Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation

Neglected volar Barton fracture in adult managed in a rural setting: a case report

Introduction

Barton fractures are distal radius fractures that extend through the dorsal aspect of the articular surface, with associated dislocation of the radiocarpal joint. They are extremely unstable and require open reduction and internal fixation (ORIF). Delayed presentation is often encountered with difficulty in achieving reduction, and more extensive surgery may be needed. Here, we present a case of a 3-week-old neglected volar Barton fracture of the right wrist treated with the conventional method in a rural setting.

Case presentation

A 32-year-old gentleman was initially denied surgical intervention for a distal radius fracture he sustained after a motor vehicle accident and was discharged with a long arm slab plus analgesics represented in the outpatient department and agreed upon surgical intervention after his condition did not improve with conservative treatment. The trans-FCR (flexor carpi radialis) approach was used for surgery under the brachial plexus block. The fragment was reduced by applying pressure volarly into the distal radius and was confirmed with imaging. A K-wire (Kirschner) was used to temporarily hold the fragment. A volar distal radius locking plate was used to buttress the distal fragment. Final fixation was made using altogether six screws. The wrist was splinted in a short dorsal slab. Skin sutures were removed after 2 weeks, and an active assisted range of motion of the wrist was begun after 6 postoperative weeks.

Discussion

Volar Barton is an uncommon subset of intra-articular fractures and typically results from damage sustained at high speeds. The general agreement for neglected fractures is that 'fractures that are not handled or mishandled resulting in treatment delay, worsening of the fracture and even a disability' are to be considered neglected fractures. Rebuilding the damaged anatomy properly and enabling a prompt, problem-free recovery of hand function are the main objectives of treatment. As conservative therapy is often ineffective and rife with side effects, including early osteoarthrosis, deformity, subluxation, and instability, stabilization and anatomic reduction by surgery is the key to managing these fractures. Plating is one of the therapeutic modalities among various therapeutic modalities depicted in the literature that enables shorter time of immobilization and early restoration of wrist function through direct anatomic repair and stable internal fixation. In our case, the callus was relatively immature, and the original fracture site could easily be cleared. Also, there was no significant soft tissue shortening, and the volar fragment had not migrated proximally, in contrast to what is expected in prolonged neglected cases. Hence, the intraoperative reduction was possible, and the fracture was fixed with a volar locking plate as usual.

Conclusion

Given the modest tissue shortening and young callus, such cases may be treated as conventional Barton's fractures and managed using conventional means of fixation with locking buttress plates. However, it makes sense to prepare for potential malreduction by carrying K wires and wrist distractions. To restore complete function to the injured wrist, adequate physiotherapy and postoperative splinting are essential components of postoperative rehabilitation.

Are Observational Studies on Distal Radius Fracture Treatment Robust? An E-value Approach to Analysis

BACKGROUND

Reported complication frequencies after distal radius fracture (DRF) treatment vary widely in the literature and are based mostly on observational evidence. Whether that evidence is sufficiently robust to use in practice is controversial. The E-value is an innovative sensitivity analysis that quantitates the robustness of observational evidence against unmeasured confounders, whereby a greater E-value usually implies more robust evidence and vice versa; with DRF complications, this approach can help guide readers to a more confident interpretation of the available evidence.

QUESTIONS/PURPOSES

In this study, we sought (1) to compare the complication frequencies among different DRF treatment modalities, and (2) to evaluate the robustness of these observational studies using the E-value as an index for unmeasured confounding.

METHODS

We searched PubMed, Embase, and SCOPUS for observational studies on the management of DRFs that were published from January 2001 to July 2021 with the last database search performed on July 31, 2021. All articles that compared different DRF treatment modalities with reported complication frequencies were included to accurately capture the quality of the observational studies in research about DRF. Risk ratios (RRs) of the overall complication and major complication risks were calculated for each subgroup comparison: volar plating versus dorsal plating, casting, external fixation, and percutaneous K-wire fixation. The RRs and their corresponding lower limits of the 95% confidence intervals (CIs) were used to derive the E-values. E-values can have a minimum possible value of 1, which signifies that the treatment-outcome association is not strong and can readily be overturned by unmeasured confounders. By contrast, a large E-value means that the observed treatment-outcome association is robust against unmeasured confounders. We averaged RRs and E-values for the effect estimates and lower limits of CIs across studies in each treatment comparison group. We identified 36 comparative observational studies that met the inclusion criteria. Seven studies compared volar with dorsal plating techniques. Volar plating was also compared with casting (eight studies), external fixation (15 studies), and percutaneous K-wire fixation (six studies).

RESULTS

Total and major complication risks did not differ among different DRF treatments. The mean RRs for total and major complications were 1.2 (95% CI 0.4 to 3.9; p = 0.74) and 1.8 (95% CI 0.4 to 11.4; p = 0.52) for the volar versus dorsal plating group; 1.2 (95% CI 0.3 to 11.2; p = 0.87) and 1.5 (95% CI 0.3 to 14.9; p = 0.74) for the volar plating versus casting group; 0.6 (95% CI 0.2 to 2.2; p = 0.33) and 0.8 (95% CI 0.2 to 6.7; p = 0.86) for the volar plating versus external fixation group; and 0.6 (95% CI 0.2 to 2.6; p = 0.47) and 0.7 (95% CI 0.2 to 4.0; p = 0.67) for the volar plating versus K-wire fixation group. The mean E-values for total and major complication frequencies for the between-group comparison ranged from 3.1 to 5.8; these were relatively large in the context of a known complication risk factor, such as high-energy impact (RR 3.2), suggesting a reasonable level of robustness against unmeasured confounding. However, the E-values for lower limits of CIs remained close to 1, which indicates the observed complication frequencies in these studies were likely to have been influenced by unmeasured confounders.

CONCLUSION

Complication frequencies did not differ among different DRF treatment modalities, but the observed complication frequencies from most comparative observational studies were less robust against potential unmeasured confounders. The E-value method, or another type of sensitivity analysis, should be implemented in observational hand surgery research at the individual-study level to facilitate assessment of robustness against potential unmeasured confounders.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Are external fixators as effective as volar plates in multi-fragmented radius distal intra-articular fractures (AO type C)?

INTRODUCTION

This study aimed to compare the radiological and clinical results of VP and EF applications in multi-fragmented radius distal intra-articular fractures (AO type C) in our clinic.

METHODS

We retrospectively analysed 80 patients who underwent surgery for radius distal fracture (AO type C) between 2014 and 2020. Group 1 comprised patients who were treated with VP, and Group 2 comprised patients who were treated with EF. Radiological evaluation was performed by measuring radial inclination, radial length, volar tilt, intra-articular step-off and ulnar variance by two-way radiography. The clinical findings were evaluated using the Gartland and Werley scoring system, and complications were noted.

RESULTS

There were no statistically significant differences between the two groups in terms of age, gender, side, fracture subtypes and follow-up time (p > 0.05). There were no statistically significant differences between the two groups in radiological parameters (based on cut-off values) (p > 0.05). The clinical evaluation did not reveal a statistically significant difference between the two groups (p = 0.613).

CONCLUSION

EF is as successful as VP in providing radiological cut-off values. EF treatment can be used as an effective and safe alternative method for multi-fragmented radius distal intra-articular fractures.

Outcomes of Arthroscopic-Assisted Distal Radius Fracture Volar Plating: A Meta-Analysis

PURPOSE

The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature.

METHODS

A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength).

RESULTS

Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes.

CONCLUSIONS

The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

Comparison of immobilization periods following open reduction and internal fixation of distal radius fracture: A systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

INTRODUCTION

The use of volar locking plate (VLP) in the fixation of fracture fragments promised a new era in the management of distal radius fracture (DRF).

PURPOSE OF THE STUDY

To compare the patient-reported outcomes, functional outcomes, pain, and adverse events between the different periods of immobilization following open reduction and internal fixation of DRFs with VLP.

METHODS

We searched Medline/Pubmed, Web of Science, Ovid, and CINAHL. The inclusion criteria was randomized controlled trials that compared different immobilization periods after open reduction and internal fixation of DRFs with VLP. The last search was performed on 2 June 2020. The different immobilization periods were divided into the following 3 groups: ≤1-week group, 2-3-week group, and 5-6-week group.

RESULTS

Seven eligible randomized controlled trials provided data on 509 patients. We found that compared to 5-6-week group, ≤1-week and 2-3-week groups showed a reduction in overall Patient-Reported Wrist Evaluation score (SMD = -0.48, 95% CI -0.73 to -0.22, P < .001; SMD = -0.69, 95% CI -0.97 to -0.41, P < .001, respectively). We also found that there were improvements in the other patient-reported outcomes including overall Disabilities of the Arm, Shoulder, and Hand score and pain; and functional outcomes including overall grip strength and range of motion measures in favor of ≤1-week and 2-3-week groups.

CONCLUSION

This systematic review and meta-analysis showed that compared to immobilization for 5 to 6 weeks after DRF repair, immobilization for ≤1 week or 2-3 weeks showed improvements in the patients-reported outcomes and functional outcomes. The differences between the 3 immobilization groups may not be clinically important considering the small changes as follow up progresses.

The external fixation can be a good alternative to plate-screw treatment in the surgical treatment of bilateral distal radius fractures: A retrospective cohort study

Objectives

We aimed to compare the outcomes of two surgical treatment options, external fixator (EF) or open reduction and internal fixation (ORIF), in patients with bilateral distal radius fractures (DRFs).

Patients and methods

Twenty-one patients (11 males 10 females; mean age: 40.0±16.0 years; range, 20 to 67 years) who underwent ORIF (n=10) or EF (n=11) due to bilateral DRF at between January 2011 and December 2019 were retrospectively analyzed. The Quick Disability of the Arm, Shoulder and Hand (Q-DASH) was used to calculate functional and symptomatic evaluation. The MAYO wrist scores were used to evaluate pain, functional status, ROM, and grip strength and the Michigan Hand Outcomes Questionnaire (MHOQ) was used to measure hand performance in daily life.

Results

The operation time was statistically significantly longer in the ORIF group, compared to the EF group (p<0.001). Radial shortening was statistically significantly greater in the EF group, compared to the ORIF group (p<0.001). While the Q-DASH score was lower in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.507). The MAYO wrist score was higher in the EF group on Day 15 and at one and two months and one year (p<0.05, for each). While the MHOQ score was higher in the EF group on Day 15 and at one and two months (p<0.001, for each), it was similar between the groups at one year (p=0.557).

Conclusion

In bilateral DRF cases, hand functions in the first two months after treatment were better in the EF group, compared to the ORIF group. This functional difference between the two groups gradually decreased in the first year and reached similar levels. Our results demonstrate that EF can be a good alternative in the surgical treatment of bilateral DRFs owing to its acceptable results, particularly in the short-term.

A Critical Assessment of the Most Cited Papers on Distal Radius Fractures

This article reviews the impact of the most cited works on distal radius fractures. Judged by the most cited works in this field, distal radius fracture research has followed other paradigm shifts in the history of science. Landmark papers showed that restoring premorbid anatomy led to better outcomes, and a plurality of fixation strategies emerged. A breakthrough in technology came with volar plating, and the new paradigm emerged: precise anatomic reduction is achieved typically with volar plates, unless fragment-specific approaches are needed. This paradigm is being challenged as the association among malunion, arthritis, and function continues to be understood. The best treatment of distal radius fractures in the elderly has also evolved through time.

Ilizarov ligamentotaxis versus volar locked plating in the management of AO type C2/C3 distal radius fractures-a prospective non-randomised comparative trial

PURPOSE

The aims of this study were to compare radiological and functional outcomes of Ilizarov ligamentotaxis and locked volar plating in comminuted intra-articular distal radius fractures (AO type C2/C3) using a non-randomised superiority trial.

METHODS

A total of 72 patients with AO C2/C3 distal radius fractures were allotted into Ilizarov ligamentotaxis (n = 30) and locked volar plating (n = 42) groups based on patient preference. Primary outcome was the ability to achieve and stably maintain acceptable radiological parameters (post-operative, 6 weeks, 3 months, 12 months), and secondary outcome was functional scoring (at 12 months).

RESULTS

All patients completed the study. All fractures united uneventfully. Plating was superior to Ilizarov in restoring ulnar variance (100% versus 80%, p value 0.004), but Ilizarov was superior to plating in restoring volar tilt (as opposed to neutral tilt, 83.3% versus 47.8%, p value 0.002). Both groups were comparable in restoring radial height, radial inclination and intra-articular reduction and stably maintaining all five parameters over long term. There was a statistically significant difference between the two groups with regard to mean ulnar variance (plating superior) and volar tilt (Ilizarov superior) at all stages of follow-up, whereas radial height and radial inclination were comparable at all points. There was no significant change of all radiological parameters over a follow-up period. At the end of one year, DASH score was slightly better (not clinically appreciable) in the Ilizarov group (8.47 versus 13.61, p value 0.03), but Gartland and Werley scores were comparable between both groups. Mean duration of external fixation in the Ilizarov group was 43.07 ± 8.94 days. Apart from five cases of pin site infections, there were no complications.

CONCLUSION

Ilizarov ligamentotaxis is a comparable option to locked volar plating in achieving radiological restoration and clinical function in comminuted intra-articular distal radius fractures, AO types C2 and C3. Restoration of ulnar variance needs utmost care while performing Ilizarov ligamentotaxis. Ilizarov comes with the disadvantages of reduced patient preference, pin site infections, need for removal of external fixator and slightly slower return to activity.

TRIAL REGISTRATION NUMBER

 CTRI/2018/08/015549 LEVEL OF EVIDENCE: Level III, Non-randomised prospective trial.

Effect of Metacarpal Fixation Configuration on Strength and Fracture Gap Displacements in a Cadaveric Model of Externally Fixed Distal Radius Fractures

Background: The purpose of the study was to determine the biomechanical effect of distal pin configuration in unilateral external fixation of distal radius fracture in a cadaveric model. Methods: A standardized 2-part extra-articular distal radius fracture model with dorsal comminution was created in 6 matched pairs of cadaveric upper extremities. Specimens within each matched pair were randomly assigned to either 4 or 6 cortices of distal pin metacarpal fixation. Cyclic, compressive loads were applied to the palmar hand. Results: No significant differences were detected in maximum forces. Six-cortex metacarpal fixation showed significantly lower magnitude of actuator displacement at 100 N cyclic loading. The difference in construct stiffness did not translate to disparities in angular and translational interfragmentary displacement at the fracture gap. Conclusions: Utilizing only 4 cortices and sparing the middle finger metacarpal avoids the need for a more transverse orientation required with 6-cortex fixation, which may otherwise impede thumb motion.

Temporary external fixation versus direct ORIF in complete displaced intra-articular radius fractures: a prospective comparative study

PURPOSE

In complex distal radius fractures (DRF), both direct osteosynthesis (one-stage approach) and temporary external fixation as a bridge to definitive osteosynthesis (two-stage approach) are used. Studies directly comparing these two management options are lacking. This study aims to compare the two procedures with regard to complications, and radiological and functional outcomes.

MATERIAL

This prospective observational study included all patients presenting with AO OTA C2 or C3 DRF (1) between January 2011 and January 2018. All patients were categorised into two groups according to received treatment: patients who underwent direct definitive osteosynthesis (Group One Stage) and patients who received an external fixator followed by definitive fixation (Group Two Stage). Primary outcome was the Patient-Rated Wrist Evaluation score (PRWE) measured at 1 year follow-up. Secondary outcomes included complications, range of motion (ROM), and radiologic parameters (ulnar variance, radial inclination and volar tilt).

RESULTS

A total of 187 patients were included in Group One Stage with a mean age of 55.6 years (SD 17.2), of which 67 had a C2 and 120 a C3 fracture. Group Two Stage consisted of 66 patients with a mean age of 53.7 years (SD 20.4 years), of which 6 patients having a C2 and 60 a C3 fracture. There was no significant difference in complications and median PRWE between Group One Stage (12.0, IQR 2.0-20.0) and Group Two Stage (12.2, IQR 5.5-23.4) (p = 0.189), even after correction for differences in baseline characteristics. The ROM and radiologic parameters did not show any significant differences as well.

CONCLUSION

No differences were found in clinical, functional, and radiological outcome between one- and two-staged surgical techniques. It may be concluded that a two-stage approach is a viable and safe alternative.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture

Introduction

There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience.

Material & Methods

A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed.

Results

A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios.

Discussion and Conclusions

This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Effectiveness of early versus delayed motion in patients with distal radius fracture treated with volar locking plate: A systematic review and meta-analysis

The aim of this study was to determine the effectiveness of early versus delayed motion on the functional outcomes in patients with distal radius fracture (DRF) treated with a volar locking plate. A systematic review and meta-analysis of randomized clinical trials was performed. An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria included randomized clinical trials that compared the effect of early versus delayed motion on wrist and/or upper limb function, pain, grip strength, and wrist range of motion in subjects older than 18 years with DRF treated with a volar locking plate. Five clinical trials were included that met the eligibility criteria for the quantitative synthesis. At 6 weeks, the PRWE questionnaire showed a mean difference (MD) of -10.6 points (p < 0.001), the MD was -11.1 points for the DASH questionnaire (p < 0.001), -0.56 cm for pain on VAS (p = 0.01), 5.0 kg for grip strength (p = 0.01), 12.5 degrees for wrist flexion (p = 0.07), and 12.8 degrees for wrist extension (p = 0.05). All differences favored the early motion treatment. At 3 months of follow-up, only the DASH, pain on VAS, and grip strength showed significant differences in favor of early motion. At 1 year of follow-up, none of the variables studied were different between groups. In the short term, there was moderate to high evidence of clinically and statistically significant differences in the functional outcomes in favor of early versus delayed motion in patients with DRF treated with a volar locking plate. But these differences were not observed at 1 year of follow-up. PROSPERO registration no.: CRD42020158706.

Early Mobilization After Volar Locking Plate Osteosynthesis of Distal Radial Fractures in Older Patients-A Randomized Controlled Trial

PURPOSE

To investigate if early mobilization after open reduction internal fixation of distal radius fractures improved the functional outcome. We hypothesized that early mobilization would lead to improved patient-reported outcome. Second, we aimed to assess whether early mobilization increased the risk of postoperative implant loosening or breakage.

METHODS

All included patients were treated with a volar locking plate. After surgery, patients were randomized to either early mobilization (E-MOB) with a removable orthosis (wrist lacer) and daily wrist exercises or to late mobilization (L-MOB) with a standard dorsal plaster cast for 2 weeks and, after that, a removable orthosis and exercises. We measured all patients at 4 weeks and at 3, 6, and 12 months after surgery. At each postoperative visit, we measured range of motion and grip strength and patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographic implant loosening or breakage was assessed 14 days after surgery.

RESULTS

A total of 47 patients were allocated to E-MOB and 48 to L-MOB. The DASH score improved substantially throughout the follow-up period with no significant differences between the 2 groups at any time point. Implant loosening and fracture redisplacement was observed in 1 patient in the E-MOB group. Range of motion and grip strength were similar between the 2 groups at all time points.

CONCLUSIONS

Early mobilization after surgical treatment of distal radius fractures does not lead to improved patient-reported outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Biomechanical Stability of Volar Plate Only Versus Addition of Dorsal Ulnar Pin Plate: A Dorsal Ulnar Fragment, C-3-Type, Distal Radius, Cadaver Fracture Model

OBJECTIVE

To determine if the addition of a dorsal ulnar pin plate provides improved stability characteristics in the management of intra-articular distal radius fractures with an associated dorsal ulnar fragment.

METHODS

OTA/AO type C3 fractures, with a dorsal ulnar fragment of one-third or one-half the width of the distal radius, were simulated in 9 matched pairs of fresh-frozen cadaveric arms randomized between fixed-angle volar plate only versus volar plate with addition of a dorsal ulnar pin plate. Prepared specimens were mounted in a custom load frame and loaded in extension with stepwise cyclic load increase. Dorsal plane interfragmentary displacements were compared between the 2 fixation constructs at 50-N and 100-N cyclic load.

RESULTS

The addition of the dorsal ulnar pin plate significantly reduced interfragmentary displacements for the dorsal ulnar fragment at the 50 N load application, resulting in mean interfragmentary displacements of -0.1 ± 0.2 mm in comparison to -0.3 ± 0.2 mm with the volar plate-only construct. No other interfragmentary displacement comparisons were significant. No differences were found comparing the one-third and one-half size fragments.

CONCLUSIONS

The addition of a dorsal ulnar pin plate improved stability characteristics with respect to the dorsal ulnar fragment.

CLINICAL RELEVANCE

The addition of the dorsal ulnar pin plate, although statistically significant, improved displacement by less than 0.3 mm on average and thus may not prove to be important in clinical scenarios.

Biomechanics of external fixator of distal radius fracture, a new approach: Mutifix Wrist

BACKGROUND

The purpose of this study was to assess factors affecting fixator stiffness with a finite element model and an experimental validation with particular attention to a new fixator device named Mutifix Wrist^® (NCS Lab srl, Carpi, MO, Italy).

MATERIALS AND METHOD

Mechanical tests were carried out to determine the stiffness of the construct with different configurations. The obtained results were compared to those obtained with the Hoffmann II Compact (Howmedica-Osteonics Inc. Rutherford, NJ, USA). Data were sampled at 20 Hz and test speed was 0.05 mm/s. For each loading condition, tests were performed four times. A FEM campaign was also conducted to analyze how geometrical variables (type of configuration and K-wire diameter) affect both stiffness and stress distribution of the fixator.

RESULTS

Stiffness, axial displacement, magnitude of the displacement, magnitude and localization of the peak stress of the construct were all analyzed. Axial compression tests showed that the axial displacement reached by the machine actuator when the measured force reached 45 N was 0.56 mm ± 0.13 on average. Magnitude of the displacement along with peak stress magnitude and localization varied through the several configuration tested, but it resulted that the distal pin near the fracture gap was the more stressed one in all cases except those in which the fracture line is crossed.

CONCLUSIONS

From the tests performed, it emerged that the addiction of a K-wire provides a construct stiffening and a consequent local stress reduction; while span increase reduces stiffness and increase the local stress. If a K-wire is implanted through the fracture site, the axial stiffness is significantly increased.

The evolution of radiological measurements and the association with clinician and patient reported outcome following distal radius fractures in non-osteoporotic patients: what is clinically relevant?

Introduction: Following distal radius fractures in young non-osteoporotic patients, clinical relevancy of outcome has been scarcely reported. Outcome can be put in perspective by using measurement errors of radiological measurements and Minimal Important Change when reporting on clinician and patient reported outcome. Aim of this study was to assess the clinical relevance of radiological measurements, clinician and patient reported outcomes following distal radius fractures in young non-osteoporotic patients.Methods: Retrospective cohort study. Non-osteoporotic patients following a distal radius fracture were selected. Radiographs of both wrists were obtained at baseline, 6 weeks and at follow-up. Active range of motion and grip strength measurements were obtained at the follow-up visit and 4 questionnaires were answered to assess pain, upper extremity functioning, and health status.Results: Seventy-three patients (32 women, 41 men) with a mean age of 33.5 (SD 9.2) years at the time of injury were included. Median follow up was 62 months (IQR 53.0-84.5). Several radiological measurements evolved statistically significantly over time, however none exceeded measurement errors. Flexion/extension difference of injured compared to uninjured wrist (mean difference 11.2°, t = -7.5, df = 72, p < 0.001), exceeded Minimal Important Change, while grip strength differences did not. When comparing patients with DRFs to healthy controls, only the differences on Patient Reported Wrist Evaluation subscales "pain", "function" and total scores exceeded minimal important change (8, 10 and 13 points, respectively). Multivariable regression analysis revealed statistically significant relationships between residual step-off and respectively diminished flexion/extension (B = -36.8, 95% CI -62; -11.1, p  =  0.006), diminished radial/ulnar deviation (B = -17.9, 95% CI -32.0; -3.9, p  =  0.013) and worse ShortForm-36 "mental component score" (B = -15.4, 95% CI -26.6; -4.2, p < 0.001).Conclusion: Radiological measurements following distal radius fractures seem to evolve over time, but differences were small and were probably not clinically relevant. Range of motion, in particular flexion/extension, was impaired to such extend that it was noticeable for a patient, whereas grip strength was not impaired. The Patient Reported Wrist Evaluation was clinically relevantly diminished. Residual articular incongruency seems to influence range of motion.Implications for rehabilitationReporting Minimal Important Change regarding clinician and patient reported outcome following distal radius fractures is of more clinical value than reporting on statistical significance.Following distal radius fractures, the changes in radiological measurements do not seem to reflect a clinical relevant change.Range of motion, in particular flexion/extension, should be measured following distal radius fractures, as this might be impaired in a clinically relevant way.Measuring grip strength is of less importance following distal radius fractures, because grip strength does not seem to be affected.Residual articular incongruency seems to influence range of motion and therefore should be reduced to a minimum when treating non-osteoporotic patients.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Comparison of volar locking plates with external fixation and K-wires in arthroscopically assisted intra-articular distal radial fracture fixation

This article presents the results of a prospective cohort study that included 63 patients with intra-articular (AO Type C) distal radial fractures who were treated using an arthroscopically assisted approach with either volar locking plates or external fixator and K-wires. Postoperative analysis was carried out using X-ray assessment, clinical data, Patient-Rated Wrist Evaluation score, Gartland and Werley score, Modern Activity Subjective Survey of 2007 score, range of motion, grip, pinch and tripod pinch assessment at 1, 3, 6 and 12 months postoperatively. Despite the statistically significant differences found in a number of parameters during the period of observation, there were no clinically relevant differences determined between the two methods. There was a greater number of complications in the external fixator and K-wire treated patients. Level of evidence: II.

Dorsal Bridge Plating versus External Fixation for Distal Radius Fractures

Background  External fixation and dorsal bridge plating are wrist spanning fixation options for distal radius fractures; however, their comparative effectiveness is not well understood. A meta-analysis was conducted to compare the clinical outcomes between these two techniques. Materials and Methods  A PubMed database query of all distal radius fracture cases managed with spanning external fixation or dorsal bridge plating was performed. A total of 28 articles met inclusion criteria, yielding 895 patients for data extraction and comparative analysis. Results  Dorsal bridge plating demonstrated lower rates of infection (2 vs. 10%, p  = 0.05) and complex regional pain syndrome (1 vs. 4%, p  = 0.04) but higher rates of hardware failure (4 vs. 1%, p  = 0.026). Bridge plating also demonstrated higher rates of excellent/good ratings under the Gartland and Werley outcome score (91 vs. 83%, p  = 0.016). There was no significant difference in DASH (Disability of the Arm, Shoulder, and Wrist) scores, radiographic parameters, or unplanned reoperations between the two spanning fixation options. Conclusion  Bridge plating and external fixation both appear to be comparable for spanning fixation constructs for distal radius fractures, but with bridge plating having a potentially lower complication profile.

Surgical outcomes of elderly patients aged more than 80 years with distal radius fracture: comparison of external fixation and locking plate

BACKGROUND

To compare the outcomes after surgical intervention, including external fixation (EF) with the optional addition of K-pins or open reduction and internal fixation (ORIF) with a volar locking plate (VLP), in patients with distal radius fracture aged > 80 years.

METHODS

We reviewed 69 patients with a distal radius fracture aged > 80 years who treated under surgical intervention from 2011 to 2017 retrospectively. Their demographic data and complications were recorded. Preoperative, postoperative, and last follow-up plain films were analyzed. The functional outcomes of wrist range of motion were also evaluated.

RESULTS

41 patients were treated with EF with the optional addition of K-pins, while 28 patients were treated with ORIF with a VLP. The radiological parameters, including ulnar variance and radial inclination, at the last follow-up were significantly more acceptable in the VLP group (p = 0.01, p = 0.03, respectively). The forearm supination was significantly better in patients treated with VLP (p = 0.002). The overall incidence of complications was lower in the VLP group (p = 0.003).

CONCLUSION

VLP provides better radiological outcomes, wrist supination and lower complication rates than EF. Therefore, although EF is still widely used because of its acceptable results and easy application, we recommend VLP as a suitable treatment option for distal radius fracture in the geriatric population aged > 80 years.

Early Versus Late Motion Following Volar Plating of Distal Radius Fractures

Background: Distal radius fractures are common, and the trend in fixation has included the use of locked volar plating. The duration of splinting required after surgery and the effect splinting has upon outcome of the wrist are not clear. Our aim was to compare outcome of patients treated with early versus late motion protocol after volar plating. Methods: Thirty-three patients with distal radius fractures were prospectively and randomly enrolled into an early versus late motion study including volar plating of the distal radius fracture. Early motion included an active and passive wrist motion protocol by 14 days after surgery and delayed motion was initiated at 5 weeks. Fractures were defined as intra-articular and extra-articular, and those with, and without, ulnar styloid fracture. Motion and outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]/patient-rated wrist evaluation [PRWE]), and strength were measured through 1 year. Results: Wrist motion, DASH, and PRWE scores were only significantly different at 6 weeks with no significant differences at any later time points up to 1 year. One patient had complex regional pain syndrome (CRPS) and one had adhesive capsulitis in the late motion group. Conclusions: Following locked volar plating of distal radius fractures, early motion favored earlier return of motion along with lower DASH, PRWE, and pain scores within first 6 weeks. Although the late motion group had delayed recovery, there were no long-term significant differences in motion, strength, outcome, or pain scores. The 2 cases with complications (CRPS and adhesive capsulitis) did occur in the late motion group and may implicate late motion with these problems.

Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis

Distal radius fractures are among the most common fractures encountered in the clinical setting. Of these common fractures, it has been said that up to 60% are intraarticular in nature. Intra-articular or unstable and comminuted fractures represent severe and high energy injuries. Despite a large amount of literature, it is surgeon preference which determines the fixation method employed. There are only a few randomised control trials that report 2-year outcomes. There has yet to be a meta-analysis comparing the long-term outcomes of open reduction internal fixation (ORIF) and external fixation (EF). The aim of this metaanalysis is to identify any difference in the outcomes of either fixation method in the long term. We pooled the data of all the available randomised control trials that followed the patients for a minimum of 2 years and compared outcomes of ORIF against EF of distal radius fractures as per PRISMA guidelines from inception of the databases to December 2016. We then performed our meta-analysis using RevMan 5.3 software. Flexion/extension arcs were significantly improved in ORIF, and 7 of the 10 analysed outcomes supported ORIF, although most not to a significant degree. The meta-analysis indicated that there is no difference in outcomes with either form of treatment. Even though the flexion extension arc was statistically better in the ORIF group, the difference is not clinically meaningful.

No influence of ibuprofen on bone healing after Colles' fracture - A randomized controlled clinical trial

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) may delay bone healing. This knowledge is mainly derived from retrospective uncontrolled clinical studies and from animal experiments. The purpose of this prospective controlled study was to investigate whether ibuprofen influences pain, function, and bone healing after a Colles' fracture.

PATIENTS AND METHODS

A single center, triple-blind, randomized clinical trial. 95 patients, 80 females and 15 males, with displaced Colles' fracture aged median 65 (range 40-85) years old were included and operated by external fixation from June 2012 through June 2015. 89 participants received interventional medicine and 83 completed the one-year follow-up. The 7-day ibuprofen group received 600 mg of ibuprofen three times a day, the 3-day ibuprofen group received ibuprofen for three days and a placebo for the following four days, and finally, the placebo group received a placebo for seven days. All patients received paracetamol 1000 mg four times a day and 50 mg tramadol if needed. The primary outcome were radiological changes in radius tilt, length, and inclination observed during and 6 weeks after the surgery. The analgesic outcome were 14 days experience of pain, and registered use of tramadol. The functional outcomes were the percentage differences in the motion between the injured and non-injured wrist, and the DASH score at 3 and 12 months. All analyses were performed according to the intention to treat.

RESULTS

No clinically relevant difference was observed in the radiological migration between the treatment groups, 0.064≤P ≤ 0.81. There was no difference in the pain score between the treatment groups, P = 0.13. The use of tramadol was lower in the ibuprofen groups than in the placebo group, P = 0.035. Ibuprofen treatment did not affect the range of motion, 0.148 ≤P ≤ 0.963. Patients in all groups demonstrated DASH score, and wrist motion improvement, close to 90% of normal amplitude. The complication rate was higher in the 7-day ibuprofen group compared to the placebo group, P = 0.043.

CONCLUSIONS

Ibuprofen treatment demonstrated a tramadol-sparing effect during the postoperative period. Neither wrist function nor radiological migration were influenced. The complication rate was higher in the ibuprofen-treated group compared the placebo-treated group.

Combined Volar T-Plate and Dorsal Pi-Plate for Distal Radius Fractures: A Consecutive Series of 80 AO type C2 and C3 Cases

Background  The distal radius fracture (DRF) is the most common fracture among adults. In recent years, there has been a shift toward volar locking plates in the treatment of DRFs, and this shift has taken place with a low degree of evidence. Question/purposes  Can combined volar T-plating and dorsal pi-plating of AO type C fractures yield a good functional and radiographic outcome 1 year postoperatively? Patients and Methods  In a retrospective cohort study, we evaluated 102 consecutive patients operated with combined dorsal and volar plating, of whom 80 completed the 1-year follow-up. The DRFs were operated between 2012 and 2013. All cases were AO type C2 and C3 fractures. The primary outcome was functional scoring including radiographic examination. Secondary outcome measures included range of motion, visual analog scale (VAS) pain scores, and hand grip strength. Results  The median Batra radiographic score was 84.5. Wrist extension was 74% of the uninjured side, flexion was 70%, pronation was 94%, and supination was 90%. The Patient-Rated Wrist Evaluation score was 21 points, and the Disabilities of the Arm, Shoulder, and Hand score was 19.4 points. VAS pain scores were 0 at rest and 3 during activity. Hand grip strength was 80% of the uninjured side. Radiographic outcome did not correspond to a patient-reported outcome. Hardware removal was performed in 15/80 cases. Conclusions  We conclude that a good outcome can be expected after combined dorsal and volar plating of DRFs. Radiographic outcome is not necessarily associated with functional outcome 1 year postoperatively. The rate of hardware removal was acceptable. Level of Evidence  III.

A Meta-analysis of Studies of Volar Locking Plate Fixation of Distal Radius Fractures: Conventional versus Minimally Invasive Plate Osteosynthesis

Background

Open reduction and internal fixation using a volar locking plate has been increasingly performed for distal radius fractures. Both conventional and minimally invasive plate osteosynthesis (MIPO) techniques are widely used to treat distal radius fractures. However, it is unclear which of the techniques yields better outcomes after surgery for distal radius fractures. The purpose of this meta-analysis was to compare the benefits of conventional and MIPO techniques for distal radius fractures in terms of clinical outcomes.

Methods

Medline, Embase, and the Cochrane Central Register of Controlled Trials electronic databases were searched for articles comparing the outcomes of the conventional and MIPO techniques and published up until July 2017. Data search, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome measures.

Results

Four clinical studies were included in the analysis. No significant clinical differences were found between the techniques in clinical hand scoring, grip strength, and range of motion. However, patient satisfaction after surgery was significantly higher in the MIPO group than that in the conventional group (standard mean difference, −0.54; 95% confidence interval [CI], −0.79 to −0.29; I² = 0%). Furthermore, although there were no significant differences in volar tilt and ulnar variance between the two groups, radial inclination revealed a significant difference between the two groups (radial inclination: weighted mean difference, 1.20; 95% CI, 0.25 to 2.15; I² = 19%).

Conclusions

Both conventional and MIPO techniques were effective for patients with distal radius fractures. Despite limited high quality evidence to compare osteosynthesis with a volar locking plate via the conventional and MIPO techniques, the present study showed that the MIPO technique was associated with more favorable patient satisfaction.

Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures

"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."

Factors predicting adverse outcome in complete intra-articular distal radius fractures

PURPOSE

To determine risk factors associated with adverse functional and radiological outcome in complete intra-articular distal radius fractures (AO 23 C2-3) with a minimum follow-up of 1 year.

METHODS

Retrospective case series of 87 consecutive patients with a complete intra-articular distal radius fracture (AO/OTA 23 C2-3) and a minimum follow-up of 1 year between 2012 and 2016. Risk factors for adverse clinical [using the Patient-Rated Wrist Evaluation (PRWE) score] and radiological outcome (positive ulnar variance 1 year postoperative) were analysed in a linear regression model.

RESULTS

PRWE scored a median of 4.5 points (range 0-72.5) after a median follow-up of 31 months (range 12-70 months). A concomitant polytrauma was associated with a worse PRWE (β = 23.34, p < 0.01) and was also significantly associated with the use of a temporary external fixator (χ² = 11.93; p < 0.01) and high-energy trauma (χ² = 19.39; p < 0.01). Radiological outcome measures 1 year postoperative did not correlate with clinical outcome measures.

CONCLUSION

This cohort of complete intra-articular distal radius fractures (AO/OTA 23 C2-3) shows a good clinical outcome at medium-term follow-up independent of the radiological outcome. A concomitant polytrauma was associated with worse functional outcome and a higher complication rate. This is most likely due to the associated injury severity. These factors help the treating physician in decision-making and informing patients when treating displaced intra-articular radius fractures.

The Role of Additional K-Wires on AO Type C Distal Radius Fracture Treatment with External Fixator in Young Population

Objectives

Several methods have been proposed to treat AO type C distal radius fracture. External fixator has gained popularity for its simple procedure and rapid recovery. Some surgeons suggested that additional K-wires may play a critical role in the outcome. The purpose of study is to evaluate the role of additional K wires in treating distal radial fracture with external fixator regarding its outcome.

Material and Methods

From January 2006 to January 2010, 40 patients with AO type C distal radius fracture were treated with external fixator, with (EF) or without additional K wires (EFK). Radiologic outcome parameters include radial inclination, volar tilt, radial length, and the presence of radiocarpal arthritis according to Knirk and Jupiter. Clinical outcomes include New York Orthopedic Hospital (NYOH) wrist scoring scale.

Results

Radiographic outcome showed significant difference in regard of articular congruency at the final follow-up with the EFK group showing the advantage in maintaining the articular incongruity. NYOH wrist scoring scale showed no significant difference between both groups at final follow-up. The amount of articular step-off was less in EFK group with significant statistical finding on the final follow up.

Conclusion

Both EF and EFK technique were able to provide satisfactory result in treating AO type C distal radius fractures. We observed that EFK is superior in reducing the number of radiocarpal arthritic changes compared to EF group due to its superiority in reducing articular step-off.

Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries

BACKGROUND

In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded.

METHODS

We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]).

RESULTS

A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003).When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion.

CONCLUSIONS

In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities.In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.

[Distal radius fractures : Current treatment concepts and controversies]

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

Is volar locking plate superior to external fixation for distal radius fractures? A comprehensive meta-analysis

Objective

The aim of this meta-analysis of randomized controlled trials (RCT) and retrospective cohort studies (CS) regarding the use of volar locking plate (VLP) and external fixation (EF) in distal radius fractures was to determine whether there was any evidence that one treatment was superior to the other.

Methods

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electrical databases (PubMed, EMBASE and the Cochrane library) were retrieved to find RCTs and CSs met the eligibility criteria. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis with RevMan 5.1. The publication bias was test by Stata 14.0. The Begg's and Egger's test were performed by Stata 14.0. The quality of evidence was graded according to the criteria of GRADE. We ultimately included ten RCTs and eleven CSs.

Results

A total of 1590 subjects were reported. Publication bias was detected by funnel plot in RCTs. VLP could provide better results such as DASH scores (RCT: MD = −6.12, 95%CI = −12.07–0.17; CS: MD = −6.43, 95%CI = −12.53–0.3), ulnar variance (RCT: MD = −0.81, 95%CI = −1.25–0.37) and infection rate (RCT: RR = 0.25, 95%CI = 0.10–0.65; CS: RR = 0.15, 95%CI = 0.06–0.40). There were no significant differences for G-W scores, VAS and grip strength between the VLP group and EF group. There was significantly greater loss of volar tilt (P = 0.01) and radial inclination (P = 0.02) in patients receiving EF, basing on the CSs.

Conclusions

VLP could provide better results, such as DASH scores, ulnar variance, volar tilt, radial inclination and infection rate. The use of VLP appear to be associated with better results of ROM (flexion, pronation, supination and radial deviation), radiographic parameters (volar tilt and radial inclination) and lower total complication rate and CRPS rate in CSs.

Level of evidence

Level 1, Therapeutic study.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating

We compared outcomes in elderly patients with intra-articular distal radius fractures treated by closed reduction and plaster immobilization or open reduction and internal fixation with a volar plate. Ninety-seven patients older than 60 years were randomly allocated to conservative (47 patients) or surgical (50 patients) treatment. Over a 2-year period, we assessed patient-rated wrist evaluation score, DASH (disability arm, shoulder and hand) questionnaire, pain, wrist range of motion, grip strength, and radiological parameters. The functional outcomes and quality of life were significantly better after volar plating fixation compared with conservative treatment. We found that restoration of the articular surface, radial inclination, and ulnar variance affected the outcomes, but the articular step-off did not. Twenty-five per cent of the patients with conservative treatment had secondary loss of reduction. We conclude that surgical plating leads to better outcomes than conservative treatment for elderly patients with intra-articular distal radius fractures.

LEVEL OF EVIDENCE

I.

Preexisting Carpal and Carpometacarpal Osteoarthritis Has No Impact on Function after Distal Radius Fractures

Background  Functional outcomes of distal radius fractures vary widely regardless of treatment methods. Purpose  This study aims to verify whether preexisting carpal and carpometacarpal (CMC) osteoarthritis (OA) will negatively impact wrist functional outcome in patients with distal radius fractures. Patients and Methods  A retrospective case-control study was done using a prospective trauma database. Patients were matched 1:1 in two groups based on the presence of wrist or carpal arthritis (OA). The groups were matched for sex, follow-up, and treatment type. Patients were followed up for a minimum of 1 year and functional outcomes were assessed using validated scores. Results  A total of 61 patients were included. Mean age was 63 years (range: 20-85) and average follow-up was 26 months. There were 31 patients in the OA+ group and 30 in the OA- group. Forty-one patients were treated surgically and 20 nonoperatively. None of the patients in the OA- developed OA during follow-up. Both groups were comparable for sex, residual deformity, and follow-up. There was no significant difference for the visual analog scale, Short Form-12, Quick Disability Arm Shoulder Hand, and Patient-rated Wrist Evaluation, or for radiographic outcomes. Conclusion  Preexisting OA in the wrist or CMC does not seem to impact outcomes of distal radius fractures, regardless of treatment, age, or sex. Although this is a negative study, the results are important to help counsel patients with distal radius fractures. Further work must be done to identify other potential causes for negative outcomes. Level of Evidence  Level III, prognostic study.

Radial Plate Fixation: A Novel Technique for Distal Radius Fractures

BACKGROUND

Distal radius fractures represent a common fracture pattern frequently treated with volar locked plating for fixation. However, other methods may provide equivalent outcomes and minimize risks associated with the volar approach and hardware placement. One such method is the radial plate.

METHODS

After confirmation of institutional board review, we retrospectively reviewed data from 7 patients with our primary functional outcomes measured by Mayo wrist and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. The most recent radiographic and motion parameters were recorded.

RESULTS

Mean age at time of injury was 49 years (range, 19-68 years) with clinical follow-up of 81.6 months (range, 43.5-95.5 months). Five patients had good to excellent outcomes with a mean QuickDASH score of 0.92 for those patients. The mean QuickDASH score for all patients was 18.5. Mean radial height, inclination, and volar tilt were within 5% of the contralateral side. Standard deviation values for radiographic measures and clinical range of motion indicate significant variability in our data set.

CONCLUSIONS

Although the results are mixed, our small cohort indicates radial plate fixation could provide a viable alternative to volar plate fixation of distal radius fractures. Further prospective investigation is warranted to better describe long-term outcomes using this technique.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation

PURPOSE

To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model.

METHODS

We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique.

RESULTS

Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation.

CONCLUSIONS

A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction.

CLINICAL RELEVANCE

External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Comparison of outcome of VLCP versus PKEF in the treatment of AO type C2-3 distal radial fractures

Purposes

Fractures of the distal radius are extremely common in adults. However, the optimal management remains controversial, especially in AO type C2-3 (Type23 C2 or C3 of distal radial fracture, according to AO classifications). The purpose of this study was to compare the results of the volar locking compression plate (VLCP) and percutaneous Kirschner-wires combined with external fixation (PKEF) in the treatment of the AO type C2-3 fractures.

Methods

From July 2012 to June 2015, 62 patients with AO type C2-3 fractures, treated by VLCP or PKEF, were included in this retrospective study. Patients were followed up at 3 months, 6 months after operation, and final follow up. Outcomes were assessed by radiographic features in all follow up and by DASH and Sarmiento's modification of the Gartland-Werley score at final follow up.

Rusults

No significant difference was noted between these two groups in terms of volar inclination, ulnar angulation and ulnar variance. There was also no significant difference on DASH score between these two groups. However, according to the Sarmiento's modification of the Gartland-Werley scores, the scores was higher in VLCP group than the PKEF group, and ratings of excellent and good were lower in the VLCP group (P = 0.05).

Conclusions

Both techniques could get satisfactory results in the treatment of AO type C2-3 fractures, but PKEF leads to better wrist function than VLCP .

•

This is a retrospective study.

•

The purpose of this study was to compare the therapeutic effects of the VLCP and PKEF in the treatment of the AO type C2-3 distal radial fractures.

•

Both techniques could get satisfactory results in the treatment of AO type C2-3 fractures, but PKEF leads to better wrist function than VLCP.

Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review

To position the volar plate on the distal radius fracture site, the pronator quadratus muscle needs to be detached from its distal and radial side and lifted for optimal exposure to the fracture site. Although the conventional approach involves repair of the pronator quadratus, controversy surrounds the merits of this repair. The purpose of this study was to compare the functional outcomes of patients with distal radius fractures treated with pronator quadratus repair after volar plate fixation versus no pronator quadratus repair. A systematic search was conducted in Medline, EMBASE and the Cochrane Central Register of Controlled Trials, on 23 July 2015. All studies comparing pronator quadratus repair with no pronator quadratus repair in adult patients undergoing volar plate fixation for distal radius fractures were included. The primary outcome was the Disability of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes included range of motion, grip strength, post-operative pain and complications. A total of 169 patients were included, of which 95 underwent pronator quadratus repair, while 74 patients underwent no pronator quadratus repair. At 12 months follow-up no statistically significant differences in DASH-scores and range of motion were observed between pronator quadratus repair and no repair. Moreover, post-operative pain and complication rates were similar between both groups. At 12 months of follow-up, we do not see any advantages of pronator quadratus repair after volar plate fixation in the distal radius. However, a definitive conclusion cannot be drawn from this systematic review due to a lack of available evidence.

Early Rehabilitation of Distal Radius Fractures Stabilized by Volar Locking Plate: A Prospective Randomized Pilot Study

Background Distal radius fractures are very common and an increased incidence of 50% is estimated by 2030. Therefore, both operative and postsurgical treatment remains pertinent. Main aim in treating intra-articular fractures is to restore the articular surface by internal fixation and early mobilization (EM). Questions/Purposes The purpose of this study was to compare functional results between EM immediately after surgery and 5 weeks of immobilization (IM). Patients and Methods In a randomized prospective study, 30 patients with an isolated distal radius fracture were treated by open reduction and internal fixation using a single volar locking plate excluding bone graft. Fifteen patients were randomized in the EM group and 15 in the IM group. At 6 weeks, 9 weeks, 3 months, 6 months, and 1 year postsurgery, range of motion, grip strength and X-rays were evaluated. Additionally, Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Patient-Rated Wrist Evaluation (PRWE), modified Green O'Brien (Mayo) score, and pain according to the Visual Analog Scale score were analyzed. Results Patients in the EM group had a significantly better range of motion in the sagittal plane, in grip strength up to 6 months, in the frontal plane up to 9 weeks, and in forearm rotation up to 6 weeks. Also QuickDASH and PRWE scores were better up to 6 weeks postsurgery. The Green O'Brien score differed significantly up to 1 year. At 1 year, 93% "excellent" and "good" results in the Green O'Brien score with a mean QuickDASH of 5.98 ± 10.94 and PRWE score of 4.27 ± 9.23 were observed in the EM group. No differences regarding loss of reduction, pain, duration of physiotherapy, and sick leave were noted. Conclusion EM of surgically treated distal radius fractures (without bone graft) is a safe method for postoperative aftercare and leads to an improved range of motion and grip strength at 6 months postsurgery compared with an IM of 5 weeks. Level of Evidence This is a level Ib clinical study.

Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

INTRODUCTION

Using network meta-analysis, we evaluated the adverse effects of the seven most common treatment methods, i.e., bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating, by their associated risk of developing complex regional pain syndrome (CRPS) in distal radius fracture (DRF) patients.

MATERIAL AND METHODS

Following an exhaustive search of scientific literature databases for high quality studies, randomized controlled trials (RCTs) related to our study topic were screened and selected based on stringent predefined inclusion and exclusion criteria. Data extracted from the selected studies were used for statistical analyses using Stata 12.0 software.

RESULTS

A total of 17 RCTs, including 1658 DRF patients, were enrolled in this network meta-analysis. Among the 1658 DRF patients, 452 received bridging external fixation, 525 received non-bridging external fixation, 154 received K-wire fixation, 84 received plaster fixation, 132 received dorsal plating, 123 received volar plating, and 188 received dorsal and volar plating. When compared to bridging external fixation patients, there was no marked difference in the CRPS risk in DRF patients receiving different treatments (all p > 0.05). However, the surface under the cumulative ranking curves (SUCRA) for plaster fixation (77.0%) and non-bridging external fixation (71.3%) were significantly higher compared with the other five methods.

CONCLUSIONS

Our findings suggest that compared with bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation might be the better treatment methods to reduce the risk of CRPS in DRF patients.

Volar locking distal radius plates show better short-term results than other treatment options: A prospective randomised controlled trial

AIM

To compare the outcomes of displaced distal radius fractures treated with volar locking plates and with immediate postoperative mobilisation with the outcomes of these fractures treated with modalities that necessitate 6 wk wrist immobilisation.

METHODS

A prospective, randomised controlled single-centre trial was conducted with 56 patients who had a displaced radius fracture were randomised to treatment either with a volar locking plate (n = 29), or another treatment modality (n = 27; cast immobilisation with or without wires or external fixator). Outcomes were measured at 12 wk. Functional outcome scores measured were the Patient-Rated Wrist Evaluation (PRWE) Score; Disabilities of the Arm, Shoulder and Hand and activities of daily living (ADLs). Clinical outcomes were wrist range of motion and grip strength. Radiographic parameters were volar inclination and ulnar variance.

RESULTS

Patients in the volar locking plate group had significantly better PRWE scores, ADL scores, grip strength and range of extension at three months compared with the control group. All radiological parameters were significantly better in the volar locking plate group at 3 mo.

CONCLUSION

The present study suggests that volar locking plates produced significantly better functional and clinical outcomes at 3 mo compared with other treatment modalities. Anatomical reduction was significantly more likely to be preserved in the plating group. Level of evidence: II.

Recovery of Wrist Function after Volar Locking Plate Fixation for Distal Radius Fractures

BACKGROUND

The purpose of our present study was to examine the recovery of the postoperative wrist function, and to compare the range of motion among each direction ofthe wrist joint during the same time periods after surgery for distal radius fractures.

METHODS

Twenty patients treated with a volar locking plate were evaluated. The active range of motion and grip strength were assessed at four weeks, six weeks, three months, six months and one year after surgery.

RESULTS

The ratio of the range of motion in pronation and supination recovered significantly earlier than for any other directions within six months after surgery (p = 0.0205), however, the ratio of the range of motion among the six directions was not significantly different at one year after surgery (p = 0.0823). The recovery of the range of motion in flexion was 96.8% compared with the contralateral wrist at one year after surgery, and it was not significantly lower than that in extension, radial deviation or ulnar deviation (97.8%, 93.5%, 94.4%, respectively). The grip strength of dominant hand recovered from 50% after four weeks to 66% after six weeks, 83% after three months, 91% after six months and 106% at the examination performed after one year compared with the uninjured non-dominant hand. The grip strength of non-dominant hand recovered from 52% after four weeks to 59% after six weeks, 79% after three months, 84% after six months and 94% at the examination performed after one year compared with the uninjured dominant hand. The mean DASH score was 5.3.

CONCLUSIONS

The range of motion in flexion can achieve similar improvement to that in the other directions by obtaining the appropriate postoperative parameters. The optimal postoperative radiographic parameters were thus identified to be essential for successfully obtaining a recovery of the wrist function for unstable distal radius fractures.

External Fixator for Maintaining Reduction Before Volar Plating: A Simple Treatment Method for Association of Osteosynthesis Type C3 Distal Radius Fracture

Volar plating for Association of Osteosynthesis type C3 distal radius fractures involves more time and more radiation exposure because it is extremely difficult to simultaneously maintain the reduction and restore the congruity of the articular surface. The authors present a technique of maintaining the acceptable reduction by using an external fixator followed by open volar plating for restoring articular congruity. A consecutive series of 96 Association of Osteosynthesis type C3 distal radius fractures treated with the technique were retrospectively reviewed between January 2004 and December 2012. The technique makes surgery simpler and more effective, and reduces radiation exposure.