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Dijkmans AL, Laane CLE, Fernandez Dell'Oca A, Jupiter JB, Garg R, Bhashyam AR. Binary Soong grading as a predictor for flexor pollicis longus tendon rupture after distal radial fracture fixation: a retrospective study. J Hand Surg Eur Vol 2024:17531934241258312. [PMID: 39169760 DOI: 10.1177/17531934241258312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
This retrospective cohort study evaluates the concordance between Soong grades classified from radiographs and computed tomography (CT) scans and whether a Soong grade ≥1 is associated with flexor pollicis longus (FPL) injury and reoperation incidence. We included 181 patients with 185 dorsally displaced distal radial fractures treated with anterior locking plates. For the analysis of binary Soong grades, grade 0 was compared with grades 1 and 2. A moderate correlation was found between Soong grades on radiographs and CT scans (MCC 0.66). FPL injury occurred in 3% (6/185) and reoperation in 15% (28/185) of cases. There was no statistically significant difference between Soong grades when correlated with the incidence of FPL injury or reoperation, but no patients with a Soong grade 0 had an FPL injury. Binary Soong grading is non-inferior in predictive value and has a better correlation between radiographs and CT scans. Using the Soong classification as a binary system may be easier than a ternary system in clinical practice.Level of evidence: IV.
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Affiliation(s)
- Anjuli L Dijkmans
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlotte L E Laane
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - Jesse B Jupiter
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rohit Garg
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abhiram R Bhashyam
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Adams AJ, Patel SJ, Arango SD, Smithson K, Tosti RJ, Miller AJ. Extensor tendon transfer for fracture-related extensor pollicis longus rupture: Long-term outcome case series. J Hand Ther 2024:S0894-1130(24)00006-1. [PMID: 38490877 DOI: 10.1016/j.jht.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/10/2024] [Accepted: 02/09/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Spontaneous rupture of the extensor pollicis longus (EPL) tendon following both nonoperative and operative treatment of distal radius fractures has been well described. PURPOSE The purpose of this study was to assess long-term outcomes of extensor indicis proprius to EPL tendon transfers for patients following distal radius fracture and EPL tendon repair. STUDY DESIGN Retrospective case series focusing on long-term clinical outcomes. METHODS A retrospective review was conducted for patients who sustained a distal radius fracture and subsequently underwent extensor tendon transfer from 2005-2015 at a private practice center. Outcome measures including index finger (IF) metacarpophalangeal (MCP) and thumb interphalangeal (IP) active range of motion (ROM), digital extension against resistance, subjective complaints, and QuickDASH scores were recorded at final follow-up. RESULTS Seven patients were included in the study. There were six females and one male subject, mean age of 54 ± 13 years at injury of EPL, and 5/7 involved the left upper extremity. For isolated function, 7/7 (100%) patients had isolated, active IF MCP extension, 6/7 (86%) could extend IF MCP and thumb IP against resistance. Mean IF MCP extension was 1° ± 2°, mean IF MCP flexion was 89° ± 2°, mean thumb IP extension was -5° ± 4°, and mean thumb IP flexion was 67° ± 15°. Mean QuickDASH score was 16 ± 14. CONCLUSIONS This series shows good long-term functional and patient reported outcomes in patients following extensor indicis proprius to EPL tendon transfers at a single center.
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Affiliation(s)
- Alexander J Adams
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Saral J Patel
- Division of Hand Surgery, Philadelphia Hand to Shoulder Center of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Sebastian D Arango
- Division of Hand Surgery, Philadelphia Hand to Shoulder Center of Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Kaleb Smithson
- Division of Hand Surgery, Philadelphia Hand to Shoulder Center of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Rick J Tosti
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Andrew J Miller
- Division of Hand Surgery, Philadelphia Hand to Shoulder Center of Thomas Jefferson University, Philadelphia, PA 19107, USA
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Jacobsen ME, Nayahangan LJ, Ghidinelli M, Subramaniam C, Hare KB, Konge L, Gustafsson A. Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study. J Hand Surg Am 2023; 48:875-885. [PMID: 37389496 DOI: 10.1016/j.jhsa.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/25/2023] [Accepted: 05/10/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture. METHODS International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results. RESULTS Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters. CONCLUSIONS Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool. CLINICAL RELEVANCE This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.
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Affiliation(s)
- Mads Emil Jacobsen
- Department of Orthopedic Surgery, Center for Orthopaedic Research and Innovation (CORI), Næstved, Slagelse and Ringsted Hospitals, Slagelse, Region Zealand, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Capital Region, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Leizl Joy Nayahangan
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Capital Region, Denmark
| | | | | | - Kristoffer Borbjerg Hare
- Department of Orthopedic Surgery, Center for Orthopaedic Research and Innovation (CORI), Næstved, Slagelse and Ringsted Hospitals, Slagelse, Region Zealand, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Capital Region, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Amandus Gustafsson
- Department of Orthopedic Surgery, Center for Orthopaedic Research and Innovation (CORI), Næstved, Slagelse and Ringsted Hospitals, Slagelse, Region Zealand, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Capital Region, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Nwosu C, Rodriguez K, Zeng S, Klifto KM, Klifto CS, Ruch DS. Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials. J Hand Surg Am 2023; 48:861-874. [PMID: 37552141 DOI: 10.1016/j.jhsa.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs). METHODS A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence. RESULTS Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%). CONCLUSIONS A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Chinemerem Nwosu
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | | | - Steven Zeng
- Duke University School of Medicine, Durham, NC
| | - Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO
| | - Christopher S Klifto
- Division of Hand Surgery, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - David S Ruch
- Division of Hand Surgery, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
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Husain TM, Jabbour JI, Sudduth JD, Lessard AS, Patete CL, Panthaki ZJ, Salloum GE. Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5227. [PMID: 37654680 PMCID: PMC10468108 DOI: 10.1097/gox.0000000000005227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/12/2023] [Indexed: 09/02/2023]
Abstract
Background Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes. Methods A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap. Results Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation. Conclusions The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.
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Affiliation(s)
| | - Jacob I. Jabbour
- The Hand Center at HOCC, Hartford Healthcare Medical Group, New Britain, Conn
| | - Jack D. Sudduth
- Division of Plastic Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Anne-Sophie Lessard
- Division of Plastic, Aesthetic, and Reconstructive Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Carissa L. Patete
- University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Zubin J. Panthaki
- Division of Plastic, Aesthetic, and Reconstructive Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
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Macken AA, Lans J, Özkan S, Kramer S, Jupiter JB, Chen NC. Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures. J Hand Microsurg 2023; 15:212-218. [PMID: 37388558 PMCID: PMC10306991 DOI: 10.1055/s-0041-1739961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Aim A rare complication following volar plate fixation of a distal radius fracture is flexor pollicis longus (FPL) rupture. This study aims primarily to analyze the radiographic features and secondly to report the patient-reported outcomes of FPL reconstruction after volar plate fixation. Methods Ten patients were retrospectively identified and contacted for follow-up. Seven patients participated in the study and completed the numeric rating scale (NRS) for pain, patient-reported outcome measurement information system-upper extremity (PROMIS-UE), and quick disability of arm, shoulder, and hand (QuickDASH) questionnaires at a median of 3.4 years following FPL reconstruction. Soong grade was determined on preoperative radiographs. Results Six patients were classified as Soong grade 1 and two patients had a screw or wire protruding volarly. The median time to tendon rupture was 21.6 months. At final follow-up, the median NRS pain score was 0 (range: 0-7); the median PROMIS-UE score was 47.1 (range: 25.9-61); and the median QuickDASH-score was 12.5 (range: 4.5-75). Conclusions The outcome of FPL reconstruction after volar plate fixation is highly variable. All ruptures in our cohort occurred in patients with plate positioning classified as Soong grade 1 and occurred at up to 3 years following distal radius fixation.
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Affiliation(s)
- Arno A. Macken
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jonathan Lans
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Sezai Özkan
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Simon Kramer
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jesse B. Jupiter
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neal C. Chen
- Department of Orthopedic Surgery, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Vasara H, Tarkiainen P, Stenroos A, Kosola J, Anttila T, Aavikko A, Nordback PH, Aspinen S. Higher Soong grade predicts flexor tendon issues after volar plating of distal radius fractures - a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:271. [PMID: 37038208 PMCID: PMC10084605 DOI: 10.1186/s12891-023-06313-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/11/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND AND PURPOSE Soong classification is used to estimate volar locking plate prominence and evaluate the risk for flexor tendon ruptures after surgical treatment of distal radius fractures (DRFs). However, the scientific community has questioned the Soong classification due to lacking evidence. Therefore, this study aimed to evaluate the accuracy of Soong grading as a predictor for flexor tendon issues and plate removal. PATIENTS AND METHODS We performed a retrospective single-center review of adult distal radius fracture patients treated with a volar locking plate between 2009 and 2019. In total, 2779 patients were included in the study. The primary outcome was a flexor tendon issue (flexor tendon rupture, tendinitis, or flexor irritation), whereas plate removal was a secondary outcome. Using Soong grade 0 as a reference, we used univariable and multivariable logistic regression to calculate odds ratios (OR) with 95% confidence intervals (CI) for flexor tendon issues and plate removal. RESULTS In total, 756 (27%) patients were graded as Soong 0, 1679 (60%) Soong 1, and 344 (12%) Soong 2, respectively. There were 32 (1.2%) patients with flexor tendon issues, of which 4 were flexor tendon ruptures, 8 tendinitises, and 20 flexor irritations. The adjusted OR for flexor tendon issues was 4.4 (CI 1.1-39.7) for Soong grade 1 and 9.7 (CI 2.2-91.1) for Soong grade 2. The plate was removed from 167 (6.0%) patients. Soong grade 1 had a univariable OR of 1.8 (CI 1.2-2.8) for plate removal, and Soong grade 2 had an OR of 3.5. (CI 2.1-5.8), respectively. CONCLUSION Flexor tendon ruptures are rare complications after the volar plating of DRFs. A higher Soong grade is a risk factor for flexor tendon issues and plate removal. TRIAL REGISTRATION The trial was retrospectively registered.
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Affiliation(s)
- Henri Vasara
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Petra Tarkiainen
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jussi Kosola
- Department of Orthopedics and Traumatology, Kanta-Häme Central Hospital and University of Helsinki, Hämeenlinna, Finland
| | - Turkka Anttila
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anni Aavikko
- Department of Orthopedics and Traumatology, Päijät-Häme Central Hospital and University of Helsinki, Lahti, Finland
| | - Panu H Nordback
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Samuli Aspinen
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Andersen MF, Landgren M, Schmidt LB, Hassani G. Complications associated with anterior plate fixation of distal radial fractures: a retrospective study of 599 patients. J Hand Surg Eur Vol 2022; 47:825-830. [PMID: 35400207 DOI: 10.1177/17531934221089225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the incidence of postoperative complications following anterior locking plate fixation of distal radial fractures. We investigated whether there is an association with the patient's age, severity of the fracture or surgeon's experience. The medical records of all patients treated with anterior locking plate for a distal radial fracture between 2016 and 2018 were retrospectively reviewed. Radiographs were evaluated regarding Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification, Soong grade and dorsal screw prominence. Six-hundred and three distal radial fractures treated with anterior locking plate fixation in 599 patients were included. The overall postoperative complication incidence was 11%. Secondary surgery was performed in 9%. No statistical significance in the incidence of complications was found regarding age, AO/OTA type or surgeon experience.Level of evidence: IV.
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Affiliation(s)
- Michelle Fog Andersen
- Department of Orthopaedic Surgery, Hand Surgery Unit, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Marcus Landgren
- Department of Orthopedic Surgery, Hand Surgery Unit, Copenhagen University Hospital, Herlev and Gentofte, Gentofte, Denmark
| | - Linnea Bøgeskov Schmidt
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Denmark
| | - Galal Hassani
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Denmark
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Moriya K, Maki Y, Tsubokawa N, Koda H. Trends in digital joint motion following surgical reconstruction of a tendon rupture after distal radius fracture. J Orthop Sci 2022; 27:1032-1038. [PMID: 34332854 DOI: 10.1016/j.jos.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/27/2021] [Accepted: 06/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tendon rupture has been recognized as a complication of distal radius fracture (DRF); however, the clinical outcome of reconstructive surgery for this injury remains unclear. We examined prognostic factors for the outcomes of reconstructive surgery in patients with a tendon rupture after DRF. METHODS This study was a retrospective review of a case series. Seventy-five consecutive patients were treated at our institution for tendon rupture after DRF. The cohort included 14 males and 61 females with a mean age of 67.7 years at the time of tendon reconstruction. Sixty-four and eighteen tendon ruptures occurred after non-operative management for DRF and palmar locking plate fixation, respectively. Seven ruptured tendons received a free tendon graft from the palmaris longus tendon, and the others underwent tendon transfers. All patients were managed postoperatively by our hand therapy unit according to a controlled active mobilization regime. RESULTS The mean follow-up period was 28 weeks (range: 12-80 weeks). Patients with extensor tendon ruptures were significantly younger than those with flexor tendon ruptures regardless of the initial DRF treatment. The mean percentage active range of motion of the injured digits relative to normal active motion (%AROM) at the final follow-up was 70% (range: 30-101%) in all patients. The %AROM after flexor tendon reconstruction for patients after non-operative management was significantly inferior to that of other patients. Multiple regression analysis revealed that aging and non-operative management of DRF are independent risk factors for poor %AROM. CONCLUSIONS This study confirmed that advanced age and non-operative management of DRF were prognostic factors for digital joint motion following surgical reconstruction for tendon rupture. Our results suggest that it may be difficult to achieve good clinical outcomes in elderly patients with tendon ruptures (particularly flexor tendon ruptures) following non-operative management of DRF.
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Affiliation(s)
- Koji Moriya
- From Niigata Hand Surgery Foundation, Niigata, Japan.
| | - Yutaka Maki
- From Niigata Hand Surgery Foundation, Niigata, Japan
| | | | - Hisao Koda
- From Niigata Hand Surgery Foundation, Niigata, Japan
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Zukawa M, Osada R, Hirokawa T, Suzuki K, Makino H, Kawaguchi Y. Usefulness of Wide-Awake Local Anesthesia No Tourniquet Surgery to Decide on Tendon Transfer Versus Grafting in Chronic Flexor Tendon Rupture. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:408-413. [DOI: 10.1016/j.jhsg.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/04/2022] [Indexed: 10/18/2022] Open
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Miyaoka S, Yamazaki H, Hayashi M, Takahashi J. Implant removal following open reduction and internal fixation for distal radius fracture: A study based on the Diagnosis Procedure Combination database in Japan. J Orthop Sci 2022; 28:645-650. [PMID: 35428544 DOI: 10.1016/j.jos.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/03/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The rate of implant removal and the factors influencing its indication in patients with distal radius fracture (DRF) in Japan are unclear. METHODS We retrospectively evaluated the incidence rate of implant removal in a large cohort of DRF patients obtained from the Diagnosis Procedure Combination database in Japan between April 2014 and March 2019. Patient- and hospital-related factors possibly affecting removal rate, including age, sex, annual number of open reduction and internal fixation (ORIF) for DRF procedures per hospital, number of hospital beds, advanced or general care hospital, and hospital location were analyzed as well. Hospital location was classified into three types based on population and population density as 1) large city, 2) local city, and 3) sparse area. RESULTS Implant removal was performed in 3242 (26.3%) of 12,328 DRF patients receiving ORIF. According to multivariate analysis, the significant factors related to a decreased probability of removal were older patients, male, large annual number of ORIF for DRF procedures per hospital, large number of hospital beds, advanced care hospital, and hospital in large city. CONCLUSIONS This study clarified the current implant removal rate and trends following ORIF for DRF in Japan. Both patient- and hospital-related factors significantly impacted the decision for implant removal.
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Affiliation(s)
- Shunsuke Miyaoka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan
| | - Hiroshi Yamazaki
- Department of Orthopaedic Surgery, Aizawa Hospital, Honjo 1-5-2, Matsumoto 390-8510, Japan.
| | - Masanori Hayashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan
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Huang YM, Chen CY, Lin KC, Tarng YW, Liao CY, Chang WN. Functional outcomes following fixation of a marginal distal radius fracture with two commonly used volar locking plates: a retrospective cohort study. BMC Musculoskelet Disord 2022; 23:18. [PMID: 34980102 PMCID: PMC8725281 DOI: 10.1186/s12891-021-04984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, marginal distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on marginal distal radius fractures. This study compared functional outcomes in patients with marginal distal radius fractures treated with two different implants. Materials and methods A retrospective study was conducted, all patients who received a Synthes 2.4 mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The marginal distal radius fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa’s joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded. Results Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and grip strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006). Conclusions Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius’s volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating marginal distal radius fractures.
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Affiliation(s)
- Yin-Ming Huang
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China
| | - Chun-Yu Chen
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China. .,Department of Occupational Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, Republic of China. .,Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan, Republic of China.
| | - Kai-Cheng Lin
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China
| | - Yih-Wen Tarng
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China
| | - Ching-Yi Liao
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China
| | - Wei-Ning Chang
- Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung City, Taiwan, Republic of China
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Lv YX, Chen MM, Su CX, Ye HN, Yang J, Li J. Analysis of risk factors associated with flexor pollicis longus injury after volar plating of distal radius fractures. J Int Med Res 2021; 49:3000605211031438. [PMID: 34369195 PMCID: PMC8358517 DOI: 10.1177/03000605211031438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective This study was performed to analyze the risk factors associated with flexor pollicis longus (FPL) attrition or rupture after volar plating of distal radius fractures. Methods Three hundred thirty-eight patients with distal radius fractures were included in this retrospective study. Univariate analysis and multivariate logistic regression analysis were performed to predict risk factors. Results Univariate analysis showed that sex, volar tilt, the Soong grade, the plate-to-critical line distance (PCLD), the plate-to-volar rim distance (PVRD), and the time of plate removal were significantly associated with FPL attrition or rupture. Multivariate logistic regression analysis demonstrated that decreased volar tilt, Soong grade 2, PCLD of >2 mm, PVRD of <3 mm, and plate removal at ≥1 year were the risk factors significantly associated with FPL attrition or rupture. Conclusions Reduced volar tilt, Soong grade 2, PCLD of >2 mm, and PVRD of <3 mm appear to be risk factors that are significantly associated with FPL attrition or rupture. The findings of this study also suggest that the risk of tendon rupture is lower if a Soong grade 2 plate is removed, the PCLD is >2 mm, the PVRD is <3 mm, or reduced volar tilt is achieved earlier (at <1 year).
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Affiliation(s)
- Yang-Xun Lv
- Department of Orthopedics, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Mang-Mang Chen
- Department of Orthopedics, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Chen-Xian Su
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hao-Nan Ye
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jie Yang
- Department of Orthopedics, Wenzhou People's Hospital, Wenzhou, Zhejiang, China
| | - Jing Li
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Neder Filho AT, Mazzer N, Bataglion LR, Pires RE, Macedo AP, Shimano AC. Distal radius fracture fixation using volar plate: A comparative study evaluating the biomechanical behavior of uni and bicortical distal screws. Injury 2021; 52 Suppl 3:S38-S43. [PMID: 34172266 DOI: 10.1016/j.injury.2021.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 02/02/2023]
Abstract
Extensor tendon ruptures caused by bicortical screws impingement following distal radius fracture fixation with volar plates are extensively reported in the literature. Thus, a biomechanical study comparing unicortical and bicortical fixations in intra-articular distal radius fracture models is critical in decision-making regarding distal radius fracture management. Forty-two synthetic radius models were fixed using a variable angle volar distal locking plate with seven screws. They were divided into 6 groups (n = 7): G1/G3/G4 unicortical fixation (75% of anteroposterior distal radius lenght); G2/G4/G6 bicortical fixation. Each group underwent a different mechanical test: axial compression (G1/G2), dorsal flexion (G3/G4), and volar flexion (G5/G6). The load application rate was 5 mm/min and 1000 cycles of 50 to 250 N at 1 Hz were performed between both static tests. Comparative results in the first static test, in the second static test, and in failure generally showed a very similar behavior. Models depicted similar behavior in the second static test when cyclic load was performed. Therefore, one can realize that stiffness differed during dorsal flexion only in the first static test. Maximum force to break the model in axial compression was greater in bicortical than in unicortical construct. Since biomechanical properties are similar, we recommend using unicortical distal locking screws in distal radius fracture fixation with volar plates to prevent extensor tendon ruptures.
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Affiliation(s)
- Antonio Tufi Neder Filho
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP, Brazil.
| | - Nilton Mazzer
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP, Brazil
| | - Leonardo Rigobello Bataglion
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP, Brazil
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Faculdade de Medicina da Universidade Federal de Minas Gerais. Belo Horizonte MG, Brazil
| | - Ana Paula Macedo
- Departamento de Materiais Dentários e Próteses, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP, Brazil
| | - Antonio Carlos Shimano
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP, Brazil
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Artuso M, Protais M, Herisson O, Miquel A, Cambon-Binder A, Sautet A. Systematic use of short unicortical epiphyseal locking screws versus full-length unicortical locking screws in distal radius fracture volar plating: A prospective and comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:11-18. [PMID: 33661374 DOI: 10.1007/s00590-021-02899-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/08/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Volar locking plates, used in distal radius fracture (DRF), present a risk of injuring extensor tendons with screws penetrating the dorsal cortex of the radius. Actually, even when aiming to use maximum-length unicortical locking screws, some still could be bicortical. We hypothesize the use of only short unicortical screws would allow a proper stabilization of the radial epiphysis without the risk of dorsal cortex penetration. MATERIALS AND METHODS A prospective monocentric non-randomized study was conducted. Patients with DRF (excepted for partial dorsal joint fractures) were treated in group A with short locking epiphyseal screws (16 mm for females, 18 mm for males) and in group B with full-length unicortical locking screws. Ultrasound was done 3 months postoperatively to evaluate the number and length of prominent dorsal screws. X-rays were performed after 6 weeks to assess stability according to volar tilt and radial inclination variations. RESULTS There were 37 patients in group A and 39 in group B with 148 and 156 epiphyseal screws, respectively. In group A, there were 0% of dorsal penetrating screws against 6.5% (10 screws from 8 patients) in group B (p < 0.05). There was no significant difference for the stability between the groups: mean volar tilt variation ( - 0.6° vs. - 0.7°) and mean radial inclination variation ( - 0.4° vs. - 0.4°). CONCLUSION For a same stability with volar locking plates for DRF, short epiphyseal locking screws should be preferred to full-length unicortical screws in order to prevent extensor tendon injuries. Based on 75% of distal radial average anteroposterior width for each sex, screw lengths of 16 mm for females and 18 mm for males seem to be the length to use. LEVEL OF EVIDENCE 2: Prospective, Comparisons made, non-randomized.
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Affiliation(s)
- M Artuso
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France.
| | - M Protais
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France
| | - O Herisson
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France
| | - A Miquel
- Radiology Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France
| | - A Cambon-Binder
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France
| | - A Sautet
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, Paris, 75012, France
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16
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Stirling PHC, Ng N, Duckworth AD, McEachan JE. Extensor indicis transfer improves function in patients after rupture of the extensor pollicis longus tendon. HAND SURGERY & REHABILITATION 2021; 40:343-346. [PMID: 33401007 DOI: 10.1016/j.hansur.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/27/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
The primary aim was to determine the improvement in patient-reported functional outcomes (PROMs) following extensor indicis proprius (EIP) transfer for a closed rupture of the extensor pollicis longus (EPL) tendon. Secondary aims were to analyze the impact of this procedure on health-related quality of life (HRQoL) and satisfaction. Preoperative and one-year postoperative PROMs were collected prospectively at a single institution over a two-year period (2014-2016). The primary outcome measure was the QuickDASH score. Patients also completed satisfaction scores, and the EQ-5D-5L score was used to evaluate HRQoL. Paired data was available for 12 patients (92%) at mean 19 months following surgery. A statistically-significant improvement in mean QuickDASH score was observed from 29.7 (SD: 21.7) preoperatively to 15.2 (SD: 16.4) postoperatively (p?=?0.05). Nine patients reported an improvement, one patient reported no change, and the remaining two reported deterioration in QuickDASH score. Median EQ-5D-5L improved significantly from 0.82 (IQR: 0.71 - 1.0) to 0.93 (0.77 to 1.0) postoperatively (p?<?0.05). Eleven patients were satisfied and no complications were reported. This study has demonstrated an improvement in upper-limb specific function and HRQoL following EIP transfer for rupture of the EPL. This procedure was also associated with a low rate of complications and a high rate of patient satisfaction. LEVEL OF EVIDENCE: III (cohort study).
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Affiliation(s)
- P H C Stirling
- Department of Orthopedics and Traumatology, Queen Margaret Hospital, Dunfermline, Whitefield Rd, Dunfermline KY12 0SU, United Kingdom; Fife Virtual Hand Clinic, United Kingdom.
| | - Nathan Ng
- Department of Orthopedics and Traumatology, Queen Margaret Hospital, Dunfermline, Whitefield Rd, Dunfermline KY12 0SU, United Kingdom
| | - A D Duckworth
- Department of Orthopedics and Traumatology, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - J E McEachan
- Department of Orthopedics and Traumatology, Queen Margaret Hospital, Dunfermline, Whitefield Rd, Dunfermline KY12 0SU, United Kingdom; Fife Virtual Hand Clinic, United Kingdom
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17
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Sonntag J, Landale K, Brorson S, Harris IA. Can the results of a randomized controlled trial change the treatment preferences of orthopaedic surgeons? Bone Jt Open 2020; 1:549-555. [PMID: 33215153 PMCID: PMC7659699 DOI: 10.1302/2633-1462.19.bjo-2020-0093.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The aim of this study was to investigate surgeons' reported change of treatment preference in response to the results and conclusion from a randomized contolled trial (RCT) and to study patterns of change between subspecialties and nationalities. Methods Two questionnaires were developed through the Delphi process for this cross-sectional survey of surgical preference. The first questionnaire was sent out before the publication of a RCT and the second questionnaire was sent out after publication. The RCT investigated repair or non-repair of the pronator quadratus (PQ) muscle during volar locked plating of distal radial fractures (DRFs). Overall, 380 orthopaedic surgeons were invited to participate in the first questionnaire, of whom 115 replied. One hundred surgeons were invited to participate in the second questionnaire. The primary outcome was the proportion of surgeons for whom a treatment change was warranted, who then reported a change of treatment preference following the RCT. Secondary outcomes included the reasons for repair or non-repair, reasons for and against following the RCT results, and difference of preferred treatment of the PQ muscle between surgeons of different nationalities, qualifications, years of training, and number of procedures performed per year. Results Of the 100 surgeons invited for the second questionnaire, 74 replied. For the primary outcome, six of 32 surgeons (19%), who usually repaired the PQ muscle and therefore a change of treatment preference was warranted, reported a change of treatment preference based on the RCT publication. Of the secondary outcomes, restoring anatomy was the most common response for repairing the PQ muscle. Conclusion The majority of the orthopaedic surgeons, where a change of treatment preference was warranted based on the results and conclusion of a RCT, did not report willingness to change their treatment preference.Cite this article: Bone Joint Open 2020;1-9:549-555.
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Affiliation(s)
- Jesper Sonntag
- Department of Orthopaedic Surgery, Nordsjaellands Hospital, University of Copenhagen, Hilleroed, Denmark
| | - Keith Landale
- Department of Orthopaedic Surgery, Tamworth Rural Referral Hospital, Tamworth, Australia
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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The Relationship of Volar Plate Position and Flexor Tendon Rupture: Should We Question the Validity of the Soong Classification? Plast Reconstr Surg 2020; 146:581-588. [PMID: 32459734 DOI: 10.1097/prs.0000000000007080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The authors sought to determine the reliability of the Soong classification, which relates the position of the implant to the watershed line of the distal radius, for predicting flexor tendinopathy in distal radius fractures treated with volar plate fixation. METHODS Medical records were reviewed, including demographics, fracture and operative characteristics, tendon-related complications, and radiographic outcomes. Six hundred fifty-nine distal radius fractures were reviewed with a mean duration of clinical follow-up of 12.9 ± 0.7 months. RESULTS The incidence of isolated flexor tendinopathy and tendon rupture was 0.9 and 0.3 percent, respectively. The Soong classification failed to independently predict flexor tendon rupture or tendinopathy. Fractures classified as inadequately reduced were significantly associated with Soong grade 0 or grade 2, whereas adequately reduced fractures were significantly associated with Soong grade 1. CONCLUSION The Soong classification is not the sole predictor of flexor tendinopathy and may be viewed as a reflection of the overall appropriateness of fracture reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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19
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Lalchandani GR, Chan A, Nagao M, Immerman I. Flexor Tendon Rupture After Distal Radius Malunion Associated With Electromyographic Abnormalities: A Case Report. JBJS Case Connect 2020; 10:e0309. [PMID: 32649090 DOI: 10.2106/jbjs.cc.19.00309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 63-year-old woman with a history of a malunited distal radius fracture presented with left hand pain and inability to flex her thumb, index, and middle fingers. Anterior interosseous neuropathy was suggested because of abnormal electromyography findings. However, magnetic resonance imaging later revealed flexor tendon ruptures. A distal radius corrective osteotomy with autograft and volar fixation was performed with tendon transfers and carpal tunnel release. CONCLUSIONS Attritional flexor tendon rupture after a nonoperatively managed distal radius fracture is rare but remains an important differential diagnosis in patients with signs and symptoms of anterior interosseous nerve paralysis.
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Affiliation(s)
- Gopal R Lalchandani
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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20
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Kikuchi Y, Sato K, Mimata Y, Murakami K, Takahashi G, Doita M. Ulnar facet locking screw locations of volar locking plates placed without flexor pollicis longus tendon contact: A cadaver study. Orthop Traumatol Surg Res 2020; 106:365-370. [PMID: 31899118 DOI: 10.1016/j.otsr.2019.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 11/08/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The volar locking plate (VLP) system provides stable fixation and is widely used for distal radius fractures. Studies have shown that irritation of the implant prominence is a risk factor for flexor tendon rupture, especially of the flexor pollicis longus (FPL). Contact between VLPs and flexor tendons should be avoided. We aimed to investigate the ulnar facet locking screw locations of various VLPs placed without FPL tendon contact in cadaver wrists. HYPOTHESIS We hypothesized that ulnar facet locking screws would be in the vicinity of the subchondral bone when the plate is placed in the most distal position without FPL tendon contact. MATERIALS AND METHODS The study assessed two variable-angles and four fixed locking plates. We placed each plate in six different cadavers, resulting in 36 different plate-cadaver combinations. Plates were placed in the most distal position without FPL tendon contact. We drilled the most ulnar hole (hole A) and the second ulnar hole (hole B) of the distal row. All drilling procedures were performed using a specific jig for each fixed locking plate. For variable-angle locking plates, we drilled with a fixed jig for each plate. We obtained lateral radiographs when the drill penetrated the dorsal cortex and measured the distance between the drill and the articular surface. RESULTS With regard to hole A, the mean distances between the drill and the center of the articular surface were 2.6-5.2mm for the four fixed locking plates and 4.9-5.6mm for the two variable-angle locking plates. With regard to hole B, the mean distances between the drill and the center of the articular surface were 3.8-5.9mm for the four fixed locking plates and 5.5-5.9mm for the two variable-angle locking plates. DISCUSSION When clinicians place a VLP without FPL tendon contact, the distance between the ulnar facet screws and the center of the articular surface is over 3mm in most cases. Surgeons should select variable-angle drilling for strong articular support when using variable-angle locking plates. LEVEL OF EVIDENCE III, diagnostic Level.
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Affiliation(s)
- Yuki Kikuchi
- Department of Orthopaedic Surgery, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan
| | - Kotaro Sato
- Department of Orthopaedic Surgery, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan.
| | - Yoshikuni Mimata
- Department of Orthopaedic Surgery, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan
| | - Kenya Murakami
- Department of Orthopaedic Surgery, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan
| | - Gaku Takahashi
- Department of Critical Care Medicine, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan
| | - Minoru Doita
- Department of Orthopaedic Surgery, Iwate Medical University, 1-1-1, Idaidori, Yahaba-cho, Shiwa-gun, 028-3694 Iwate, Japan
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Pulos N, DeGeorge BR, Shin AY, Rizzo M. The Effect of Radial Shaft Dorsal Screw Prominence in Volar Locking Plate Fixation of Distal Radius Fractures. Hand (N Y) 2020; 15:271-275. [PMID: 30081647 PMCID: PMC7076618 DOI: 10.1177/1558944718793171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The purpose of this study was to determine whether prominent radial shaft screws in volar locked plating of distal radius fractures increase the risk of tendon irritation, tendon rupture, or hardware removal. Methods: Patients who underwent volar locked plating of distal radius fractures from April 2002 to March 2016 with at least 6 months of follow-up were evaluated. Variables examined included demographics, extensor tendon irritation, extensor tendon rupture, and hardware removal. The most prominent cortical screws on postoperative lateral radiographs were identified and measured from the dorsal cortex of the radial shaft to the tip of the screw. Results: In all, 261 distal radius fractures in 255 patients were identified. Thirty-nine patients (14.9%) underwent subsequent hardware removal at a mean 15.8 ± 18.6 months. Nine patients (3.45%) were found to have clinically significant extensor tendon irritation including one patient (0.38%) with extensor tendon rupture. The average screw was 1.48 mm proud of the dorsal radial cortex. In all, 22.6% of screws were greater than 2 mm proud. Comparing patients who underwent hardware removal with those who did not, there was no statistically significant difference in mean screw prominence or proportion of patients with screws greater than 2 mm. There was no statistically significant difference between shaft screw prominence and extensor tendon irritation. Conclusions: The effect of dorsal screw prominence of radial shaft screws is not significant. This study does not support the downsizing of prominent screws 2 mm or less.
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Affiliation(s)
| | | | | | - Marco Rizzo
- Mayo Clinic, Rochester, MN, USA,Marco Rizzo, Department of Orthopaedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Hinds RM, Montero-Lopez N, Brock K, Adler R, Sapienza A, Capo JT, Paksima N. Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures. Hand (N Y) 2020; 15:111-115. [PMID: 30003811 PMCID: PMC6966279 DOI: 10.1177/1558944718787327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. Methods: Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. Results: Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate (P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion (P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. Conclusions: The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.
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Affiliation(s)
- Richard M. Hinds
- NYU Langone Orthopedic Hospital, New
York, USA,Richard M. Hinds, Department of Orthopaedic
Surgery, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY
10003, USA.
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23
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Zhang J, Zhuang YQ, Zhou L, Jiang GQ, Zhang YD, Wu J. Sparing the pronator quadratus for volar plating of distal radius fractures: a comparative study of two methods. J Int Med Res 2019; 48:300060519893851. [PMID: 31854221 PMCID: PMC7459187 DOI: 10.1177/0300060519893851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives The objective of this study was to compare the results of two methods for
sparing the pronator quadratus in volar plating of distal radius
fractures. Methods A total of 110 patients were randomized to volar plating with sparing of the
pronator quadratus either by a transverse incision along the distal border
of the pronator quadratus (Group A, 55 people) or by the brachioradialis
splitting method (Group B, 55 people). The operative and radiation time,
range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand
(DASH) scores, Visual Analog Scale (VAS) scores, and complications were
recorded. Results There were no significant differences in the mean operative time, radiation
time, mean bone union time, or total complication rate between the groups.
We found no significant differences in range of motion, grip strength, VAS
scores, and DASH scores at any of the study intervals between the groups.
Although neurapraxia of the superficial branch of the radial nerve was more
common in Group B than in Group A (6.7% vs. 0%), the difference was not
significant. Conclusions Both methods were efficient approaches for sparing the pronator quadratus and
had similar clinical outcomes, but they had different indications.
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Affiliation(s)
- Jun Zhang
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Yun-Qiang Zhuang
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Long Zhou
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Gang-Qiang Jiang
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Ya-Di Zhang
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Ji Wu
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
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Bergsma M, Board J, Doornberg JN, Sierevelt I, Rickman M, Jaarsma RL, Obdeijn MC. MRI Study on the Distance between the Distal Radius and the Flexor and Extensor Tendons: Is There Any Room for Error/Hardware? J Wrist Surg 2019; 8:470-476. [PMID: 31815061 PMCID: PMC6892652 DOI: 10.1055/s-0039-1693053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
Purpose This study aims to quantify the distances between the cortex of the distal radius and flexor and extensor tendons. Methods We analyzed 50 magnetic resonance images (MRI) of intact wrist without pathology. The distances between the volar cortex and the flexor pollicis longs (FPL), index flexor digitorum profunduns (FDPi), flexor digitorum profundus (FDP), and flexor digitorum superficialis (FDS) were measured at the level of the watershed line and 3- and 6-mm proximal to this level. The distances between the dorsal cortex and the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor pollicis longus (EPL), extensor indicis proprius (EIP), and the extensor digitorum communis (EDC) were measured at the level of Lister's tubercle and 5-mm distal to this level. Analysis was descriptive. Results At the watershed line, the FPL, FDPi, FDP, and FDS were located at an average of 3.1, 2.4, 3.6, and 5.1 mm, respectively, volar to the volar cortex. The distances of the FDP and FDS increased at 3-mm proximal to the watershed line and increased for all four tendons at 6-mm proximal to the watershed line. Dorsally, at Listers' tubercle the ECRL, ECRB, EPL, EIP, and EDC were identified at an average of 0.7, 0.5, 0.5, 2.6, and 3.2 mm, respectively, dorsal to the dorsal cortex of the distal radius. At 5-mm more distal, these tendons were located on average 1.2, 1.0, 0.7, 1.9, and 1.8 mm, respectively, dorsal to the dorsal cortex. Conclusion On the volar side, on average there is enough room for a volar plate when staying proximal to the watershed line. On the dorsal side, there is virtually no room for protruding screws as physical anatomical space is limited to a maximum of 0.7 mm from cortex to the closest tendon (the FDP), with screw increments being 2 mm. Level of Evidence This is a Level II Study.
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Affiliation(s)
- Minke Bergsma
- Department of Orthopaedic & Trauma Surgery, Medical Centre/Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery/Department of Plastic Reconstructive and Hand Surgery, Asterdam Medical Centre/University of Amsterdam, Amsterdam, the Netherlands
| | - Jemara Board
- Department of Orthopaedic & Trauma Surgery, Medical Centre/Flinders University, Adelaide, Australia
| | - Job N. Doornberg
- Department of Orthopaedic & Trauma Surgery, Medical Centre/Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery/Department of Plastic Reconstructive and Hand Surgery, Asterdam Medical Centre/University of Amsterdam, Amsterdam, the Netherlands
| | - Inger Sierevelt
- Speciaized Centre of Orthopedic Research and Education, Amstelveen, the Netherlands
| | - Mark Rickman
- Department of Orthopaedic Trauma/Orthopaedics & Trauma Research Group, The Royal Adelaide Hospital, Adelaide, Australia
| | - Ruurd L. Jaarsma
- Department of Orthopaedic & Trauma Surgery, Medical Centre/Flinders University, Adelaide, Australia
| | - Miryam C. Obdeijn
- Department of Orthopaedic Surgery/Department of Plastic Reconstructive and Hand Surgery, Asterdam Medical Centre/University of Amsterdam, Amsterdam, the Netherlands
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Pathak S, Anjum R, Gautam RK, Maheshwari P, Aggarwal J, Sharma A, Pruthi V. Do we really need to repair the pronator quadratus after distal radius plating? Chin J Traumatol 2019; 22:345-349. [PMID: 31753761 PMCID: PMC6921198 DOI: 10.1016/j.cjtee.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/28/2019] [Accepted: 10/10/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Fractures of distal radius are one of the common orthopaedic injuries. Placing the plate on volar surface requires release of underlying pronator quadratus (PQ) muscle. No consensus is present in the literature about the repair or not of the PQ. The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications. METHODS Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated. Demographic data, operative notes and physical therapy records were retrieved. Patients were divided into group A where PQ repair was done and group B where no repair was done. Functional data such as range of motion (ROM), grip strength, visual analogue scale (VAS) score and disabilities of arm, shoulder and hand (DASH) score at 4 weeks, 3 months, 6 months and finial follow-up were retrieved. RESULTS Totally 63 patients (n = 29 in group A and n = 34 in group B) with the mean age of 51.64 years were examined. Patients were followed up for a mean of 35.2 months (range 27.2-47.1 months) in group A and 38.6 months (range 28.6-51.0 months) in group B. Though functional outcome of the affected limb was not significantly different between two groups after 3 months, PQ repair did affect the recovery at an early stage. Repair group had significantly better ROM (p = 0.0383) and VAS score at 4 weeks (p = 0.017) while grip strength (p = 0.014) was significantly better at 3 months. CONCLUSIONS Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.
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Affiliation(s)
- Subodh Pathak
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India
| | - Rashid Anjum
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India
| | - Rakesh Kumar Gautam
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India,Corresponding author.
| | - Pritam Maheshwari
- Department of Orthopedics, Pramukhswami Medical College, Anand, Gujarat, India
| | - Jatin Aggarwal
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India
| | - Aryan Sharma
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India
| | - Vineet Pruthi
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research, MM (Deemed to be University), Ambala, Haryana, India
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Stepan JG, Marshall DC, Wessel LE, Endo Y, Miller TT, Sacks HA, Weiland AJ, Fufa DT. The Effect of Plate Design on the Flexor Pollicis Longus Tendon After Volar Locked Plating of Distal Radial Fractures. J Bone Joint Surg Am 2019; 101:1586-1592. [PMID: 31483402 DOI: 10.2106/jbjs.18.01087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination. METHODS We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist. RESULTS Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = -0.51; p < 0.001) and 45° (r = -0.53; p < 0.001). There were no cases of tendon rupture in the cohort. CONCLUSIONS We found that the FPL volar locking plate and increased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Jeffrey G Stepan
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY
| | | | - Lauren E Wessel
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY
| | - Yoshimi Endo
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY
| | - Theodore T Miller
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY
| | | | - Andrew J Weiland
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY
| | - Duretti T Fufa
- Departments of Orthopedic Surgery (J.G.S., L.E.W, A.J.W., and D.T.F.) and Radiology and Imaging (Y.E. and T.T.M.), Hospital for Special Surgery, New York, NY.,Weill Cornell Medical College, New York, NY
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27
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Hinchcliff KM, Volk I, Ivanova X, Taylor S, Szabo RM. Impact of Design on Force between Flexor Tendons and Distal Radius Volar Plates. J Wrist Surg 2019; 8:280-287. [PMID: 31404222 PMCID: PMC6685735 DOI: 10.1055/s-0039-1683845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
Abstract
Background Flexor tendon injury is a rare but serious complication of distal radius volar plating. Purpose This study aims to determine whether the design of distal radius volar plates impacts the amount of force exerted on the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons when the plates are placed proximal and distal to the watershed line. Methods Three commercially available plates were applied to 10 fresh, matched-pair upper extremity specimens. Cyclical loading was applied to the tendons, and the force generated between tendon and plate was measured. Linear mixed effect models were used to evaluate differences in maximum and mean forces by plate position, plate design, and the interaction between position and design. Results Forces on the tendons differed significantly by position but not plate design. For the FPL tendon, the average maximum force with a plate in Soong's grade 2 was 4.50 (95% confidence interval [CI]: 2.8-7.3) times higher than when the plate was in a Soong's grade 0 placement, and 4.63 (95% CI: 2.82-7.61) times higher for the FDP tendon. While not statistically significant, lower observed force values with thinner plates when plates were placed distal to the watershed line suggest that that plate thickness could also be a critical plate characteristic for distally placed plates. Conclusion Despite differences in plate design, the main determinant of plate prominence and therefore flexor tendon injury potential is placement in relation to the watershed line. Clinical Relevance This study may help to guide surgeon implant selection and volar plate design.
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Affiliation(s)
- Katharine M. Hinchcliff
- Division of Plastic Surgery, University of California–Davis Medical Center, Sacramento, California
| | - Ido Volk
- Department of Orthopedic Surgery, University of California–Davis Medical Center, Sacramento, California
| | - Xenia Ivanova
- Department of Orthopedic Surgery, University of California–Davis Medical Center, Sacramento, California
| | - Sandra Taylor
- Department of Public Health, University of California–Davis Medical Center, Sacramento, California
| | - Robert M. Szabo
- Department of Orthopedic Surgery, University of California–Davis Medical Center, Sacramento, California
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28
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Tokunaga S, Abe Y. Asymptomatic Flexor Tendon Damages after Volar Locking Plate Fixation of Distal Radius Fractures. J Hand Surg Asian Pac Vol 2019; 22:75-82. [PMID: 28205485 DOI: 10.1142/s0218810417500137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate. METHODS The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles). RESULTS Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion. CONCLUSIONS The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.
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Affiliation(s)
- Susumu Tokunaga
- 1 Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshihiro Abe
- 1 Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Fox HM, Thompson AR, Nazir OF, Mirarchi AJ. Use of a Large Tenaculum Clamp as a Reduction Technique for Treatment of Distal Radius Fractures. J Hand Surg Am 2019; 44:427.e1-427.e8. [PMID: 30660399 DOI: 10.1016/j.jhsa.2018.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/23/2018] [Accepted: 11/27/2018] [Indexed: 02/02/2023]
Abstract
Distal radius fractures are common upper extremity injuries requiring surgical treatment. In the context of management with a volar locking plate (VLP), a number of described techniques assist with restoration of individual anatomical parameters such as radial length, volar tilt, and articular congruity. We present a surgical technique that utilizes a large tenaculum bone clamp to provide an efficacious reduction in several planes. With anteroposterior compression, the clamp enables volar translation of the distal fracture fragment. This compression also decreases the interval between the distal portion of the VLP and the fracture fragments. With a rotational force, the clamp can restore volar tilt of the articular surface. By positioning the tines of the clamp across the fracture in the coronal plane, a clamping force can correct medial or lateral translation of the distal fracture fragment. Proper reduction substantially minimizes complications such as abrasion or rupture of the flexor tendons along the VLP.
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Affiliation(s)
- Henry M Fox
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Omar F Nazir
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Adam J Mirarchi
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR.
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30
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Wide-Awake Flexor Pollicis Longus Tendon Reconstruction with Evaluation of the Active Voluntary Contraction of the Ruptured Muscle-Tendon. Plast Reconstr Surg 2019; 143:176-180. [PMID: 30325897 DOI: 10.1097/prs.0000000000005092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The purpose of this study was to investigate the clinical outcome of the wide-awake tendon reconstruction for chronic rupture of the flexor pollicis longus tendon with evaluation of the voluntary active contraction distance of the ruptured musculotendinous unit. Eleven consecutive patients underwent tendon reconstruction under wide-awake surgery. If the total of the passive distraction distance and the active contraction distance of the ruptured flexor pollicis longus musculotendinous unit was greater than 30 mm, tendon grafting was performed. If not, tendon transfer was performed using the fourth flexor digitorum superficialis. Patients were evaluated with total active motion before surgery, during surgery, and in final follow-up and subjectively surveyed with quick Disabilities of the Arm, Shoulder and Hand scores. The final outcomes of tendon grafting and of tendon transfer were compared. Tendon grafting was performed in four patients, and tendon transfer was performed in seven patients. The final follow-up total active motion was 84.3 ± 12.7 percent in the tendon transfer group and 80.7 ± 10.2 percent in the tendon grafting group. There were no significant differences between the two groups in the final follow-up total active motion percentage and quick Disabilities of the Arm, Shoulder and Hand scores. The functional outcomes of both tendon grafting and tendon transfer were acceptable based on evaluating the active contraction distance and passive distraction distance of the ruptured musculotendinous unit during wide-awake surgery. Evaluating these distances may be a useful index to assess the ruptured musculotendinous unit. The greatest advantage of the wide-awake tendon reconstruction is that surgeons can evaluate the ruptured musculotendinous unit and measure total active motion during surgery while adjusting suture tension. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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31
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Tokutake K, Iwatsuki K, Tatebe M, Okui N, Mizuno M, Hirata H. Usefulness of CT-based measurement of volar prominence for evaluation of risk of flexor tendon injury following fixation of a distal radius fracture. J Orthop Sci 2019; 24:263-268. [PMID: 30245089 DOI: 10.1016/j.jos.2018.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although some radiographic evaluations of the risk of flexor tendon injury following fixation of a distal radius fracture are useful, these radiographic measurements are limited because of their inability to obtain three-dimensional measurements. We hypothesized that CT-based measurements would be more sensitive indicators for risk estimation than radiography. METHODS We retrospectively evaluated the relationship between plate positioning and the incidence of flexor tendon symptoms based on postoperative radiographic and CT-based measurements in 99 hands that were followed up for more than 12 months. We also compared the reproducibility, diagnostic accuracy, and ability to detect the plate-bone gap between radiographic and CT-based measurements. We also assessed the correlation between the volar prominence and plate-bone gap using CT. Multivariable analysis using stepwise logistic regression was performed to identify factors independently associated with tendon rupture or irritation. RESULTS In single variable analysis, we found that the volar tilt was significantly smaller and the radiographic plate-to-critical line distance (PCL), CT-PCL, and CT-gap were significantly greater in the group with tendon irritation or rupture. Multivariable logistic regression analysis indicated that the CT-based measurement of the volar prominence is a significantly positive independent predictor of tendon rupture or irritation. CONCLUSION CT-based measurement of the volar prominence may be one of the best radiographic predictors of the risk of flexor tendon injury following fixation of a distal radius fracture regardless of the plate type and distal prominence and the extent of rotation. This measurement may assist surgeons when deciding on the need for removal of hardware to decrease the long-term risk of flexor tendon rupture.
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Affiliation(s)
- Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan; Department of Orthopedic Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi, 510-8567, Japan.
| | - Katsuyuki Iwatsuki
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masahiro Tatebe
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Nobuyuki Okui
- Department of Orthopedic Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi, 510-8567, Japan
| | - Masanori Mizuno
- Department of Orthopedic Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi, 510-8567, Japan
| | - Hitoshi Hirata
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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32
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Hodel S, Schraner C, Oehme F, van Leeuwen R, Link BC, Babst R, Beeres FJP. Factors predicting adverse outcome in complete intra-articular distal radius fractures. Eur J Trauma Emerg Surg 2019; 46:1413-1419. [PMID: 30820598 DOI: 10.1007/s00068-019-01102-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/25/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland.
| | - Christian Schraner
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Florian Oehme
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Robbert van Leeuwen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
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Seki Y, Aoki T, Maehara H, Shirasawa S. Distal locking screw length for volar locking plate fixation of distal radius fractures: Postoperative stability of full-length unicortical versus shorter screws. HAND SURGERY & REHABILITATION 2018; 38:28-33. [PMID: 30509732 DOI: 10.1016/j.hansur.2018.10.246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/29/2018] [Accepted: 10/17/2018] [Indexed: 11/28/2022]
Abstract
We compared post-operative distal radius fracture (DRF) displacement after volar locking plate fixation using full-length unicortical and shorter-length distal locking screws. In this non-inferiority, retrospective cohort study, DRFs treated with volar locking plate fixation were evaluated on X-rays. In the full-length group, volar locking plate fixation was performed with full-length unicortical distal locking screws. In the shorter-length group, the distal locking screws were planned pre-operatively to be approximately 75% of the distal radius depth based on the lunate depth, and the same depth was drilled. Three radiographic parameters - ulnar variance, volar tilt, and radial inclination - were measured intra-operatively and at the final follow-up. The displacements were compared between the two groups. Each group contained 34 fractures. The mean ulnar variance between the two periods increased 1.1 mm in the full-length group and 1.3 mm in the shorter group (mean difference, 0.2 mm; 90% confidence interval, -0.3 to 0.6). The shorter group was not significantly inferior to the full-length one. Volar tilt increased 0.6° in the full-length group and -0.1° in the shorter group, while the radial inclination increased 0.1° in the full-length group and 0.2° in the shorter one. The differences in the increases were not significant. The post-operative DRF stability of 75%-length distal locking screws was not inferior to that of full-length unicortical screws. To prevent extensor pollicis longus tendon rupture, shorter distal locking screws and the same drilling depth may be preferable for volar locking plate fixation.
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Affiliation(s)
- Y Seki
- Department of Orthopedic Surgery, Suwa Central Hospital, 4300 3918503 Tamagawa, Chino, Nagano, Japan.
| | - T Aoki
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 6068501, Japan
| | - H Maehara
- Department of Orthopedic Surgery, Suwa Central Hospital, 4300 3918503 Tamagawa, Chino, Nagano, Japan
| | - S Shirasawa
- Department of Orthopedic Surgery, Suwa Central Hospital, 4300 3918503 Tamagawa, Chino, Nagano, Japan
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Alter TH, Ilyas AM. Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures. JBJS Rev 2018; 6:e7. [DOI: 10.2106/jbjs.rvw.18.00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Wilson J, Viner JJ, Johal KS, Woodruff MJ. Volar Locking Plate Fixations for Displaced Distal Radius Fractures: An Evaluation of Complications and Radiographic Outcomes. Hand (N Y) 2018; 13:466-472. [PMID: 28691543 PMCID: PMC6081777 DOI: 10.1177/1558944717717505] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A volar locking plate (VLP) is the most frequently used form of implant used for open reduction and internal fixation of distal radius fractures. They are known to have a complication rate of up to 27%. We hypothesized that plate design could influence complication rates. METHODS We performed a review of patients undergoing VLP fixation for distal radius fracture. A total of 228 patients underwent fixation with the Distal Volar Radial Anatomical (DVR) plate; 388 patients underwent fixation with the VariAx plate. Independent observers performed blinded case note and radiographic review, to assess for the quality of reduction, and complications for the inserted VLP. RESULTS Mean time to surgery was 6.0 days; mean follow-up was 17.5 weeks. Mean age was 56.5 years. The quality of reduction was classified as anatomical (46%), good (36.3%), moderate (13.0%), or poor (3.9%). Complications were identified in 109 patients (17%). Plate prominence was seen in 133 patients (21%). The DVR plate was less prominent ( P < .001) and had better overall radiographic appearances ( P = .025). Flexor tendon complications were related to plate prominence ( P = .005). Inferior reduction was associated with increased time to surgery ( P = .020). CONCLUSIONS This study highlights the importance of prompt surgery, effective fracture reduction, and careful plate positioning to avoid volar prominence.
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Affiliation(s)
- James Wilson
- Lancashire Teaching Hospitals NHS
Foundation Trust, Preston, UK
| | - Jeremy J. Viner
- Lancashire Teaching Hospitals NHS
Foundation Trust, Preston, UK,Jeremy J. Viner, 14 Haddon Grove, Timperley,
Altrincham, Cheshire, WA15 6SA, United Kingdom.
| | - Kavan S. Johal
- Lancashire Teaching Hospitals NHS
Foundation Trust, Preston, UK
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Jamka K, Szczechowicz J, Pieniążek M, Kubasiak K. Comparing the effectiveness of mobilization techniques with movement and myofascial techniques in patients following distal radius fractures treated conservatively. REHABILITACJA MEDYCZNA 2018. [DOI: 10.5604/01.3001.0012.0895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Fractures of the distal radius are one of the most common types in the upper limb area. They lead to significant reduction in range of mobility, muscle weakness and the occurrence of serious pain.
Material and methods: The research involved 20 patients from the Specialist Hand Rehabilitation Centre in Krakow, who were rehabilitated after fractures to the distal radial bone. They were randomly divided into two groups. In group A (n = 10), there were patients who underwent mobilization techniques with movement according to the Mulligan concept as part of their manual work. Group B (n = 10) consisted of patients subjected to myofascial techniques. Functional examination of the hand was carried out twice before and after beginning rehabilitation. The range of active mobility, muscle strength and superficial feeling were examined. Based on the obtained results, functional loss was calculated according to Swanson’s method, Total Active Motion and the sensory index. The obtained results were subjected to statistical analysis using the Excel 10 programme.
Results: Significant improvement in hand and muscle strength was noted in both groups. In the group of patients treated with myofascial techniques, better rates of improvement for the tested parameters were obtained than in the group treated with the use of joint mobilization techniques.
Conclusions: 1. The applied programme of rehabilitating patients following fracture of the distal radial bone is characterized by statistically significant improvement in hand function. 2. The use of soft-tissue techniques is a more effective method of hand function restitution than the method of mobilization with movement.
myofascial techniques, forearm fractures, physiotherapy
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Affiliation(s)
- Krzysztof Jamka
- Studia doktoranckie, AWF im. B. Czecha w Krakowie / Ph.D. student, University of Physical Education, Krakow, Poland
| | - Jakub Szczechowicz
- Katedra Fizjoterapii, AWF im. B. Czecha w Krakowie / Department of Physiotherapy, University of Physical Education, Krakow, Poland
| | - Marek Pieniążek
- Katedra Fizjoterapii, AWF im. B. Czecha w Krakowie / Department of Physiotherapy, University of Physical Education, Krakow, Poland
| | - Katarzyna Kubasiak
- Specjalistyczny Ośrodek Rehabilitacji Ręki w Krakowie / Specialized Hand Therapy Centre in Krakow, Poland
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Incidence of tendon rupture following volar plate fixation of distal radius fractures: A survey of 2787 cases. J Orthop 2018; 15:236-238. [PMID: 29657475 DOI: 10.1016/j.jor.2018.01.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/14/2018] [Indexed: 11/22/2022] Open
Abstract
This study assessed the comprehensive incidence of tendon rupture following volar locking plate (VLP) surgery for a large number of patients with distal radius fractures (DRFs) at multiple facilities in one prefecture, Japan. During the 4-year period, 2787 patients with DRFs underwent fixation using VLP. The overall incidence rates of rupture of the FPL, the extensor pollicis longus, the flexor digitorum profundus of the index finger, and the extensor digitorum communis were 0.35% (10 patients), 0.29% (8 patients), 0.04% (1 patient), and 0.04% (1 patient), respectively.
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Herisson O, Delaroche C, Maillot-Roy S, Sautet A, Doursounian L, Cambon-Binder A. Comparison of lateral and skyline fluoroscopic views for detection of prominent screws in distal radius fractures plating: results of an ultrasonographic study. Arch Orthop Trauma Surg 2017; 137:1357-1362. [PMID: 28707132 DOI: 10.1007/s00402-017-2759-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Extensor tendon rupture is a recognized complication of volar plate fixation of distal radius fractures due to screws protruding past the dorsal cortex. The aim of this study was to compare the Skyline view with traditional lateral fluoroscopic views using ultrasonography as a reference standard in the postoperative assessment. MATERIALS AND METHODS A monocentric prospective study was conducted to identify screws penetrating the dorsal cortex after volar plating of distal radius fractures. PATIENTS AND INTERVENTION Intraoperative anteroposterior (AP) and lateral views were used for group A (28 patients). AP, lateral and skyline fluoroscopic views were used for Group B (40 patients). Prominent screws were changed. MAIN OUTCOME MEASUREMENTS Ultrasound was done 6 months postoperatively to evaluate the number and length of prominent dorsal screws and any signs of extensor tenosynovitis. RESULTS The number of prominent dorsal screws exceeding 1 mm was 14 in group A (14.9%), and 16 screws (11.8%) in group B (p = 0.487). Average length of prominent dorsal screw was 1.9 mm (range 1-2.1 mm) for group A and 2.4 mm (range 1.1-4.8 mm) for group B (p = 0.534). The number of patients with extensor tenosynovitis was 11 for group A and 12 for group B (p = 0.66). CONCLUSIONS The Skyline view does not provide sensitive and reliable detection of the dorsal screw penetration. Intraoperative ultrasound might be a better tool to detect screw prominence. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Olivier Herisson
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | - Caroline Delaroche
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Sandrine Maillot-Roy
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Alain Sautet
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Levon Doursounian
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Adeline Cambon-Binder
- Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
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Abstract
PURPOSE Intraarticular distal radius fractures are often treated with open reduction and internal fixation (ORIF) through a volar approach. This common approach, however, is technically demanding to restore the articular surface of the radiocarpal joint while respecting soft tissue integrity. The purpose of this video is to demonstrate the surgical technique of volar plate fixation of an intraarticular distal radius fracture. METHODS A 32-year-old patient who sustained multiple injuries including an intraarticular distal radius fracture was treated with ORIF by a volar approach. RESULTS Exposure is performed through a standard flexor carpi radialis approach. The intraarticular fracture of the distal radius is reduced, and a volar plate is applied. Careful measurement of screw length is described in detail to minimize postoperative tendon irritation. Closure of the soft tissues is completed and early postoperative rehabilitation is emphasized. DISCUSSION Multiple, varied techniques for fixation of intraarticular distal radius fractures are described in the literature. As demonstrated in this video of ORIF with a volar plate, attention to articular reduction, soft-tissue protection, and postoperative rehabilitation are key components used to achieve good clinical outcomes.
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Hill JR, Alluri RK, Ghiassi A. Acute Isolated Flexor Tendon Laceration Associated With a Distal Radius Fracture. Hand (N Y) 2017; 12:NP39-NP42. [PMID: 28453343 PMCID: PMC5480671 DOI: 10.1177/1558944716668850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Subacute rupture of the flexor tendons secondary to distal radius fractures is well documented. Recently, accounts of flexor tendon rupture following open reduction internal fixation have been associated with volar plate fixation. However, discovery of an occult traumatic flexor tendon laceration during fixation of an acute distal radius fracture is not well described. This case indicates the importance of careful preoperative and intraoperative examination of the flexor tendons in the setting of comminuted distal radius fractures. METHODS A forty-seven-year-old male sustained a comminuted, dorsally displaced distal radius fracture. Initial and post-reduction examinations revealed no gross functional abnormalities. Upon operative fixation of the fracture, laceration of the flexor digitorum profundus (FDP) tendon to the index finger was incidentally noted at the level of the fracture site. RESULTS Due to extensive dorsal comminution, shortening, and the presence of a lunate facet fragment, we performed volar fragment-specific and dorsal spanning bridge plate fixation. The proximal and distal ends of the FDP tendon were marked, but repair was deferred until implant removal. This allowed for proper informed consent and avoided potential compromise of the repair given the presence of a volar implant. CONCLUSIONS Acute flexor tendon rupture secondary to closed distal radius fractures may go unnoticed if a high index of suspicion is not maintained. Delayed diagnosis of these ruptures convolutes the mechanism of injury and disrupts the recovery process. Hand surgeons should be vigilant in examining flexor tendon function during the preoperative evaluation, especially in the setting of acute high-energy injury.
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Affiliation(s)
- J. Ryan Hill
- Keck School of Medicine of the University of Southern California, Los Angeles, USA,J. Ryan Hill, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1200 N. State Street, GNH 3900, Los Angeles, CA 90033, USA.
| | - Ram K. Alluri
- Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Alidad Ghiassi
- Keck School of Medicine of the University of Southern California, Los Angeles, USA
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Mahylis JM, Burwell AK, Bonneau L, Marshall LM, Mirarchi AJ. Drill Penetration Injury to Extensor Tendons: A Biomechanical Analysis. Hand (N Y) 2017; 12:301-306. [PMID: 28453347 PMCID: PMC5480667 DOI: 10.1177/1558944716668824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about extensor tendon failure following drill injury at the time of volar plate fixation. Our goals were to analyze extensor tendon injury following simulated drill penetration, and change in tendon displacement during cyclic loading following simulated drill penetration injury. METHODS Extensor pollicis longus (EPL) and extensor carpi radialis brevis (ECRB) tendons were harvested from 9 fresh frozen cadaveric arms. Eighteen EPL and 18 ECRB samples were created from harvested tendons. Drill penetration injury was performed in either a continuous or an oscillating mode. Injured tendons were subjected to 1200 cycles at 1- to 15-kg cyclic load at a frequency of 1 Hz, and analyzed for failure at drill sites and change in displacement throughout the testing cycle. RESULTS Ten EPL samples and 16 ECRB samples completed testing without failure. Tendon type (ECRB, EPL), mode of injury (continuous, oscillating), and location (proximal, distal) did not affect tendon displacement during loading. A single EPL tendon failed following continuous drill penetration injury. Extensor carpi radialis brevis samples had a mean change in displacement of 2.8 (standard deviation [SD]: 1.5 mm) and 5.9 mm (SD: 4.7 mm) for oscillating and continuous modes, respectively. Six EPL samples had a mean change in displacement of 4.7 (SD: 2.7 mm) and 4.3 mm (SD: 1.8 mm) for oscillating and continuous modes, respectively. CONCLUSIONS Complete extensor tendon failure due to drill penetration was rare. Drill mode did not affect the degree of elongation. Increasing cyclic loading of extensor tendons after drill injury caused modest extensor tendon elongation.
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Affiliation(s)
| | | | | | | | - Adam J. Mirarchi
- Oregon Health & Science University, Portland, USA
- Adam J. Mirarchi, Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Mail Code OP-31, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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Wich M, Sixto R, Spranger N. [Design of distal radius volar locking plates : Anatomical, surgical and biomechanical aspects]. Unfallchirurg 2017; 119:742-6. [PMID: 27444999 DOI: 10.1007/s00113-016-0218-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The operative treatment of unstable distal radius fractures primarily aims for the anatomical reduction of the joint while addressing accompanying injuries. Anatomical reduction, stable fixation and early functional movement of the joint are the three cornerstones of modern treatment concepts of distal radius fractures. Distal radius volar locking plates play a major role in the treatment and rehabilitation of the most commonly occurring fracture in humans. This article outlines the different principles in the current design of available distal radius volar locking plates. The biomechanical aspects, anatomical findings and clinical evaluation that have influenced current design features and trends in new developments of the latest plates are emphasized. This is an ongoing process that is supported through the investigation and feedback of clinical science.
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Affiliation(s)
- M Wich
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland. .,Abteilung für Unfallchirurgie und Orthopädie, Achenbach Krankenhaus, Köpenicker Str. 29, 15711, Königs-Wusterhausen, Deutschland.
| | - R Sixto
- Zimmer Biomet Institute Miami, Miami, FL, USA
| | - N Spranger
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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Tendon Rupture and Tenosynovitis following Internal Fixation of Distal Radius Fractures. Plast Reconstr Surg 2017; 139:717e-724e. [DOI: 10.1097/prs.0000000000003076] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kadoma C, Takahara M, Maruyama M, Satake H, Takagi M. Ultrasonographic Assessment of the Flexor Pollicis Longus Tendon After Plate Fixation. Orthopedics 2017; 40:e104-e108. [PMID: 27783838 DOI: 10.3928/01477447-20161017-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 08/23/2016] [Indexed: 02/03/2023]
Abstract
Rupture of the flexor pollicis longus tendon is a major complication after volar locking plate fixation of distal radius fracture. This study used ultrasonography to assess the flexor pollicis longus tendon and intermediate tissue. The study assessed 27 patients (28 wrists) who underwent removal of the volar locking plate. Before plate removal, radiography and ultrasonography were performed to assess the relation between the flexor pollicis longus tendon and the volar locking plate. Intraoperatively, the authors evaluated the intermediate tissues between the flexor pollicis longus tendon and the distal volar margin of the plate. Preoperative and intraoperative findings were compared. Intraoperative findings were strongly related to the distance between the flexor pollicis longus tendon and the volar locking plate on ultrasonography. The sensitivity of ultrasonography in detecting thin, membrane-like intermediate tissue through which the plate was visible was 95%, and the specificity was 89% if the distance between the flexor pollicis longus tendon and the plate was less than 0.7 mm. Compression of the flexor pollicis longus tendon was seen in 11 cases (39.3%), and this finding suggested the presence of thin, membrane-like intermediate tissue. The study results showed that ultrasonography could be used to identify the type of intermediate tissue between the flexor pollicis longus tendon and the volar locking plate. [Orthopedics. 2017; 40(1):e104-e108.].
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Abstract
Volar plate fixation of unstable distal radius fractures has become the preferred technique by most surgeons for the operative treatment of displaced distal radius fractures. Flexor tendon rupture is a rare but serious complication associated with this operation that is thought to be due to irritation of the flexor tendons over the prominent distal edge of the plate. We describe a novel technique of using the brachioradialis tendon to cover the distal edge of the plate to help prevent tendon irritation and rupture.
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46
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The EFCR Approach and the Radial Septum-Understanding the Anatomy and Improving Volar Exposure for Distal Radius Fractures: Imagine What You Could Do With an Extra Inch. Tech Hand Up Extrem Surg 2016; 20:155-160. [PMID: 27801774 DOI: 10.1097/bth.0000000000000139] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Locked volar plating is the most common surgical procedure to address distal radius fractures. The extended flexor carpi radialis approach continues to be an excellent method for visualizing distal radius fractures and applying a volar plate. A new understanding of the anatomy allows for better visualization and reduction of the many different distal radius fracture patterns surgeons commonly see. Within the extended flexor carpi radialis approach, we describe the radial septum in further detail including the anatomy which comprises the radial septum triangle. Knowledge of this area allows for better visualization, more anatomic reductions, and fewer complications.
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Bhat AK, Acharya AM, Soni N. Reconstruction of Attritional Rupture of Flexor Tendons with Fascia Lata Graft Following Distal Radius Fracture Malunion. J Hand Surg Asian Pac Vol 2016; 21:410-3. [PMID: 27595963 DOI: 10.1142/s2424835516720176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Incidence of multiple flexor tendon rupture following distal radius fractures is rare with very few cases being reported in literature. We present an unusual case of a patient who had come to us with complaints of weakness and paresthesia of the right hand of one month prior and with a past history of dorsal plating for distal radius fracture nine years ago. Radiographs showed a distal radius fracture malunion with intact dorsal plate and protrusion of screws through the volar cortex. On exploration, attritional ruptures of all digital flexors were found with sparing of the Flexor Pollicis Longus tendon. The fibrous mass was excised and flexors reconstructed with a fascia lata graft. Attempt was made to correct the malunion with radial and ulnar osteotomies. At one year the patient had excellent restoration of digital flexion.
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Affiliation(s)
- A K Bhat
- 1 Division of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal University, India
| | - A M Acharya
- 1 Division of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal University, India
| | - N Soni
- 1 Division of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal University, India
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Watchmaker JD, Daley RA, Watchmaker GP, Grindel SI. Ultrasound Imaging Improves Identification of Prominent Hardware in the Surgical Treatment of Distal Radius Fractures: A Cadaveric and Prospective Clinical Study. J Wrist Surg 2016; 5:36-41. [PMID: 26855834 PMCID: PMC4742260 DOI: 10.1055/s-0035-1569485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
Background Volarly applied locking plates are one of several current treatment options for displaced fractures of the distal radius. Presently, surgeons use intraoperative depth gauges and fluoroscopy to select and confirm proper screw length. The contour of the dorsal cortex beneath the extensor compartments along with fracture comminution may limit the accuracy of screw length selection. Question/Purpose To evaluate the accuracy of ultrasound (US) and fluoroscopy in the detection of dorsally prominent screws placed during volar plating of experimentally created distal radius fractures and extend this prospectively into the clinical setting. Patients and Methods Distal radius fractures were experimentally induced in fresh cadaveric arms. The fractures were then internally fixated with volar locking plates utilizing fluoroscopic imaging. US imaging of the dorsal surface of the radius was then performed followed by dorsal dissection and direct caliper measurements to quantitate screw tips as recessed, flush, or protruding from the dorsal cortex. A small, prospective clinical study was also conducted to validate the clinical usefulness of using US to provide additional information regarding screw tip prominence. Results Our study demonstrated that US was able to detect dorsally prominent screw tips not visible on fluoroscopy. Cadaveric dissection showed a higher statistical correlation between US imaging and actual prominence than between fluoroscopy and actual prominence. Conclusions US examination after volar plate fixation of comminuted distal radius fractures may detect dorsal screw tip prominence when screw lengths are selected to engage the dorsal cortex. Level of Evidence IV.
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Affiliation(s)
| | - Roger A. Daley
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Steven I. Grindel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ultrasonic Evaluation of the Flexor Pollicis Longus Tendon Following Volar Plate Fixation for Distal Radius Fractures. J Hand Surg Am 2016; 41:374-80. [PMID: 26787412 DOI: 10.1016/j.jhsa.2015.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate with ultrasound the thickness of the flexor pollicis longus (FPL) tendon and its relationship to the volar locking plate after the fixation of distal radius fractures. METHODS We evaluated 27 type C2 and C3 distal radius fractures with ultrasound to evaluate damage to the FPL tendon after volar plate fixation. The thickness of the FPL tendon and its distance to the volar plate in the involved wrists and to the volar rim in the contralateral uninjured wrist were measured on sonograms taken 12 months postoperatively. Measurements of the involved wrists were compared with those of the intact wrists. RESULTS The mean plate-tendon distance in the involved wrist was considerably shorter than the mean volar rim-tendon distance in the intact wrist, and the FPL tendon was considerably thicker in the involved wrist than in the intact wrist. CONCLUSIONS In distal radial fractures treated with volar locking plates, increases in the thickness of the FPL tendon and a consequent decrease in the distance between the tendon and the plate can be determined with ultrasonography. This finding is a warning that asymptomatic tenosynovitis may eventually cause tendon ruptures. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.
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50
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Using Ultrasound to Prevent Screw Penetration. J Hand Surg Am 2016; 41:453-6. [PMID: 26803568 DOI: 10.1016/j.jhsa.2015.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/09/2015] [Accepted: 12/13/2015] [Indexed: 02/02/2023]
Abstract
Ultrasound is a readily available, inexpensive, easy-to-use, and rapid diagnostic tool. Physicians can use ultrasound to identify excessively long screws or screw penetration into joints. This article illustrates ultrasound identification of problem screws.
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