Treatment of Intra-articular Distal Radius Fractures

Percutaneous treatment of type C distal radius fractures using dual-external fixator

BACKGROUND

This study aimed to introduce a potential alternative percutaneous treatment for AO types C1, C2, and C3 distal radius fractures using dual-external fixator (a no-bridging cemented-pin frame and a conventional wrist-bridging external fixator).

MATERIALS AND METHODS

From January 2018 to January 2021, 52 patients (52 distal radius fractures) were treated with dual-external fixator. For comparison, 61 patients (61 distal radius fractures) were treated with a plate and screw system. Wrist function was assessed using the Mayo Wrist Score. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction. A P < 0.05 was considered statistically significant.

RESULTS

Fracture healing was achieved in all patients. At the final follow-up of 29 months (range, 24-34 months) vs 36 months (range, 26-39 months) (P > 0.05), the patients treated with dual-external fixator and a plate and screw system achieved mean ulnar deviations of 31° vs 29° (P < 0.05), mean Mayo Wrist Scores of 91.12 ± 5.98 vs 88.12 ± 7.54 (P < 0.05), and mean patient satisfaction scores of 23.42 ± 2.47 vs 23.04 ± 2.32 (P > 0.05).

CONCLUSIONS

AO types C1, C2, and C3 distal radius fractures can be treated successfully using dual-external fixator. The technique is a potential alternative in addition to the conventional treatments.

LEVEL OF EVIDENCE

Level IIa.

Arthroscopic-Assisted Fracture Treatment in the Wrist

Wrist arthroscopy in the setting of wrist fracture affords direct visualization of reduction and identification of associated cartilage and soft tissue injuries. Further, mitigating soft tissue insult in the setting of perilunate injuries may decrease postoperative pain and stiffness while attaining outcomes equivalent to open techniques in appropriately selected patients. Technical proficiency of the surgeon continues to be a limitation of the technique. Randomized controlled studies are needed to better understand outcomes.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases

Background  The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose  We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results  The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p  = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p  = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p  = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p  = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p  = 0.002). There was no association between operative time and 30-day readmission ( p  > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p  = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p  = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion  Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Impacted intraarticular fragments of distal radius fractures: A radiographic characterization and analysis of reliability and diagnostic accuracy

BACKGROUND

Reduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs.

METHODS

We analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment.

RESULTS

Fifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44).

CONCLUSION

Impacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.

Epidemiology of Fractures Sustained During Electric Scooter Accidents: A Retrospective Review of 563 Cases

BACKGROUND

The use of electric scooters (e-scooters) has dramatically increased as they become an attractive alternative for public transportation in busy metropolitan areas worldwide. Despite their benefits, e-scooters challenge the health-care system with poorly understood forms of injuries, mainly orthopaedic fractures. To our knowledge, this study is the first to investigate e-scooter-related orthopaedic fracture patterns, mechanisms of injury, and management.

METHODS

Data on 3,331 e-scooter-related admissions were retrospectively collected between May 2017 and February 2020 in a level-I trauma center. These admissions were analyzed for demographic variables, orthopaedic fracture diagnosis (using the AO/OTA classification), associated injuries, and surgical treatment.

RESULTS

During the study period, a total of 716 fractures were diagnosed in 563 patients, with 46.4% of the patients requiring hospitalization. Of 492 upper-limb fractures, 89.2% occurred in a rider fall mechanism; and of 210 lower-limb fractures, 15.7% occurred in rider-vehicle collisions. Fifty-nine percent of long bone fractures were complex fragmentary and/or intra-articular fractures. Orthopaedic surgeons recommended that 225 fractures undergo surgical treatment. The most common upper-limb fracture was AO/OTA class 2R1A, with open reduction and internal fixation of the distal part of the radius being the most common upper-limb procedure (n = 58). The most common lower-limb fracture was AO/OTA class 41C, with open reduction and internal fixation of the proximal part of the tibia being the most common procedure (n = 28). A total of 22 patients (3.9%) required reoperation within 1 year.

CONCLUSIONS

This investigation provides unique information on demographic characteristics, patterns, and treatment of orthopaedic fractures secondary to the high-energy mechanism of e-scooter injuries. These new in-depth data are important, first, for health-care system preparedness with regard to management and resource allocation to treat these challenging injuries and, second, for legislators promoting safety and injury prevention strategies.

Arthroscopy in Distal Radius Fractures: Indications and When to Do It

Wrist arthroscopy in the setting of distal radius fractures allows for direct visualization of the articular surface and treatment of associated soft tissue injuries. Arthroscopic techniques may be used to fine tune reductions with residual articular step-off or gap after an initial reduction attempt and are critical for addressing free articular fragments and die-punch lesions. Surgeon training, experience, and comfort with wrist arthroscopy remains a barrier to widespread adoption of this technique. Level I studies are needed to investigate whether improved articular reduction leads to meaningful clinical differences.

Clinical Utility of 3-Dimensional Reconstruction Images to Predict Conservative Treatment Outcomes of Intra-Articular Distal Radius Fractures

Background

Three-dimensional (3D) images can provide additional information on bone fractures, especially in patients with intra-articular distal radius fractures (DRFs). We aimed to identify possible risk factors for adverse outcomes using a 3D reconstruction technique.

Material/Methods

We retrospectively reviewed adult patients who underwent plaster immobilization with or without closed reduction for DRFs in our hospital between February 2016 and May 2019. The 3D reconstruction image of DRFs was viewed from multiple angles to determine the existence of gaps or steps. Then, a semiquantitative standard was used to assess the severity of fracture. The patients’ basic data and radiographic data were collected, and multiple linear regression analyses were used to identify possible risk factors associated with adverse outcomes.

Results

A total of 89 cases were analyzed in our study. There were 28, 39, and 22 patients with level 1, 2, or 3 fractures, respectively, based on the semiquantitative standard. In a multiple linear regression, preoperative severity degree (β, 0.393; 95% confidence interval [CI], 0.260–0.526) and postoperative rehabilitation exercise (β, 0.352; 95% CI, 0.023–0.681) were associated with the Patient-Rated Wrist Evaluation during follow-up.

Conclusions

Our study presents a new method based on 3D reconstruction images to assess the severity of intra-articular DRFs. Patients who were identified as having severe fractures based on this method were found to have worse functional outcome.

[Research progress in the treatment of distal radius fractures assisted by wrist arthroscopy]

OBJECTIVE

To review the research progress of wrist arthroscopy assisted treatment of distal radius fractures.

METHODS

To summarize and describe the anatomical characteristics and fracture classification of the distal radius, indications and contraindications of wrist arthroscopy-assisted treatment, surgical methods, and associated soft tissue injuries, and summarize the advantages and disadvantages of the operation through a large number of literature at home and abroad on the treatment of distal radius fractures assisted by wrist arthroscopy.

RESULTS

Wrist arthroscopy as a minimally invasive technique for the treatment of distal radius fractures, compared with traditional surgery, can accurately observe intra-articular damage and perform operations under the microscope to avoid secondary damage to blood vessels, nerve, and tendon, etc., and can achieve one-stage repair and reconstruction by repairing the ligament, trigonal fibrocartilage complex, and carpal dislocation. It has the advantages of less trauma, fast postoperative recovery, extensive indications, fewer complications, and satisfactory effectiveness.

CONCLUSION

Wrist arthroscopy has advantages that traditional X-ray film, CT, MRI, and arthrography examinations do not have. Moreover, wrist arthroscopy has achieved satisfactory effectiveness in the adjuvant treatment of intra-articular distal radius fractures.

Anatomical reduction and precise internal fixation of intra-articular fractures of the distal radius with virtual X-ray and 3D printing

To evaluate and precisely internal fix intra-articular distal radial fracture (IDRF) using the virtual X-ray and three-dimensional (3D) printing technologies. Twenty-one patients with IDRF were recruited, and the data from digital design group (DDG) and real surgery group (RSG) were collected and analyzed. In DDG, the data from thin-slice computed tomography scan, virtual X-ray measurement parameters, including volar tilt, palmar tilt, radius length (D1), ulnar variation (D2), locking plate position parameter (D3) and distance between key nail and joint surface (D4) were collected. The bone was virtually fixed with the locking plate, and the final model of radius with the screw was obtained by 3D printing. In RSG, the locking plate was precisely pre-bended and used in surgery. During the surgery, the key K-wire was accurately placed and the locking plate was adjusted with the aid of the U-shaped navigation arm. The C-arm was used to observe the positions of key K-wires and the locking plate, and the same above-mentioned parameters were measured intra- and post-operatively. The data from RSG and DDG were compared statistically by t test. This approach proved to be successful in all 21 patients, and none of the screws pierced through the wrist joint surface. All the measured parameters, including the volar tilt, palmar tilt, D1-4, in RSG were not significantly different from preoperative DDG data. Virtual X-ray measurement of anatomical reduction parameters and 3D printing can help the anatomical reduction and precise internal fixation by providing quantitative references, preoperatively, intraoperatively and postoperatively.

Analyses of fracture line distribution in intra-articular distal radius fractures

Purpose

To assess the association between the fracture line distribution and the location of comminution in intra-articular distal radius fractures by building fracture mapping.

Patients/methods

Forty cases with intra-articular fractures of distal radius were enrolled in the current prospective clinical study. Fracture lines and comminution zones were identified by reduced three-dimensional computed tomography reconstructions and then graphically superimposed onto a standard template to create two-dimensional fracture maps, followed by the conversion into heating maps. Based on qualitative descriptive fracture mapping analyses, the patterns of intra-articular distal radius fractures were determined.

Results

It was observed that the highest fracture line intensity was located as an inverted “T” shape zone in the dorsal aspect of the joint with high incidence of fractures and the prominently intense color in heat mapping. The keystone projected area, the radial styloid process and the metacarpal radial side articular surface were found to be the least involved parts of the fracture. According to the mapping of the number and distribution of fracture lines, a new classification method for intra-articular fractures of the distal radius was redefined. Different surgical approaches and internal fixation techniques were proposed for different types. In this paper, we retrospectively compared the preoperative X-ray findings between different types. Based on the preoperative X-ray prediction, the distal intra-articular radius fractures were classified, so as to develop effective surgical strategies. In this study, a new surgical approach was attempted, but due to the lack of evidence-based evidence, long-term postoperative complications and hand function should be further evaluated.

Conclusion

This study redefines a new method for the classification of intra-articular fractures of the distal radius, which allows doctors to have a clearer understanding of the characteristics of distal radius fractures. Moreover, the application value in fracture diagnosis is more significant, and the best surgical approach is selected for different types.

Juxta-articular Plate Fixation in Distal Radius Intra-articular Fractures with Accompanying Volar Free Fragments beyond the Watershed Line

Background

Although distal radius fractures (DRF) are common fractures, intra-articular comminuted DRF with volar free fragments are uncommon. There is considerable difficulty in the fixation of free fragments beyond the watershed line using the existing volar locking plate. We aimed to examine the efficacy and potential complications associated with the use of juxta-articular volar plates in intra-articular DRF accompanied by free fragments beyond the watershed line.

Methods

The patients were enrolled in a consecutive manner between 2007 and 2016. In cases of DRF with free fragments beyond the watershed line, we employed a 2.4-mm small fragment juxta-articular volar locking compression plate using a volar Henry approach. A total of 32 patients were included in this study. There were 15 males and 17 females with a mean age of 52.3 years (range, 33 to 69 years). The mean follow-up period was 14.5 months (range, 10 to 24 months). Preoperative radiographs and three-dimensional computed tomography images were used to analyze fracture patterns and assess the free fragments beyond the watershed line. The mean number of free fracture fragments beyond the watershed line was 2.33. Plain radiographs of immediate postoperative and last follow-up were used to confirm fracture union, incongruence, radial height, volar tilt, radial inclination, and arthritic changes. For functional assessment, we measured grip strength, range of motion (ROM), modified Mayo wrist score (MMWS) and determined Disabilities of Arm, Shoulder and Hand (DASH) scores at the last follow-up. Postoperative complications were monitored during the follow-up period.

Results

All patients obtained sound union without significant complications. At the last follow-up, 16 cases presented with an articular step-off of more than 1 mm (mean, 1.10 mm). The mean MMWS was 76.3 (range, 55 to 90), mean DASH score was 15.38 (range, 9 to 22), mean visual analogue scale score for pain was 1.2 and mean grip strength was 75.5% of the opposite side. The mean ROM was 74.3° for volar flexion and 71.5° for dorsiflexion.

Conclusions

In cases of intra-articular DRF with free fragments beyond the watershed line, a volar approach with use of a juxtaarticular plate provided favorable outcomes without significant complications.

Volar Distal Radius Anatomy Applied to the Treatment of Distal Radius Fracture

Volar locking plate (VLP) fixation has become the standard surgical treatment for distal radius fractures. However, flexor tendon rupture is one of the major complications following volar plating. This detailed review on the anatomy and morphology of the volar distal radius might facilitate appropriate placement of the volar plate and thereby avoid flexor tendon rupture. We introduce safe and secure VLP fixation along standard surgical procedures to avoid complications based on anatomy of the volar surface of the distal radius.