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Tuaño KR, Mudgal CS. Management of isolated volar lunate facet fractures of the distal radius. J Orthop 2024; 51:46-53. [PMID: 38299064 PMCID: PMC10827500 DOI: 10.1016/j.jor.2024.01.002] [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: 11/26/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
Distal radius fractures are among the most common fractures treated globally. Consideration of the mechanism of injury and careful radiographic assessment contributes to appropriate management of these injuries in isolation or jointly with other fractures or injuries affecting the wrist joint. Treatment options can range from non-operative management to a variety of fixation techniques. Interest in the distal radius fractures was renewed as open reduction and monoblock volar locking plate fixation became the preferred contemporary treatment in the last few decades. Isolated volar lunate facet (VLF) fractures are uncommon. However, the stability of the entire carpus may be compromised with fractures of the volar marginal rim. Inadequately or improperly treated fractures of the VLF can lead to significant long-term complications. A critical approach to this unique fracture pattern's evaluation, management, and surgical fixation is paramount for successful and reproducible outcomes in stability and durability.
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Affiliation(s)
- Krystle R. Tuaño
- Hand & Arm Service, Massachusetts General Hospital, Boston, MA, USA
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chaitanya S. Mudgal
- Hand & Arm Service, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Hubbard J, Berry D, Chauhan A, Casstevens C, Shin AY, Abrams RA. A three-dimensional computed tomography study of the palmar ulnar corner fragment in distal radial fractures. J Hand Surg Eur Vol 2024; 49:300-309. [PMID: 37974338 PMCID: PMC10882950 DOI: 10.1177/17531934231211570] [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] [Indexed: 11/19/2023]
Abstract
Fixing palmar ulnar corner fragments of distal radial fractures can be challenging. We described the palmar ulnar corner fragment morphology in a retrospective cohort study of 40 patients who underwent preoperative wrist computed tomography scans. Palmar ulnar corner fractures were categorized based on articular cross-sectional area, sagittal angulation relative to the radius long axis, palmar cortical length, radioulnar width and associated palmar radiocarpal subluxation. Three types emerged: type 1 fragments involved 37% (SD 10) of the radiocarpal articular surface and were extended in the sagittal plane; type 2 fragments involved 28% (SD 10) of the articular surface and had a long palmar cortex, of which 57% had palmar carpal subluxation; and type 3 fragments involved 13% (SD 2) of the articular surface, had a short palmar cortex and all had palmar carpal subluxation. Understanding palmar ulnar corner fragment morphology may guide optimal reduction and fixation strategy and prevent palmar radiocarpal subluxation, especially in type 3 fractures.Level of evidence IV.
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Affiliation(s)
- James Hubbard
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - David Berry
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Aakash Chauhan
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Chris Casstevens
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Reid A Abrams
- Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, San Diego (UCSD), La Jolla, CA, USA
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Kim MB, Lee JH, Lee YH. Arc center distance as a novel quantitative radiographic parameter for volar Barton fractures. Arch Orthop Trauma Surg 2022; 142:3765-3770. [PMID: 34739580 DOI: 10.1007/s00402-021-04240-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The aims of this study were to investigate conventional radiographic parameters and introduce a novel parameter (arc center distance, ACD) for volar Barton fractures. METHODS Twenty-four cases of volar Barton fracture were retrospectively analyzed. We measured volar tilt angle (VTA), anteroposterior distance (APD), teardrop angle (TDA), and capitate-to-axis-of-radius distance (CARD) on lateral plain radiographs. The ACD was measured on the sagittal images of computed tomography scans. VTAs, APDs, TDAs, and CARDs were compared between the fractured and normal contralateral wrist. The area under the receiver operating characteristic curve was calculated for each parameter. RESULTS TDAs did not differ significantly between the fractured wrists and the controls. On the other hand, VTAs, APDs, and CARDs were all significantly greater in the fractured wrists (mean values were 17.25°, 20.70 mm, and - 3.40 mm, respectively). The area under the curve value was highest (0.943) for the ACD. When a cutoff value of 1.02 mm was used as a threshold, a sensitivity of 100% and specificity of 80.95% were achieved. CONCLUSIONS The mean values of conventional parameters (VTA, APD, TDA and CARD) in volar Barton fractures were presented. The ACD can be useful parameter for quantitatively evaluating volar Barton fractures.
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Affiliation(s)
- Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jeong Hyun Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea.
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea
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Fogel N, Shapiro LM, Roe A, Denduluri S, Richard MJ, Kamal RN. Outcomes of Supplementary Spring Wire Fixation With Volar Plating for Volar Lunate Facet Fragments in Distal Radius Fractures. Hand (N Y) 2022; 17:1163-1169. [PMID: 33319593 PMCID: PMC9608301 DOI: 10.1177/1558944720976404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intra-articular distal radius fractures with small volar lunate facet fragments can be challenging to address with volar plate fixation alone. Volar locked plating with supplementary spring wire fixation has been previously described in a small series but has not been further described in the literature. We hypothesized that this technique can provide adequate fixation for volar lunate facet fragments smaller than 15 mm in length, which are at risk of displacement. METHODS We completed a retrospective chart review (2015-2019) of patients who underwent volar locked plating with the addition of supplementary spring wire fixation for intra-articular distal radius fractures with a volar lunate facet fragment (<15 mm). Postoperative radiographs were assessed to evaluate union, evidence of hardware failure, escape of the volar lunate facet fragment, and postoperative volar tilt. Clinical outcome was assessed with wrist flexion/extension, arc of pronosupination, and Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH) scores. RESULTS Fifteen patients were identified, of which all went on to fracture union. There were no hardware failures or escape of the volar lunate facet fragment at final follow-up. One patient underwent hardware removal for symptoms of flexor tendon irritation. The mean wrist flexion was 59°, wrist extension was 70°, pronation was 81°, and supination was 76°. The mean QuickDASH score was 18.5. The mean postoperative volar tilt was 3.6°. CONCLUSIONS Supplementary spring wire fixation with standard volar plating provides stable fixation for lunate facet fragments less than 15 mm. This technique is a safe and reliable alternative to commercially available fragment-specific implants.
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Imatani J, Kondo H. Volar Lunate Facet Rim Fractures: K-I Classification and Technique. J Wrist Surg 2022; 11:230-237. [PMID: 35837593 PMCID: PMC9276066 DOI: 10.1055/s-0041-1739144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022]
Abstract
Background and Purpose It is difficult to capture and safely support a small volar lunate facet (VLF) fragment and obtain sufficient initial fixation. The challenge in treating VLF rim fractures has resulted in various management options. The purpose of this study was to evaluate the clinical and radiological outcomes of a consecutive series of VLF rim fractures of the distal radius treated surgically and to report the Kondo-Imatani (K-I) classification of these fractures, using computed tomography (CT) images and surgical technique, which is termed the Plate buttress and Double tiered subchondral support (PD) technique. Patients and Methods A retrospective review was conducted on 35 patients with VLF rim fractures that included postoperative clinical evaluations, CT images, and radiographs. Description of Technique The PD technique to stabilize the VLF fragment with an anatomical and low-profile volar locking plate (VLP). Results All fractures healed at the final follow-up; Mayo wrist performance score average was 81.7 points (45-100), and the quick disabilities of the arm, shoulder, and hand (quick-DASH) score average was 9.5 points (0-31.8), showing relatively good clinical results. Conclusion VLF rim fragments are not amenable to standard VLP fixation. Unstable fixation may result in postoperative correction loss, aseptic necrosis, malunion, radiocarpal subluxation, and wrist dysfunction. This report described the K-I classification for VLF rim fractures of the distal radius and surgical technique, termed the PD technique, to stabilize the VLF rim fragment with an anatomical and low-profile VLP. Level of Evidence This is a Level IV, case series study.
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Affiliation(s)
- Junya Imatani
- Department of Orthopaedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Hidenori Kondo
- Department of Orthopaedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
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Biondi M, Poggetti A, Fagetti A, Di Maro A, Bigazzi P, Pfanner S, Lauri G. Fragment specific fixation with APTUS wrist system for volar rim fractures of the distal radius: a multicentric study. Eur J Trauma Emerg Surg 2021; 48:4577-4584. [PMID: 34041552 DOI: 10.1007/s00068-021-01710-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Volar rim fractures of the distal radius are a spectrum of pathology that must be well identified and treated to achieve good outcomes and avoid surgical failures. New devices of fragment specific fixation have been developed during the last decades to fix this fragment. The purpose of this retrospective study was to evaluate the ability of APTUS® wrist distal radius system to securely fix different types of volar rim fractures. METHODS Patients with at least 1 year of follow-up and a preoperative CT-scan evaluation of the fracture pattern were included in the study. Clinical, radiological and functional outcomes were assessed. RESULTS Sixty-eight patients with an average follow-up of 34, 1 months (12-61) were included in the study. There were no clinical and radiological complications, including loss of reduction, device failure and tendon ruptures. No patients required hardware removal. Wrist range of motion in flexion-extension averaged 96°, while in pronation-supination 144°. At final follow-up mean visual analogue scale pain was 1,8. Questionnaires, as dissabilities of the arm, shouldder and hand (DASH) score and patient-related wrist evolution (PRWE) score were 6,6 and 3 respectively. Grip strenght measured 86% compared to the normal side. CONCLUSION APTUS® wrist presents a versatile set of fragment specific fixation plates able to easily and securely fix all types of volar rim fracture. The system can be used with other devices without any kind of interference between them. When correctly placed and used with the right indications, no late complications can be recorded.
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Affiliation(s)
- Marco Biondi
- Surgery and Reconstructive Microsurgery Unit of the Hand, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Andrea Poggetti
- Surgery and Reconstructive Microsurgery Unit of the Hand, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Agostino Di Maro
- Division of Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Prospero Bigazzi
- Surgery and Reconstructive Microsurgery Unit of the Hand, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Sandra Pfanner
- Surgery and Reconstructive Microsurgery Unit of the Hand, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulio Lauri
- Surgery and Reconstructive Microsurgery Unit of the Hand, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Daly MC, Horst TA, Mudgal CS. Dorsal Cortical Breaks in Volar Barton Distal Radius Fractures. Hand (N Y) 2021; 16:303-309. [PMID: 31319700 PMCID: PMC8120577 DOI: 10.1177/1558944719862644] [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: 11/15/2022]
Abstract
Background: Volar Barton fractures involve the volar articular margin of the distal radius with proximal and volar subluxation of the carpus. Although traditionally conceptualized as partial articular, some volar Barton fractures are complete articular injuries due to a dorsal cortical break in the distal radial metaphysis. While dorsal cortical breaks can affect surgical strategy, they may be difficult to identify on plain radiographs and their epidemiology remains poorly characterized. Some authors have hypothesized an association with osteoporosis; however, this hypothesis remains untested. To better characterize volar Barton fractures, we analyzed fracture geometry on pre-operative computed tomography (CT) scans to: (1) determine the frequency of a dorsal cortical break; and (2) test the null hypothesis that a dorsal cortical break is not associated with age or gender. Methods: We retrospectively reviewed adults with a volar Barton distal radius fracture and an available pre-operative CT who underwent surgical fixation. Using multivariable logistic regression, we assessed whether age or gender was an independent predictor of a dorsal cortical break. Results: Forty patients (mean age 52 years, 57% female) were identified. Including the shaft as a fragment, 32 (80%) had 3 or more discrete fracture fragments. Thirty patients (75%) had a dorsal cortical break. Dorsal cortical breaks were not associated with either age or gender (P > 0.05). Conclusions: Most (75%) patients with volar Barton distal radius fractures had a dorsal cortical break. Dorsal cortical breaks were not statistically associated with age or gender, suggesting these fracture patterns may not be associated with osteoporosis as previously hypothesized.
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Affiliation(s)
| | | | - Chaitanya S. Mudgal
- Massachusetts General Hospital, Boston, USA,Harvard Medical School, Boston, MA, USA,Chaitanya S. Mudgal, Hand & Upper Extremity, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 2C, Hand Clinic, Boston, MA 02114, USA.
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Bui CNH, Rafijah GH, Lin CC, Kahn T, Peterson A, Lee TQ. Dorsal Wrist Extrinsic Carpal Ligament Injury Exacerbates Volar Radiocarpal Instability After Intra-Articular Distal Radius Fracture. Hand (N Y) 2021; 16:193-200. [PMID: 31155949 PMCID: PMC8041416 DOI: 10.1177/1558944719851210] [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] [Indexed: 11/15/2022]
Abstract
Background: Volar radiocarpal instability is often seen after loss of fixation of volar lunate facet fragments. The pathogenesis of post-traumatic volar radiocarpal instability is poorly understood. The purpose of this study was to determine if injury to the dorsal wrist extrinsic carpal ligaments contributes to volar radiocarpal instability. Methods: Six matched pairs of cadaveric upper extremities were tested using a dynamic hand testing system. In group 1, the intact wrist, the wrist with a volar lunate facet fracture, and the fractured wrist after 500 cycles of grip were tested. In group 2, in addition to the intact and fractured wrist, the fractured wrist with the dorsal extrinsic carpal ligaments cut and the fractured wrist with the dorsal extrinsic carpal ligaments cut after 500 cycles of grip were also tested. Volar-dorsal displacement of the lunate was measured from 45° wrist flexion to 45° wrist extension in 22.5° increments with the wrist flexors/extensors loaded for each condition. Results: Volar lunate translation did not significantly increase after the volar lunate facet fracture alone, and was not evident to a significant extent until the dorsal wrist extrinsic carpal ligaments were cut. Further instability of the lunate occurred after grip cycling only with the dorsal extrinsic capsular ligaments cut. Conclusions: Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability. Unrecognized dorsal sided injury may be a contributing factor to why stable fixation of volar lunate facet fragments remains problematic after volar plating of intra-articular distal radius fractures with displaced volar lunate facet fragments.
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Affiliation(s)
- Christopher N. H. Bui
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA,Department of Orthopaedic Surgery, University of California, Irvine, USA
| | - Gregory H. Rafijah
- Department of Orthopaedic Surgery, University of California, Irvine, USA
| | - Charles C. Lin
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Timothy Kahn
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Alexander Peterson
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Thay Q. Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, CA, USA,Department of Orthopaedic Surgery, University of California, Irvine, USA,Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA,Thay Q. Lee, Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, 800 South Raymond Avenue, Pasadena, CA 91105, USA.
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Obata H, Naito K, Sugiyama Y, Nagura N, Goto K, Kaneko A, Kawakita S, Kaneko K. Comparison of clinical outcomes with and without volar lunate facet fragments in dorsal displaced distal radius fractures. SICOT J 2021; 7:1. [PMID: 33416487 PMCID: PMC7792495 DOI: 10.1051/sicotj/2020047] [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] [Received: 07/23/2020] [Accepted: 12/13/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction: Although many clinical studies about distal radius fracture (DRF) accompanied by volar lunate facet fragments (VLFF) have recently been reported, none focus on the direction of displacement of distal fragments. Many previous cases with difficulty in treating DRF with VLFF were volar-displaced fractures. Thus, the postoperative risk for re-displacement is different between volar- and dorsal-displaced fractures with VLFF. The aim of this study is to compare the outcome of dorsal-displaced fractures treated using proximal volar locking plates (PVLP) between those with VLFF and those without, in order to reconsider the indications of distal volar locking plates (DVLP) and investigate the possibility of treating dorsal-displaced DRF with VLFF using PVLP. Methods: The subjects were 122 patients with dorsal-displaced DRFs treated using PVLP (42 males and 80 females, mean age: 59.2 years old). The patients were divided into 13 patients with VLFF group and 109 patients without VLFF group, and the clinical outcomes at 12 months after surgery were compared. Results: No significant difference was noted on any evaluation between the groups. In addition, no postoperative re-displacement of VLFF was observed and bone union was confirmed. Furthermore, no osteoarthritic change was noted in all patients. Conclusions: We confirmed that surgical treatment for dorsal-displaced DRF using PVLP is possible even in cases of DRF with VLFF. In addition, DVLP is an implant with a high complication risk; therefore, it may be necessary to reconsider the use of DVLP for dorsal-displaced DRF with VLFF treatable by PVLP.
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Affiliation(s)
- Hiroyuki Obata
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Kiyohito Naito
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Yoichi Sugiyama
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Nana Nagura
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Kenji Goto
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Ayaka Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - So Kawakita
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
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Nanno M, Kodera N, Tomori Y, Takai S. Volar Locking Plate Fixation for Intra-Articular Distal Radius Fractures with Volar Lunate Facet Fragments Distal to the Watershed Line. J NIPPON MED SCH 2020; 87:24-31. [PMID: 31611505 DOI: 10.1272/jnms.jnms.2020_87-106] [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: 11/19/2022]
Abstract
BACKGROUND Standard volar plating of distal radius fractures may not adequately fix the volar lunate facet (VLF) fragment, which can result in volar carpal subluxation. We hypothesized that the size of VLF fragments distal to the watershed line might affect reduction loss after distally placed volar locking plate fixation for intra-articular distal radius fracture and examined if the presence of small displaced VLF fragments was a risk factor for reduction loss. METHODS Twenty-seven hands of 27 patients with intra-articular distal radius fractures with VLF fragments distal to the watershed line were treated by using Acu-Loc 2 volar distal radius locking plate fixation. RESULTS At final follow-up, the mean Mayo Performance Score was 90.9, and the mean Quick Disabilities of Arm, Shoulder, and Hand score was 13.6. On radiography, 5 patients had a reduction loss of >2 mm in ulnar variance from immediately postoperatively to final follow-up (group 1), while 27 had no reduction loss (group 2). The mean longitudinal, transverse, and anteroposterior lengths and joint surface area of the VLF fragment were significantly smaller in group 1 than in group 2. Three-dimensional computed tomography revealed that the fracture patterns of the radiocarpal and distal radioulnar joints in group 1 were mainly volar-displaced VLF fragments. CONCLUSIONS By stabilizing fragments, distally placed volar locking plate fixation effectively treated intra-articular distal radius fractures with VLF fragments distal to the watershed line. However, the presence of small displaced VLF fragments may increase the risk of reduction loss in ulnar variance.
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Affiliation(s)
| | - Norie Kodera
- Department of Orthopedic Surgery, Nippon Medical School
| | - Yuji Tomori
- Department of Orthopedic Surgery, Nippon Medical School
| | - Shinro Takai
- Department of Orthopedic Surgery, Nippon Medical School
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Garg R, Mudgal CS. When a volar locking plate is not the right choice in fractures of the distal radius: Case based technical considerations. J Clin Orthop Trauma 2020; 11:542-553. [PMID: 32684691 PMCID: PMC7355094 DOI: 10.1016/j.jcot.2020.05.040] [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: 05/17/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 11/24/2022] Open
Abstract
A volar approach is commonly used for fixation of distal radius fractures with a volar locking plate. There are certain fracture patterns for which volar locked plating is not suitable. This case based review outlines such case examples.
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Affiliation(s)
- Rohit Garg
- Corresponding author. 55 Fruit St, Yawkey 2C, Massachusetts General Hospital, Boston, MA, 02114, USA.
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Streubel PN, Cohen MS. Isolated Partial Intra-Articular Volar Ulnar Fractures of the Distal Radius: The Tetrahedron Variant. J Hand Surg Am 2019; 44:699.e1-699.e10. [PMID: 30502017 DOI: 10.1016/j.jhsa.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to assess the treatment and complications of a distinct type of partial intra-articular distal radius fracture. METHODS Seven patients treated by the senior author between 2008 and 2013 for a partial intra-articular distal radius fracture with isolated involvement of the volar lunate facet were included. All fragments had the distinctive shape of a triangular-base pyramid (tetrahedron) extending from the metaphysis distally. All fractures were preoperatively assessed with computed tomography (CT) scans. Patients underwent surgical treatment using a standard flexor carpi radialis approach (2 patients) or a volar ulnar approach (5 patients) and were followed postoperatively for a minimum of 12 months. RESULTS Patient age ranged from 33 to 66 years. On average, fragments measured 34 ± 6 mm in length (range, 27-43 mm) and were 48% as wide as the distal radius (range, 40% to 56%) and 58% as deep as the anterior-posterior dimension of the lesser sigmoid notch (range, 33% to 83%). Loss of reduction requiring revision surgery occurred at 4 weeks in 1 patient who underwent internal fixation through the flexor carpi radialis approach. The remaining cases healed uneventfully. At the final follow-up, all, except the patient requiring revision surgery, had a painless wrist. Average total wrist motion measured 87% of the opposite side. Radiographic healing with anatomic wrist alignment was observed in all except the patient requiring revision. This patient had persistent joint subluxation. The remaining patients all achieved good or excellent functional outcomes. CONCLUSIONS Isolated tetrahedron volar lunate facet fractures of the distal radius are rare. In our experience, the use of a volar ulnar approach leads to satisfactory fixation and outcomes, yielding excellent radiographic and clinical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Philipp N Streubel
- Hand and Upper Extremity Section, Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Mark S Cohen
- Hand and Elbow Section, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Kachooei AR, Tarabochia M, Jupiter JB. Distal Radius Volar Rim Fracture Fixation Using DePuy-Synthes Volar Rim Plate. J Wrist Surg 2016; 5:2-8. [PMID: 26855829 PMCID: PMC4742267 DOI: 10.1055/s-0035-1570740] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
Background To assess the results of distal radius fractures with the involvement of the volar rim fixed with the DePuy-Synthes Volar Rim Plate. Case Description We searched for the patients with volar rim fracture and/or volar rim fractures as part of a complex fracture fixed with a volar rim plate. Ten patients met the inclusion criteria: three patients with type 23B3, six patients with type 23C, and one patient with very distal type 23A. The mean follow-up was 14 months (range: 2-26). Fractures healed in all patients. Of the three patients with isolated volar rim fractures (type 23B3), two patients had no detectable deficits in motion. These patients had an average Gartland and Werley score of 9 (range: 2-14). Of the other seven patients (six with type 23C and one with type 23A fracture), three patients healed with full range of motion and four had some deficits in range of motion. Two patients had excellent results, three had good results, and two had fair results using the Gartland and Werley categorical rating. One patient healed with a shortened radius and ulnar impingement requiring a second surgery for ulnar head resection arthroplasty. Literature Review Results after nonoperative treatment of volar rim fractures are not satisfactory and often require subsequent corrective osteotomy. Satisfactory outcomes are achieved when the fragments are well reduced and secured regardless of the device type. Clinical Relevance Volar rim plates give an adequate buttress of the volar radius distal to volar projection of the lunate facet and do not interfere with wrist mobility. Furthermore, the dorsal fragments can be fixed securely through the volar approach eliminating the need for a secondary posterior incision. However, patients should be informed of the potential problems and the need to remove the plate if symptoms develop.
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Affiliation(s)
- Amir Reza Kachooei
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew Tarabochia
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jesse B. Jupiter
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Harness NG. Fixation Options for the Volar Lunate Facet Fracture: Thinking Outside the Box. J Wrist Surg 2016; 5:9-16. [PMID: 26855830 PMCID: PMC4742269 DOI: 10.1055/s-0035-1570739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 12/31/2022]
Abstract
Background Fractures of the distal radius with small volar ulnar marginal fracture fragments are difficult to stabilize with standard volar locking plates. The purpose of this study is to describe alternative techniques available to stabilize these injuries. Materials and Methods Five patients were identified retrospectively with unstable volar lunate facet fracture fragments treated with supplemental fixation techniques. The demographic data, pre- and postoperative radiographic parameters, and early outcomes data were analyzed. The AO classification, preoperative and final postoperative ulnar variance, articular step-off, volar tilt, radial inclination, and teardrop angle were measured. The lunate subsidence and length of the volar cortex available for fixation were measured from the initial injury films. Description of Technique Lunate facet fixation was based on the morphology of the fragment, and stabilization was achieved with headless compression screws in three patients, a tension band wire construct in one, and two cortical screws in another. Results Five patients with a mean age of 58 years (range: 41-82) were included. There were two AO C3.2 and three B3.3 fractures. Preoperative radiographic measurements including radial inclination, tilt, and ulnar variance all improved after surgery and were maintained within normal limits at 3-month follow-up. There was no change in the teardrop angle at final follow-up (70-64 degrees; p = 0.14). None of the patients had loss of fixation or volar carpal subluxation. The mean visual analog scale pain score at 3 months was 1 (range: 0-2). Conclusions The morphology of volar lunate facet fracture fragments is variable, and fixation must be customized to the particular pattern. Small fragments may preclude the use of plates and screws for fixation. These fractures can be managed successfully with tension band wire constructs and headless screws. These low-profile implants may decrease the risk of tendon irritation that might accompany distally placed plates.
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Affiliation(s)
- Neil G. Harness
- Kaiser Permanente Orange County, University of California Irvine, Anaheim, California
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