Management of soft-tissue injuries in distal radius fractures

Strategies for Specific Reduction in High-Energy Distal Radius Fractures

High-energy distal radius fractures frequently result in comminution with intra-articular fragmentation. Knowledge of predictable patterns of injury allows the surgeon to develop a preoperative plan for anatomic reduction and stable fixation of individual fragments that are too small or too distal to be fixed with standard volar locked plating. We review the column model, which organizes the distal radius into an intermediate column, radial column, and pedestal as the basis of a reconstructive algorithm and emphasize the importance of the volar ulnar fragment. Specific reduction and fixation techniques are described to assist the surgeon in treating these injuries.

Distal radius fractures in the elderly population

We found no clear evidence of the clinical superiority of distal radius fracture surgery among older adults at one year.

Surgical treatment, however, may yield a faster recovery to previous level of activity in elderly patients.

With operative treatment, hardware-based problems may warrant secondary operations and implant removal, whereas in non-operative treatment, symptomatic loss of alignment and malunion can occur.

In elderly patients, non-operative treatment can be considered to be the gold standard.

Cite this article: EFORT Open Rev 2020;5:361-370. DOI: 10.1302/2058-5241.5.190060

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types

The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P<0.0001). The prevalence of soft tissue lesions secondary to intraarticular fractures of the distal radius was 68.4%. However, there was no statistically significant relationship between the different types of radius fractures and soft tissue injuries. On the other hand, ulnar styloid fracture was predictive of TFCC injury.

Spontaneous Flexor Tendon Rupture due to Primary Distal Radioulnar Joint Osteoarthritis

Spontaneous flexor tendon rupture is rare, occurring most commonly in the little finger or flexor pollicis longus. To the best of our knowledge, there have been no reports of spontaneous flexor tendon rupture due to primary distal radioulnar joint (DRUJ) osteoarthritis (OA). We present a case of spontaneous flexor tendon rupture in the index finger due to primary DRUJ OA in a 71-year-old female farmer. Surgical exploration confirmed that, at the wrist joint level, the flexor digitorum profundus of the index finger had undergone degeneration and complete rupture. The flexor digitorum superficialis of the index finger was elongated and thinned. A bony spur toward the volar side was covered with synovial fluid from a pinhole-sized perforation of the capsule. The combination of direct friction from the DRUJ spur and the matrix metalloproteinases in the synovial fluid from the perforation of the DRUJ capsule may have caused the spontaneous flexor tendon rupture. Palmar-side symptoms associated with DRUJ OA should be carefully examined because of the risk of spontaneous flexor tendon rupture.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined.

PURPOSE OF THE STUDY

Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability.

METHODS

A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale.

RESULTS

The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated.

DISCUSSION

This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations.

CONCLUSIONS

The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment.

LEVEL OF EVIDENCE

2b.

[Nerve injuries associated with distal radius fractures]

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.

Anatomical and/or pathological predictors for the "incorrect" classification of red dot markers on wrist radiographs taken following trauma

OBJECTIVE

To establish the prevalence of red dot markers in a sample of wrist radiographs and to identify any anatomical and/or pathological characteristics that predict "incorrect" red dot classification.

METHODS

Accident and emergency (A&E) wrist cases from a digital imaging and communications in medicine/digital teaching library were examined for red dot prevalence and for the presence of several anatomical and pathological features. Binary logistic regression analyses were run to establish if any of these features were predictors of incorrect red dot classification.

RESULTS

398 cases were analysed. Red dot was "incorrectly" classified in 8.5% of cases; 6.3% were "false negatives" ("FNs")and 2.3% false positives (FPs) (one decimal place). Old fractures [odds ratio (OR), 5.070 (1.256-20.471)] and reported degenerative change [OR, 9.870 (2.300-42.359)] were found to predict FPs. Frykman V [OR, 9.500 (1.954-46.179)], Frykman VI [OR, 6.333 (1.205-33.283)] and non-Frykman positive abnormalities [OR, 4.597 (1.264-16.711)] predict "FNs". Old fractures and Frykman VI were predictive of error at 90% confidence interval (CI); the rest at 95% CI.

CONCLUSION

The five predictors of incorrect red dot classification may inform the image interpretation training of radiographers and other professionals to reduce diagnostic error. Verification with larger samples would reinforce these findings.

ADVANCES IN KNOWLEDGE

All healthcare providers strive to eradicate diagnostic error. By examining specific anatomical and pathological predictors on radiographs for such error, as well as extrinsic factors that may affect reporting accuracy, image interpretation training can focus on these "problem" areas and influence which radiographic abnormality detection schemes are appropriate to implement in A&E departments.

Effectiveness of oral and topical hydrogen for sports-related soft tissue injuries

BACKGROUND

Because hydrogen therapy has been found beneficial for the treatment of inflammation, ischemia-reperfusion injury, and oxidative stress in humans, it seems useful to evaluate the effects of exogenously administered hydrogen as an element in the immediate management of sports-related soft tissue injuries. The main aim of this pilot study was to examine the effects of 2-week administration of hydrogen on the biochemical markers of inflammation and functional recovery in male professional athletes after acute soft tissue injury.

METHOD

During the 2013 season (from March to May), 36 professional athletes were recruited as participants and examined by a certified sports medicine specialist in the first 24 hours after an injury was sustained. Subjects were allocated to 3 randomly assigned trials in a single-blind design. Those in the control group received a traditional treatment protocol for soft tissue injury. Subjects in the first experimental group followed the same procedures as the control group but with additional administration throughout the study of oral hydrogen-rich tablets (2 g per day). Subjects in the second experimental group also followed the procedures of the control group, with additional administration throughout the study of both oral hydrogen-rich tablets (2 g per day) and topical hydrogen-rich packs (6 times per day for 20 minutes). Participants were evaluated at the time of the injury report and at 7 and 14 days after baseline testing.

RESULTS

Oral and topical hydrogen intervention was found to augment plasma viscosity decrease as compared with the control group (P = 0.04). Differences were found for range-of-motion recovery between the 3 groups; oral and topical hydrogen intervention resulted in a faster return to normal joint range of motion for both flexion and extension of the injured limb as compared with the control intervention (P < 0.05).

CONCLUSION

These preliminary results support the hypothesis that the addition of hydrogen to traditional treatment protocols is potentially effective in the treatment of soft tissue injuries in male professional athletes. Trial identification: Clinicaltrials.gov number NCT01759498.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture

PURPOSE

Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF.

METHODS

A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I.

RESULTS

Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively).

CONCLUSIONS

High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Factors delaying recovery after volar plate fixation of distal radius fractures

PURPOSE

To evaluate the factors influencing delayed functional recovery in patients with a distal radius fracture treated by volar plate fixation.

METHODS

A total of 122 patients with a distal radius fracture treated by volar locking plate were enrolled. The wrist range of motion, grip strength, and functional outcome by the Michigan hand score were assessed 3, 6, and 12 months after surgery. The factors assessed for their influence on delayed functional recovery include age, sex, bone mineral density (BMD), hand dominance, the type of fracture, the energy of trauma, the time to surgery, and the duration of immobilization. A multivariate regression analysis was conducted to identify independent predictors of delayed functional recovery in terms of the Michigan hand score.

RESULTS

There was a significant decrease in the wrist range of motion in patients with a high-energy trauma, severe type fracture, or increase in duration of immobilization at month 3, whereas only a severe fracture type was associated with a decreased range of motion after 6 and 12 months. An increase in age, a decrease in BMD, and high-energy trauma reduced grip strength at months 3 and 6, whereas only an increase in age and a decrease in BMD reduced grip strength at month 12. According to the multivariate regression analysis, severe type fracture and high-energy trauma reduced functional outcomes at months 3 and 6. Conversely, at month 12, an increase in age and a decrease in BMD reduced functional outcome.

CONCLUSIONS

An increase in age and a decrease in BMD were important risk factors influencing delayed functional recovery up to 12 months after distal radius fracture surgery, whereas fracture severity and high-energy trauma were associated with decreased functional outcomes up to 6 months after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Concurrent flexor carpi radialis tendon rupture and closed distal radius fracture

Tendon rupture as a complication of distal radius fractures has been documented; however, flexor tendon rupture associated with closed distal radius fractures is rare. We report a case of a 43-year-old man who suffered a closed distal radius fracture. Intraoperatively, it was discovered that the flexor carpi radialis tendon had ruptured. From the frayed ends of the tendon and review of the radiographs, it was determined that the sharp ends of the fractured radius had lacerated the tendon at the time of injury. After fixation of the fracture with locking plate, the severed tendon was repaired and the wrist immobilised with a splint. The patient has been pain free after 5 months of follow-up, with full range of motion. This outcome demonstrates that timely detection and treatment of concurrent flexor carpi radialis tendon rupture and a closed distal radius fracture can achieve good functional results and outcome.