Peripheral Nerve Compression Neuropathy after Fractures of the Distal Radius

Distal Mononeuropathy and Nerve Release After Open and Arthroscopic Shoulder Surgery: A Matched Cohort Analysis

PURPOSE

The purpose of this study was to determine if patients who have undergone prior open or arthroscopic shoulder surgery and develop distal mononeuropathy (DMN) achieve the same clinical benefit after nerve release compared with those who did not have a prior shoulder procedure.

METHODS

Patients were identified by Current Procedural Terminology code for shoulder arthroplasty, shoulder stabilization, and rotator cuff repair and if they had an ensuing nerve release (cubital or carpal tunnel) within 2 years of shoulder surgery. Another cohort that underwent nerve release surgery for DMN with no prior history of shoulder surgery was identified and subsequently matched to the first cohort by a 3:1 (control:case) ratio. Patients were included if they were over the age of 18 years. Chart reviews and surveys stored using REDCap were used to collect demographics, surgical history, EMG/nerve conduction velocity results, postoperative symptoms, and patient-reported outcomes with a minimum 2-year follow-up.

RESULTS

In total, 120 patients were included in this analysis (28 cases, 92 controls). The most common nerve release for DMN across both cohorts was open carpal tunnel release. Following nerve release, the case group had more postoperative persistent numbness/tingling than the control group. Both groups were similar with regard to postoperative pain, weakness, or patient-reported outcome measures. Residual postoperative numbness following nerve release was more likely to occur in the forearm for the case group than the control group.

CONCLUSIONS

Patients with a history of arthroscopic rotator cuff repair and reverse total shoulder replacement shoulder surgery before the presentation of DMN are more likely to experience persistent numbness or tingling after nerve release surgery as well as experience symptoms in the forearm than those without prior shoulder surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom prevalence retrospective study III.

Ulnar Neuropathy after Distal Radius Fractures - A Case Series and Review of Literature

Background: Ulnar neuropathy after a distal radius fracture is rare and has limited reports in literature. As such, there is no consensus regarding the optimal treatment and management of such injuries. We report our experience with managing these uncommon injuries. Methods: A retrospective review was conducted where patients presenting with ulnar neuropathy after sustaining a distal radius fracture were identified from January 2021 to December 2023 from our hospital database. Results: A total of four patients were identified. All of them underwent surgical fixation for their respective fractures. None of them underwent immediate or delayed exploration and decompression of the ulnar nerve. All patients had clinical improvement at 3 months after their initial injuries. Three patients eventually had resolution of the neuropathy between 5 and 9 months post injury, while one had partial recovery and developed a neuroma but declined surgery due to symptoms minimally affecting work and daily activities. Conclusions: Ulnar neuropathy after distal radius fractures may not be as rare as previously thought. Expectant management of the neuropathy would be a reasonable treatment as long as there is no evidence of nerve discontinuity or translocation and that there is clinical and/or electrodiagnostic improvement at 3-4 months after the initial injury. Level of Evidence: Level IV (Therapeutic).

Clinical and Radiographic Outcomes Following Volar-Locked Plating Versus Dorsal Bridge Plating for Distal Radius Factures

Purpose

Distal radius fractures (DRFs) indicated for operative intervention are most commonly treated with volar-locked plating (VLP); however, dorsal bridge plating (DBP) has been used as an alternative fixation method. The purpose of this study was to use a propensity score to match and compare the radiographic and clinical outcomes of patients undergoing isolated VLP or DBP for DRFs.

Methods

We performed a retrospective, propensity score-matched analysis of patients undergoing isolated VLP or DBP treatment for isolated DRFs from 2015 to 2022 at a single level-1 trauma center. Patients were propensity score-matched by a total of eight demographic and comorbidity factors, AO Foundation/Orthopedic Trauma Association classification, and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Our primary outcomes included postoperative complications, wrist and forearm range of motion (ROM), grip strength, and radiographic measurements, including radial height, radial inclination, volar tilt, and articular step-off.

Results

Overall, 415 DBP and 2075 VLP were successfully propensity score-matched and included in this study. Grip strength and ROM measurements at the 6-month follow-up, including wrist flexion, wrist extension, forearm pronation, forearm supination, radial deviation, and ulnar deviation, were increased in the VLP compared with DBP (P < .05). Complication rates among both the groups were relatively low; however, the rates of malunion and nonunion were significantly higher among the DBP group (P < .05). Radial height, radial inclination, and articular step-off were improved in the VLP group compared with the DBP group (P < .05); however, volar tilt was similar between groups. PROMIS upper extremity and physical function were significantly higher among the VLP group (P < .05). No significant difference was noted in PROMIS pain interference between the groups.

Conclusions

When compared with DBP, patients undergoing VLP are more likely to have improved clinical and radiographic outcomes. Although improvement in wrist and forearm ROM and radiographic parameters is statistically significant, it may not be clinically relevant.

Type of study/level of evidence

Therapeutic III.

Is Carpal Tunnel Release Necessary in High-Energy Distal Fractures of the Radius?

Purpose This study aimed to compare the clinical outcomes of patients who underwent volar plate osteosynthesis for high-energy distal radius fracture (DRFx) and carpal tunnel release (CTR) for acute or subacute carpal tunnel syndrome (CTS) with patients who did not undergo CTR. Methods This study is a retrospective evaluation of all high-energy DRFx treated with volar plate osteosynthesis in a regional hospital between January 2021 and January 2023. All adult patients (≥18 years) who underwent open reduction and internal fixation were included in the study after obtaining approval from the internal review board of our institution. Only patients who underwent plate osteosynthesis of the volar aspect through a modified Henry incision and patients who underwent CTR through a classic separate incision were included in the study. Clinical results include hand dynamometry, visual analog scale (VAS) scores, and physical examination findings of patients who underwent volar plate osteosynthesis because of high-energy DRFx and CTR due to CTS in the acute and subacute periods were retrospectively examined. Results Among the patients who underwent volar plate osteosynthesis because of high-energy DRFx, no statistically significant difference was detected between the hand grip strength and VAS scores of patients who underwent CTR because of acute CTS and subacute CTS at the sixth postoperative week (p>0.05). Conclusion Prophylactic CTR may be performed in the same session in selected cases, such as DRFx caused by a high-energy injury, to establish a scale for DRFx at a high risk of CTS and avoid delays in treatment. CTR for transient CTS detected in the subacute period during outpatient follow-up does not improve clinical outcomes.

Correlation between delayed carpal tunnel syndrome and carpal malalignment after distal radial fracture

BACKGROUND

Delayed carpal tunnel syndrome after Colles' fracture is a common complication particularly following conservative treatment. The aim of the study was to verify the correlation of different radiological parameters of carpal alignment and the development as well as the severity of DCTS in elderly female patients within 6 months of distal radial fracture (DRF).

METHODS

This is a retrospective case-control study that included 60 female patients with DRF within 6 months treated conservatively (30 patients with signs and symptoms suggestive of DCTS and 30 asymptomatic patients as a control group). Electrophysiological evaluation was done for all the participants, as well as radiological assessment to measure parameters of carpal alignment mainly radiocapitate distance (RCD), volar prominence height (VPH) and volar tilt (VT).

RESULTS

There was a statistical significant difference between both groups regarding the radiological parameters of carpal alignment (The mean values of RCD, VT and VPH were - 11.48 mm, - 20.68° angle, and 2.24 mm respectively in the symptomatic group). A strong correlation was found between decrease in the parameters of carpal alignment and the severity of DCTS. Logistic regression analysis showed that VT is strongly involved in the development of DCTS. The threshold value of the VT was - 20.2° angle (sensitivity 0.83; specificity 0.9; odds ratio 45; 95% CI 0.894-0.999; p < 0.001).

CONCLUSIONS

Anatomical alteration of the carpal tunnel after DRF with dorsal displacement of the carpal bones contribute to the development of DCTS. Decreasing VT and VPH and RCD are the most significant independent predictors for the development of DCTS in conservatively managed DRF. Protocol ID: 0306060.

Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning.

PURPOSE

To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over.

METHODS

Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes.

RESULTS

78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes.

CONCLUSION

Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further.

PROSPERO

CRD42018116478.

Adult Distal Radius Fracture Management

Distal radius fractures (DRFs) are some of the most commonly encountered fractures, and the incidence is increasing. Optimal treatment remains controversial. Critical evaluation of the initial imaging is necessary to recognize fracture characteristics and stability. The fracture pattern, injury mechanism, soft-tissue injury, patient characteristics, and surgeon preference are generally taken into consideration when choosing the most appropriate modality. Volar plating has become the workhorse of surgical DRF management but is not without complications. The surgeon should be comfortable using a wide variety of techniques to customize the fixation to the fracture pattern. Recognition of potential dangers and use of intraoperative imaging techniques can mitigate complications. Goals of rehabilitation after the initial treatment of DRF include regaining motion, strength, and ultimately function while managing pain.

Factors Affecting the Occurrence of Late Median Nerve Neuropathy After Open Reduction and Volar Locking Plate Fixation of Distal Radius Fracture

It is well-known that late median nerve neuropathy can occur after open reduction and internal fixation (ORIF) of distal radius fracture (DRF). The current study investigated the predictive factors of late median nerve neuropathy after ORIF with a volar locking plate for DRF. The authors retrospectively reviewed 712 patients who underwent ORIF using a volar locking plate after DRF at 3 medical institutions between 2006 and 2017. Thirty-seven (5.2%) patients developed late median nerve neuropathy at a mean of 8.25±3.47 months (range, 3-19 months) after surgery. The radiographic data of 37 patients (group A) who had late median nerve neuropathy were compared with those of 148 patients (group B) who did not. Group A had a significantly higher proportion of type C3 fracture and Soong grade 2 than group B. Postoperative dorsal tilt in group A was greater than that in group B. On multivariable logistic regression analysis, the following predictive factors were associated with late median nerve neuropathy: increased postoperative dorsal tilt and Soong grade 2. The development of late median nerve neuropathy after ORIF using a volar locking plate for DRF was associated with increased postoperative dorsal tilt and the plate being placed distal to the volar rim. Physicians should consider the possibility of late median nerve neuropathy in patients with these factors during follow-up. [Orthopedics. 2021;44(3):e367-e372.].

Haematoma block: a safe method for pre-surgical reduction of distal radius fractures

BACKGROUND

The haematoma block (HB) has been successfully used to minimise pain prior to otherwise painful closed reduction manoeuvres for distal radius fractures. However, the invasive manner of the procedure, which technically produces an open fracture, still raises the question, whether HBs increase the risk of infection compared to conventional intravenous analgesia (IA). The purpose of this study was to assess complication rates and safety of the HB procedure for the closed reduction of surgically treated distal radius fractures.

METHODS

We included 176 distal radius fractures in 170 patients in a retrospective mono-centric study, who underwent closed reduction and casting followed by definitive surgical care over a period of two years. Patients either received a HB or IA before closed reduction and were evaluated for minor and major complications over a follow-up period of four years.

RESULTS

Overall, 42 distal radius fractures were treated with a HB (23.9%) and 134 with IA (76.1%) before closed reduction. There were a single major (2.3%) and eight minor (19%) complications observed in the HB group compared to two major (1.4%) and 24 minor (17.9%) complications in the IA group. No significant differences were identified between the two groups. Sex and type of fracture had no effect on complication rates, however, younger patients experienced higher complication rates in comparison to older ones (p = 0.035).

CONCLUSION

According to our data, the apprehensions that clinicians may have of creating open fractures through HB procedures, are unnecessary and may be abandoned confidently.

Complete Transection of the Median Nerve with Distal Radius Fracture: A Case Report

CASE

We report a case of complete median nerve transection due to a distal radius fracture. In the setting of high energy trauma and a widely displaced fracture, a volar ulnar spike from the proximal fragment likely transected the median nerve. After open reduction and internal fixation of the distal radius fracture, the median nerve was repaired directly. Postoperative radiographs at 10 weeks revealed a healed fracture with clinical examination, showing good pain-free range of motion at the radiocarpal joint.

CONCLUSION

This case suggests that exploration and visualization of the median nerve to exclude injury may be considered on a case-by-case basis in the presence of sensory and motor symptoms, suggesting median nerve dysfunction after a highly displaced distal radius fracture.

Risk factors for carpal tunnel syndrome or trigger finger following distal radius fracture: a nationwide study

New-onset carpal tunnel syndrome (CTS) and trigger finger after distal radius fractures (DRFs) with or without open reduction and internal fixation (ORIF) have been reported inconsistently across different studies. This study assessed the incidence of CTS and trigger finger after DRFs using Taiwan National Health Insurance Research Database. In total, 1454 patients in the case (ORIF) cohort and 1454 patients in the control (non-ORIF) cohort were included in this retrospective study. The mean age was approximately 55 years old, and the female to male ratio was approximately 3/2. Nine patients underwent carpal tunnel release (CTR) surgery after diagnosis of CTS in the case group, and no patients did in the control group; whereas 19 cases of CTS were diagnosed without CTR in the case group, and 4 such cases were observed in the control group. Five cases of trigger finger were diagnosed in the case group, and 3 cases were diagnosed in the control group. CTS were significantly associated with ORIF for DRFs within 9 months after the fracture, whereas trigger finger was not significantly different between groups. Diabetes mellitus was a significant risk factor for CTS and trigger finger within 9 months after the incidence of DRFs.

Surgical Decision-Making in Median Neuropathy Associated with Distal Radius Fractures

Objectives  A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures. Methods  We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents. Results  Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture. Conclusion  A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures. Level of Evidence  This is a Level V study.

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227-234.].

Displaced distal radius fracture presenting with neuropraxia of the dorsal cutaneous branch of the ulnar nerve (DCBUN)

Nerve injuries, mostly to the median nerve, are common following distal radius fractures. Ulnar nerve injuries are rarely encountered, with only few case reports of motor or motor and sensory loss described in the literature. In this paper, we report two consecutive cases of young patients with a distal radius fracture and a pure sensory ulnar neuropathy. Both patients had a radially displaced fracture and presented with sensory loss and paresthesia in the distribution of the dorsal cutaneous branch of the ulnar nerve (DCBUN), which resolved after fracture reduction. We believe this clinical scenario is the result of traction or compressive neuropraxia of the DCBUN in the subcutaneous tissue around the ulnar styloid-a neurologic injury which had not yet been described for distal radius fractures.

Carpal Malalignment as a Predictor of Delayed Carpal Tunnel Syndrome after Colles' Fracture

Background

The present study aimed to clarify whether carpal malalignment associated with distal radius malunion after Colles' fracture is involved in the onset of delayed carpal tunnel syndrome (DCTS) in elderly women.

Methods

This retrospective case-control study was conducted in 40 female patients with Colles' fracture treated with a cast, including 10 patients (mean age, 71.6 years) who developed DCTS from 6 weeks to 6 months after injury (DCTS group) and 30 patients (mean age, 73.4 years) without DCTS (control group). Radiological parameters, including the radiocapitate distance (RCD), volar prominence height (VPH), and volar tilt (VT) were measured. Relationships between the RCD and both the VPH and VT were examined, and the involvement of the RCD in the onset of DCTS was analyzed.

Results

The RCD showed strong correlations with both the VPH and VT. The mean RCD was significantly lower in the DCTS group than in the control group (-12.8 mm versus -8.4 mm). Logistic regression analysis showed involvement of the RCD in the onset of DCTS, and the threshold value according to receiver operating characteristic curve analysis was -9.9 mm, with an odds ratio of 21.

Conclusions

Dorsal displacement of the capitate due to Colles' fracture malunion is involved in DCTS accompanied with anatomical alteration of the carpal tunnel. When the center of the head of the capitate is located more than 1 cm dorsally behind the volar cortical line of the radius, careful follow-up should be performed as DCTS may occur within 6 months after injury.

Carpal Tunnel Syndrome and Distal Radius Fractures

Carpal tunnel syndrome (CTS) after distal radius fractures can present in 3 forms: acute, transient, and delayed. Acute CTS requires an emergent carpal tunnel release. Many patients with transient CTS after distal radius fracture do not require surgical release of the carpal tunnel once the fracture is repaired. Prophylactic carpal tunnel release in the absence of signs and symptoms of CTS after a distal radius fracture is not indicated. For patients with delayed CTS after a distal radius fracture, all possible causes of nerve compression should be considered and addressed in standard fashion.

Gradual Onset Diseases: Misperception of Disease Onset

PURPOSE

Gradual onset diseases (eg, carpal tunnel syndrome, cubital tunnel syndrome, and trapeziometacarpal arthrosis) tend to go unnoticed for years. When a slowly progressive disease transitions from asymptomatic to symptomatic, it may seem like an acute event. The primary aim of this study was to determine the percentage of patients who perceive the slowly progressive disease as having started within 1 year. We also hypothesized that (1) there would be no factors associated with perception of an onset of disease within 1 year, more specifically among patients with advanced disease; and (2) there would be no difference in a decision to pursue operative treatment between patients who perceived the onset of the disease to be recent and those who perceived it to be long-standing.

METHODS

In this retrospective study, we reviewed the medical records of 732 patients newly diagnosed with carpal tunnel syndrome (n = 114), cubital tunnel syndrome (n = 276), or trapeziometacarpal arthrosis (n = 342), for the onset of symptoms. Multiple factors were assessed for (1) association with perception of disease onset within 1 year, and (2) choice for operative treatment in bivariate and multivariable analyses.

RESULTS

A total of 69% of all subjects and 68% of patients with advanced disease perceived the disease as having started within 1 year. A perceived provocation (such as an injury or surgery) was associated with a perception of recent onset. A decision to pursue operative treatment was not different between the 2 groups.

CONCLUSIONS

Slowly progressive diseases are often misperceived as relatively new.

CLINICAL RELEVANCE

Effective communication strategies are important to ensure that people make choices consistent with their values and not based on misconceptions.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes?

OBJECTIVE

This case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes.

METHODS

Thirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months.

RESULTS

A the T12 month follow up point the VAS average was 0.8 (range 0-3) in ORIF + CTR group compared to 1.2 (range 0-3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95-100) in ORIF + CTR group versus 97.6 (range 95-100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome.

CONCLUSIONS

Routine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

[Nerve injuries associated with distal radius fractures]

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

Volar locking plate vs epibloc system for distal radius fractures in the elderly

PURPOSE

To compare clinical outcomes of ORIF with volar locking plates and the Epibloc system (ES) in the treatment of distal radius fractures (DRFs) in patients aged over 65 years.

METHODS

We retrospectively examined a consecutive series of 100 patients with intra-articular or extra-articular DRF who were admitted to our Department of Orthopaedics and Traumatology between January 2007 and January 2013. Fifty patients were treated using the Epibloc System; and the other 50 patients using ORIF with volar locking plates. In all patients, functional evaluation (wrist range of motion [ROM], grip strength and Disability of the Arm, Shoulder and Hand [DASH] Score) and radiographic assessment (radial inclination, volar tilt, ulnar variance and articular congruity) were performed at 2 and 6 weeks, and 3, 6 and 12 months postoperatively; then every 12 months thereafter.

RESULTS

ORIF with volar locking plates was associated with better outcome than ES in the intra-articular and extra-articular DRF groups, generating higher average ROM, DASH and visual analogue scale (VAS) scores. Grip strength mean values, however, were quantified over the minimum level for a functional wrist (>60%) in both groups. There were no differences between the two techniques in X-ray parameters, and no further correlation was found with functional outcome and ROM.

CONCLUSIONS

In a low-functioning patient with multiple medical comorbidities, minimally-invasive surgery with the ES is a safe option, enables early mobilisation of the wrist and is likely to produce acceptable clinical outcomes.

Single-Incision Carpal Tunnel Release and Distal Radius Open Reduction and Internal Fixation: A Cadaveric Study

BACKGROUND

The safety of surgical approaches for single- versus double-incision carpal tunnel release in association with distal radius open reduction and internal fixation remains controversial.

PURPOSE

The purpose of this study was to identify critical structures to determine if a single-incision extension of the standard flexor carpi radialis (FCR) approach can be performed safely.

METHODS

Nine cadaveric arms with were dissected under loupe magnification, utilizing a standard FCR approach. After the distal radius exposure was complete, the distal portion of the FCR incision was extended to allow release of the carpal tunnel. Dissection of critical structures was performed, including the recurrent thenar motor branch of the median nerve, the palmar cutaneous branch of the median nerve (PCBm), the palmar carpal and superficial palmar branches of the radial artery, and proximally the median nerve proper. The anatomic relationship of these structures relative to the surgical approach was recorded.

RESULTS

Extension of the standard FCR approach as described in this study did not damage any critical structure in the specimens dissected. The PCBm was noted to arise from the radial side of the median nerve an average of 6.01cm proximal to the proximal edge of the transverse carpal ligament. The PCBm became enveloped in the layers of the antebrachial fascia and the transverse carpal ligament at the incision site, protecting it from injury. The recurrent motor branch of the median nerve, branches of the radial artery and the median nerve proper were not at risk during extension of the FCR approach to release the carpal tunnel.

CONCLUSIONS

Extension of the standard FCR approach to include carpal tunnel release can be performed with minimal risk to the underlying structures. This exposure may offer benefits in both visualization and extent of carpal tunnel release.

Complications after volar locking plate fixation of distal radius fractures

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate fixation in a busy teaching hospital. The purpose of the study was to assess whether complication rates after volar locking plate use in general, routine trauma practice were higher than published literature from expert users. A retrospective review was carried out of patients treated with a volar locking plate between January 2009 and December 2010. The series included 206 procedures in 204 patients (77 males and 127 females) with mean age of 55 years (range 16-94). Surgery was performed by 18 different consultant surgeons and 11 registrars. A total of 22 complications were observed in 20 patients with an overall complication rate of 9.7%. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Four (1.9%) patients required re-operation for metalwork problems; four patients developed complex regional pain syndrome (CRPS). Three fracture reduction problems were noted. A total of 16 further operations were carried out for complications. The overall complication rate was low even when surgery was done by many surgeons, suggesting that this is a safe and reproducible technique. This study provides information which can be used to counsel patients about risks, including those of tendon and metalwork problems. This allows patients to make an informed decision. Surgeons must have specific strategies to avoid these complications and remain vigilant so that these can be identified and managed early.

Median neuropathy in malunited fractures of the distal radius

PURPOSE

Irritation of the median nerve is a well-characterized complication after acute fractures of the distal radius, but there is limited literature on median neuropathy in malunited fractures. The aims of our prospective study were to estimate the prevalence of the median neuropathy, explore the relationship between radiographic findings and the condition, and investigate whether corrective osteotomy without carpal tunnel release was a sufficient treatment.

METHODS

Thirty consecutive patients, who were referred to us for treatment of symptomatic distal radial malunion, underwent nerve conduction studies of both wrists by one board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, radiolunate and capitolunate angle) and computer tomography (CT) based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to an electrodiagnostic re-examination by the same neurologist.

RESULTS

Nineteen patients demonstrated abnormal test results, but only seven patients complained about paresthesias of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters. Surprisingly, the cross-sectional area of the carpal canal was significantly greater for patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, six of ten patients demonstrated improved nerve conduction studies, although only four patients demonstrated normal test results.

DISCUSSION

There is a high rate of subclinical median neuropathy in malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Corrective osteotomy without carpal tunnel release is a sufficient treatment for neuropathy in malunited distal radius fractures.

Image-guided distal radius osteotomy using patient-specific instrument guides

In this article, we describe a method for computer-assisted distal radius osteotomies in which computer-generated, patient-specific plastic guides are used for intraoperative guidance. Before surgery, the correction and plate location are planned using computed tomography scans for both radii and ulnae, and the planned locations of the distal and proximal drill holes for the plate are saved. A plastic, patient-specific instrument guide is created using a rapid prototyping machine into which a mirror image of intraoperative, accessible bone structure of the distal radius is integrated. This allows for unique positioning of the guide during surgery. For each planned drill location, a guidance hole is incorporated into the guide. During surgery, a conventional incision is made, and the guide is positioned on the radius. The surgeon drills the holes for the plate screws into the intact radius and performs the osteotomy using the conventional technique. Using the predrilled holes, the surgeon affixes the plate to the radius fragments. The guides are easy to integrate into the surgical workflow and minimize the need for intraoperative fluoroscopy for guidance of the procedure.

Complications of distal radius locking plates

Fixation of distal radius fractures via locking plates is an increasingly popular method. However, these plates include variety of complications, such as flexor and extensor tenosynovitis, tendon injury and intra articular screw or peg penetration. Although they offer superior stability and early mobility, if used improperly; they may cause serious complications related to the implant. Proper use of the implant with strict adherence to the fixation principles and close follow up of patients are very important in order to decrease the rate and severity of complications.

Carpal tunnel syndrome after distal radius fracture

Carpal tunnel syndrome is a common condition and is a well-recognized phenomenon following a distal radius fracture. The treating surgeon should be vigilant in noticing the signs and symptoms. If acute carpal tunnel syndrome is noted, then surgical release of the carpal tunnel and fracture fixation should be performed urgently. If early carpal tunnel syndrome findings are noted during distal radius fracture management, all potential causes should be evaluated. Delayed carpal tunnel syndrome presenting after a distal radius fracture has healed is best managed in standard fashion. There is no role for prophylactic carpal tunnel release at the time of distal radius fixation in a patient who is asymptomatic.

Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation

BACKGROUND

Acute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ).

METHODS

A retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case-control study was performed comparing outcomes of both groups.

RESULTS

The average age of patients was 51 ± 15 years, with an average follow-up of Group A at 49 ± 21 months versus Group B at 55 ± 20 months. The mean symptom severity scale score for Group A was 1.4 ± 0.4 and for Group B was 1.4 ± 0.4. The mean functional status scale score for Group A was 1.4 ± 0.5 and for Group B was 1.3 ± 0.4. The mean total BCTQ score for Group A was 26.5 ± 7.5 and for Group B was 24.9 ± 7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores.

CONCLUSIONS

Patients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience

BACKGROUND

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction.

RESULTS

Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10 days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction.

DISCUSSION

The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.

Hand numbness and carpal tunnel syndrome after volar plating of distal radius fracture

We report the incidence of late onset post-operative carpal tunnel syndrome (late carpal tunnel syndrome) and late median nerve neuropathy after volar plating of distal radius fracture by conducting a retrospective study on volar plating for distal radius fracture performed during 2002 to 2006. Two hundred eighty-two volar plating were performed for acute distal radius fracture after exclusion. Post-operative hand numbness occurred in 24 patients of which nine had carpal tunnel syndrome. Thus, the incidence of late carpal tunnel syndrome was 3.2% (9/282). Of the eight (8/24, 33%) patients with post-operative hand numbness that failed to respond to conservative treatment, five had carpal tunnel release and three had neurolysis of median nerve at distal forearm. All had clinical improvement except in one patient. The incidence of late carpal tunnel syndrome after volar plating of distal radius in the present series is similar to the prevalence of carpal tunnel syndrome in general population. The incidence is low compared with other series, regardless of treatment method (conservative treatment, volar or dorsal plating). The outcome of post-operative hand numbness is generally favourable.

Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach

PURPOSE

To evaluate the safety and efficacy of a hybrid flexor carpi radialis (FCR) approach for volar plate osteosynthesis of displaced distal radius fractures with concurrent prophylactic carpal tunnel release (CTR) in patients without preoperative signs or symptoms of acute carpal tunnel syndrome secondary to the fracture.

METHODS

A total of 68 displaced distal radius fractures in 65 eligible adult patients (35 men, 30 women; mean age, 48.6 +/- 15.4 y) who had volar plate osteosynthesis and concomitant prophylactic CTR through a hybrid FCR approach by a single surgeon were included in this study. A systematic chart review and subsequent telephone questionnaire were performed to identify any postoperative median nerve dysfunction, recurrent motor or palmar cutaneous branch injury, tendon injury, or other complications directly related to the approach.

RESULTS

Reported symptoms consistent with late median nerve dysfunction were identified in 2 cases; however, no patients in this series required additional surgery for early or late median neuropathy. Furthermore, no cases of median nerve sensory or motor branch injury or tendon injury were identified. No other unforeseen complications specifically related to the approach were observed.

CONCLUSIONS

Volar plate osteosynthesis of distal radius fractures with a concurrent prophylactic CTR can be safely performed through the described hybrid FCR approach in patients without signs or symptoms of acute CTS. Routine release of the transverse carpal ligament with the hybrid FCR approach at the time of fracture fixation might reduce the incidence of postoperative median nerve dysfunction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Distal radius fractures--classification of treatment and indications for surgery

Distal radius fractures are common injuries. Multiple classification systems have highlighted the evolution of the understanding of distal radius fractures. Understanding the classifications of distal radius fractures is important in identifying the important aspects that affect their outcome. Surgical indications of distal radius fractures can be divided into the following categories: patient factors, fracture reduction, fracture stability, and the presence of associated injuries.

Distal radius fractures: nonoperative and percutaneous pinning treatment options

Nonoperative treatment of distal radial fractures by reduction and immobilization remains the most common treatment, based on the incidence of appropriate fracture types, as seen in many epidemiological studies in the literature. In this article, the indications, technique, predictors of failure, outcomes, and complications are reviewed. A variety of treatment options have been proposed for distal radial fractures that are predicted, or subsequently identified, to be too unstable for nonoperative management. Percutaneous pinning is an effective option for select fractures. The authors also review the indications, described techniques, complications and outcomes associated with this treatment option.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically into immediate, early (less than 6 weeks), and late (greater than 6 weeks).

Complications of volar plate fixation for managing distal radius fractures

Volar locking plate fixation via open reduction and internal fixation is an increasingly accepted method for managing displaced distal radius fractures. Volar plating offers biomechanically stable fixation, allows early rehabilitation, and enables fixation of comminuted or osteopenic bone. The literature reporting complications of volar plate fixation is limited primarily to case reports and small case series. The surgeon must be mindful of potential soft-tissue, neurovascular, and osseous complications, such as extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, and loss of reduction, as well as hardware failure. Increased awareness of potential complications may lead to more prompt recognition and treatment when they do arise.

Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius

PURPOSE

To determine whether a volar radial (Henry) exposure to the distal radius is associated with less median nerve dysfunction than a direct volar exposure of the distal radius through the carpal tunnel that has been abandoned due to median nerve problems.

METHODS

Over an 18-month period, all patients with distal radius fractures treated with volar locking plate osteosynthesis were consecutively integrated into this therapeutic study. A direct volar midline approach ulnar to the flexor tendons and median nerve including prophylactic carpal tunnel release (CTR) was routinely performed from July 2003 to December 2004 (CTR group). Due to median nerve problems, this approach was abandoned and a distal part of the classical Henry approach (HRY) through the flexor carpi radialis (FCR) tendon sheath was performed for volar locking plate osteosynthesis in a second period from April 2005 to May 2006 (HRY group). In this group, the carpal tunnel was released only in selected cases. Data were collected prospectively for both groups. Analysis included clinical examination, the Patient-Rated Wrist Evaluation, and radiological follow-up up to 1 year after surgery.

RESULTS

Eighty-three patients entered the CTR group during the initial series. Thirty-one patients showed median nerve dysfunction 6 weeks after surgery. In the second period of observation, 91 patients entered the HRY group. The carpal tunnel was therapeutically decompressed in 18 patients, leaving the carpal tunnel untouched in 91 patients. Temporary median nerve paraesthesia was seen in 4 patients without CTR in the HRY group 6 weeks after surgery. After 1 year, persistent median nerve irritation was observed in 4 patients of the CTR group and none of the HRY group. Grip strength, range of motion, and Patient-Rated Wrist Evaluation were similar after 1 year.

CONCLUSIONS

The direct volar approach to the distal radius with routine CTR should be abandoned because it was associated with an increased rate of temporary and persistent median nerve irritation compared to the distal part of the classic Henry approach in our series.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Dextrose-induced subsynovial connective tissue fibrosis in the rabbit carpal tunnel: A potential model to study carpal tunnel syndrome?

In this pilot study, hypertonic dextrose solution was used to induce fibrosis of the subsynovial connective tissue (SSCT) and create an animal model of potential use in the study of carpal tunnel syndrome (CTS). The SSCT of the carpal tunnel in 15 New Zealand white rabbits were injected with 0.05 ml of 10% dextrose solution in 1 paw and 0.05 ml of saline in the contralateral paw, to serve as a control. The animals were killed at 1, 2, 4, 8, or 12 weeks. While the saline side showed minimal changes at any time period, the hypertonic dextrose side showed progressive noninflammatory SSCT fibrosis, with vascular proliferation and thickening of collagen bundles. Demyelination of the median nerve developed at 12 weeks after the injection on the dextrose side. These findings are similar to the progression of pathology noted in humans with CTS.

Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate

OBJECTIVES

The increasing number of fixed-angle plate systems used to treat distal radius fractures carries with it the problem of determining the optimal fixation for unstable fractures. Our goal was to analyze the clinical and radiological outcomes of patients with displaced, unstable distal radius fractures treated with a palmar fixed-angle plate.

DESIGN

Prospective protocol; multicenter clinical study; retrospective analysis.

SETTING

Level 1 university trauma centers.

PATIENTS

Over a mean 15-month period (range, 12 to 27 months), 141 consecutive patients were treated for an unstable dorsally displaced distal radius fracture of which 114 or 81% were followed for 1 year or longer.

INTERVENTION

Open reduction and palmar internal fixation with a fixed-angle plate (2.4 mm LCP Distal Radius Plates; Synthes, Salzburg, Austria). Indication for surgical treatment was the inability to obtain or maintain fracture or articular alignment after initial closed reduction.

MAIN OUTCOME MEASURES

In a follow-up period, which had to be longer than 12 months, objective and subjective functional results (active range of motion; strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS); Green and O'Brien Score) and radiographic assessment (palmar tilt, radial inclination, ulnar variance, fracture union) were assessed. Potentials for complications were given special attention.

RESULTS

In the 114 patients followed for a minimum of 12 months, there were 21 men and 93 women with a mean age of 57 years (17 to 79 years). Fractures were classified according to the AO/ASIF classification system as type A2 (n = 39), A3 (n = 16), C1 (n = 24), C2 (n = 30), or C3 (n = 5). The modified Green and O'Brien Score revealed 31 excellent, 54 good, 23 fair, and 6 poor results. Active wrist motion averaged 54 degrees extension (82% as compared with the uninjured side) and 46 degrees flexion (72% as compared with the uninjured side). The average pronation was 81 degrees (95% as compared with the uninjured side), and the average supination was 82 degrees (95% as compared with the uninjured side). Mean grip strength at final follow-up was 70% of the uninjured side. Low residual pain values in the wrist were demonstrated: 81 patients (71%) were pain free, 17 patients (15%) had mild pain, 10 patients (9%) had moderate pain, and 6 patients (5%) had severe pain. The DASH score averaged 13 points (range, 0 to 39 points). Fracture union was achieved in all patients. A mean loss of palmar tilt of 3.4 degrees (range, 0 to 8 degrees), radial inclination of 0.4 degrees (range 0 to 2 degrees), and of the ulnar variance of 1.2 mm (range, 0 to 6 mm) was measured. The overall complication rate was 27% (31/114). The most frequent problems were flexor and extensor tendon irritation (57% of the total number of complications), including 2 ruptures of the flexor pollicis longus tendon, 2 ruptures of the extensor pollicis longus tendon, 4 cases of extensor tendon tenosynovitis, and 9 cases of flexor tendon tenosynovitis. Carpal tunnel syndrome was observed in 3 patients, and complex regional pain syndrome occurred in 5 patients. In 2 cases, loosening of a single screw was seen. Delayed fracture union occurred in 3 patients, and intraoperative intraarticular screw displacement was recognized in 1 patient. Neither clinical outcome nor complication rate were dependent on fracture type (intraarticular versus extraarticular).

CONCLUSION

Fixation of unstable dorsally displaced distal radius fractures with a fixed angle plate provides sufficient stability with minimal loss of reduction. Nevertheless, very distal palmar plate position can interfere with the flexor tendon system, too long screws can penetrate the extensor compartments, and distal screws in comminuted fracture patterns can cut through the subchondral bone and penetrate into the radiocarpal joint. Mindful of these problems, we consider that the complex fracture pattern of an unstable distal radius fracture cannot be treated by a single plate system and approach.

Distal radius fractures: nonoperative and percutaneous pinning treatment options

Nonoperative treatment of distal radial fractures by reduction and immobilization remains the most common treatment, based on the incidence of appropriate fracture types, as seen in many epidemiological studies in the literature. In this article, the indications, technique, predictors of failure, outcomes, and complications are reviewed. A variety of treatment options have been proposed for distal radial fractures that are predicted, or subsequently identified, to be too unstable for nonoperative management. Percutaneous pinning is an effective option for select fractures. The authors also review the indications, described techniques, complications and outcomes associated with this treatment option.

Distal radius fractures--classification of treatment and indications for surgery

Distal radius fractures are common injuries. Multiple classification systems have highlighted the evolution of the understanding of distal radius fractures. Understanding the classifications of distal radius fractures is important in identifying the important aspects that affect their outcome. Surgical indications of distal radius fractures can be divided into the following categories: patient factors, fracture reduction, fracture stability, and the presence of associated injuries.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically in to immediate, early (less than 6 weeks), and late (greater than 6 weeks).