such as flexor and extensor tendon problems, median nerve neuropathy, and screw diplacement into the radiocarpal joint are surgeon related and are avoidable with proper education. More randomized prospective studies are needed to prove superiority of any fixation method to another.

Plate fixation of osteoporotic fractures of the distal radius

Fractures of the distal radius in patients with osteoporosis constitute a unique challenge for the surgeon. They are by nature most commonly seen in the elderly population. Our understanding of the age, physiology, and functionality of the elderly has evolved considerably over the last two decades. Often these fractures simply affect a patient's already-compromised functional status. However, in active elderly adults they can also substantially reduce the functionality, and this can have a significant impact on their ability to care for themselves, pursue avocational activities, or both. In carefully selected patients, even in the face of osteoporosis, plate fixation of these fractures has satisfying outcomes for both the patient and the surgeon and must be considered part of a surgeon's armamentarium in the contemporary treatment of osteoporotic fractures of the distal radius.

Low-profile dorsal plating for dorsally angulated distal radius fractures

Dorsal plating emerged as an effective treatment for dorsally displaced distal radius fractures in the late 1980s. In addition to some mechanical advantages, this method provided a clear view of the articular surface and the ability to restore the anatomy. However, because of the frequent occurrence of extensor tendon complications in the early designs of dorsal plates, the volar approach gained favor for repairing these types of fractures. Recent improvements in dorsal plating designs have yielded increasingly thinner, precontoured plates with rounded edges and low-profile flush screw heads. These new plates have shown decreased rates of extensor tendon complications while retaining the advantages of the original dorsal approach. The authors have used this technique in more than 70 cases during a 4-year period. This article will review the history, indications, contraindications, technique, and rehabilitation for dorsal plating of dorsally angulated distal radius fractures.

Volar versus dorsal plating in the management of intra-articular distal radius fractures

PURPOSE

To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures.

METHODS

This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score.

RESULTS

Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score. Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one.

CONCLUSIONS

Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level III.

Avoidance and treatment of complications of distal radius fractures

The treatment of distal radius fractures continues to be fraught with complications. The more widespread use of internal fixation and supple-mental bone grafting with external fixation has decreased the incidence of malunions from closed-cast treatment and percutaneous pinning, but increased the risk of the complications specific to surgical intervention. Careful diagnosis, surgical planning, surgical technique, and postoperative rehabilitation can help optimize outcome in these difficult fractures.