Kinematic and torque-related effects of dorsally angulated distal radius fractures and the distal radial ulnar joint

Stability of the distal radioulnar joint before and after corrective osteotomy of the distal radius

Malunion of the distal radius with dorsal angulation reduces stability of the distal radioulnar joint. The aim of the study was to sonographically quantify the stability of the distal radioulnar joint in 20 patients following corrective osteotomy of the distal radius and to investigate the subjective and clinical results preoperatively, three and twelve months postoperatively. Sonographically measured dorsovolar ulnar head translation relative to the distal radius was significantly higher (3.6 mm) preoperatively compared to 2.9 mm three months postoperatively. Twelve months postoperatively the result was 3.2 mm, equal to the contralateral side (3.2 mm). Pain, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Reported Wrist Evaluations, wrist flexion, radial and ulnar inclination, grip strength and pronation and supination torque improved significantly. Corrective osteotomy of the distal radius shows good subjective and clinical results and improves sonographically measured distal radioulnar joint stability. LEVEL OF EVIDENCE: III.

Management of Extra-Articular and Intra-Articular Distal Radius Malunion

This article presents a comprehensive overview of managing extra-articular and intra-articular distal radius malunions (DRM), discussing the pathoanatomy, clinical, and radiologic evaluation, conservative treatment, and surgical strategies. Corrective osteotomy remains the primary surgical intervention for symptomatic DRM. Surgical planning should consider factors such as timing, approach, correction technique, implant, graft, and associated injuries. The correction of extra-articular malunion necessitates brachioradialis tenotomy, circumferential periosteum release, and intrafocal elevation with grafting to facilitate distal radius realignment following osteotomy. Computer-assisted planning with 3D-printed patient-specific instrumentation (PSI) could help execute extra-articular osteotomy with high precision. As for the management of intra-articular malunion, it may require wrist arthrotomy, arthroscopy, or PSI assistance for precise articular osteotomy and reduction of the joint surface. This review highlights the importance of early intervention, thorough preoperative planning, and appropriate surgical techniques to optimize outcomes and minimize complications. Future research should focus on large-scale randomized controlled trials to compare different surgical methods, particularly for intra-articular DRM.

Distal radius fracture osteosynthesis by volar locking plate: influence of epiphyseal screw positioning on risk of loss of reduction

Ulnar variance is an important radiological parameter for good functional outcome after distal radius fracture osteosynthesis. Secondary loss of reduction due to radial shortening is a common complication after volar locking plate fixation. Some authors recommend beginning by placing the most ulnar epiphyseal screw, ensuring that it is positioned as close as possible to the distal radioulnar and radiocarpal joints. The hypothesis of our study was that the positioning of the ulnar epiphyseal screw relative to the distal radioulnar and radiocarpal joints influences the maintenance of reduction during follow-up. 190 distal radius fractures were treated with volar locking plate fixation and divided into two cohorts: cohort A with <2 mm and cohort B with ≥2 mm loss of ulnar variance. Minimum follow-up was 45 days. The positioning of the most ulnar epiphyseal screw was evaluated using a single variable, the ulno-distal index. Means were compared using t-tests and proportions using chi-squared tests. The alpha risk was set at 5%. The intra- and inter-observer reliability of the ulno-distal index measurement were assessed. Mean ulno-distal index was significantly lower in cohort A at 11.28 mm, compared to 13.33 mm in cohort B; p < 0.0001. Ulno-distal index <12 mm was a significant protective factor: p < 0.0001 and relative risk 0.558. No other intrinsic or extrinsic factors of secondary loss of reduction significantly influenced the risk of ulnar variance alteration. The study confirmed the hypothesis that, in distal radius fracture treated with volar locking plate fixation, the closer the ulnar epiphyseal screw to the distal radioulnar joint and radiocarpal joint, the lower the risk of ulnar variance alteration.

Managing the Extra-Articular Distal Radius Malunion

Distal radius fractures are common injuries. Satisfactory outcomes are typically achieved with appropriate nonoperative or operative treatment. A proportion of these injuries develop symptomatic malunions, which may be treated surgically with distal radius corrective osteotomy. A thorough understanding of the anatomy, biomechanics, radiographic parameters, and indications is needed to provide appropriate treatment. Factors, including surgical approach, osteotomy type, use of bone graft, fixation construct, management of associated tendon and/or nerve conditions, soft tissue contracture releases, and need for ulnar-sided procedures, should be considered. A comprehensive evaluation is necessary to guide understanding for when salvage procedures may be preferred.

Clinical Features and Surgical Strategies of Distal Radius Posttraumatic Deformity

Objective

To investigate the clinical features and surgical strategies of distal radius posttraumatic deformity.

Methods

A retrospective analysis was performed on the data of 30 patients with distal radius posttraumatic deformity treated by osteotomy and orthopedic surgery in the department of orthopedics, the First Affiliated Hospital of Nanjing Medical University, from February 2016 to November 2018. All the patients underwent preoperative anterior and lateral X-ray plain scanning of bilateral wrist joints, showing different degrees of radius shortening, inferior ulnar and radial mismatch, palmar angle, and ulnar deviation angle, among which 11 patients had an uneven joint surface. After a full evaluation, osteotomy and orthopedic surgery were performed to restore the original anatomical structure, plaster fixation was performed for two weeks after surgery, and regular outpatient follow-up was conducted. The function of the wrist was evaluated by the MMWS (wrist joint improvement) scoring scale before and after surgery, and the changes in the wrist joint-related treatment parameters were evaluated according to X-ray.

Results

All 30 patients had no neurological symptoms after surgery, and all wounds healed within the first stage. All patients were followed up for 6–12 months, with an average healing time of 3.5 months. There was no reduction loss, internal fixation loosening, or fracture in the regular postoperative review. Postoperative MMWS (wrist joint improvement) score scale data were significantly higher than those before surgery, and there were differences between groups (P < 0.05). Postoperative treatment parameters of wrist joints such as palmar inclination angle, ulnar deviation angle, radius height, and lower ulnar and radial matching were significantly improved, and there were differences between groups (P < 0.05).

Conclusions

The patients with distal radius posttraumatic deformity have the clinical characteristics of shortening of radius, mismatch of lower ulnar and radius, an abnormal inclination of palm, and ulnar declination. For patients with distal radius posttraumatic deformity, osteotomy and orthopedic surgery can effectively improve wrist function and improve patients' quality of life, which is worthy of clinical reference.

Patient-Perceived Outcomes After Nonoperative Treatment of Distal Radius Fracture in Older Adults

Malunion after distal radius fracture is common in older patients; however, whether patient-perceived outcomes are influenced by radiologic outcome is controversial. This study evaluated patient-perceived outcomes according to radiologic parameters in older patients who underwent nonoperative treatment. The records of 167 patients older than 55 years who had a distal radius fracture were reviewed. All fractures were treated nonoperatively, and average length of follow-up was 7 years. Outcomes were evaluated using numeric rating scales for pain and satisfaction, as well as Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Radiographs were evaluated for dorsal tilt, radial inclination, and ulnar variance. Fifty-one patients (30%) developed malunion. The pain numeric rating scale score was 0.8 for patients with malunion and 0.4 for patients with acceptable alignment; this difference was not statistically significant. The QuickDASH score was higher for patients with malunion (14.9 vs 11.1 for patients with acceptable alignment); however, this difference was not clinically meaningful. Satisfaction scores were lower for patients with malunion than for patients with acceptable alignment (80.8 vs 92.3). Patients with malunion stated they would choose surgery rather than a cast (13.3% vs 7.2%) if they developed another fracture; this difference was not statistically significant. The subanalysis according to radiologic parameters showed dorsal tilt and ulnar variance affected patient satisfaction but not other outcomes. This study indicated nonoperative treatment in older adults obtained acceptable patient-perceived outcomes despite residual deformity. However, patients whose radiologic parameter exceeded the tolerable range were less satisfied. [Orthopedics. 2021;44(2):e190-e196.].

Distal Radius Fracture and the Distal Radioulnar Joint

In this article, we discuss the incidence and types of injuries to the distal radioulnar joint (DRUJ) that occur in the setting of a distal radius fracture. We review the anatomy of the distal radioulnar joint, which is critical to understanding its biomechanics, and how injury could cause symptomatic incongruency and instability. We highlight how patients with an injury to the distal radioulnar joint might present both at the time of injury and after treatment of a distal radius fracture, the appropriate workup, the available treatment options, and the evidence-based literature.

Patient-reported outcomes after corrective osteotomy for a symptomatic malunion of the distal radius

AIMS

The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

METHODS

We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score.

RESULTS

Long-term outcomes were available for 89 patients (72%). The mean age was 57 years (SD 15) and 68 were female (76%). The median time from injury to corrective osteotomy was nine months (interquartile range (IQR) 6 to 13). At a mean follow-up of six years (1 to 11) the median PRWE score was 22 (IQR 7 to 40), the median QuickDASH score was 11.4 (IQR 2.3 to 31.8), and the median EQ-5D-5L score was 0.84 (IQR 0.69 to 1). The NPS was 69. Multivariate regression analysis showed that the presence of an associated ulnar styloid fracture was the only significant independent factor associated with a worse PRWE score when adjusting for confounding variables (p = 0.004).

CONCLUSION

We found that corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. However, the presence of an ulnar styloid fracture may adversely affect function. Level of Evidence: III (cohort study). Cite this article: Bone Joint J 2020;102-B(11):1542-1548.

Distal Radius Malunion

Malunion remains the most common complication of nonsurgical treatment of fractures of the distal radius and represents a common clinical entity. Symptomatic treatment often involves corrective osteotomy. Surgical correction is a challenging problem with unpredictable clinical outcomes. Prevention of malunion of a distal radius fracture is the best course of action. With maintenance of volar cortical contact and the use of volar fixed-angle devices, bone grafting may not be necessary in certain cases of malunion correction. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment.

Complications in the Management of Distal Radius Fractures: How Do We Avoid them?

PURPOSE OF THIS REVIEW

Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications.

RECENT FINDINGS

Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study

BACKGROUND

Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy.

METHODS

We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups.

RESULTS

All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms.

CONCLUSIONS

Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.

[Post-traumatic growth impairment following pediatric distal radius fractures resulting in an ulnar variance : A case report]

BACKGROUND

Fractures of the distal forearm are common in children. While we treat adults by trying to anatomically reconstruct the wrist joint, in children, fracture treatment is predominantly conservative due to the high correction potential of the distal growth plate. However, the presentation of young adults with post-traumatic wrist pain is not unusual.

OBJECTIVES

Do pediatric distal forearm fractures really heal without consequences despite a large tolerance of axial deviation?

MATERIALS AND METHODS

Review of the literature, discussion of results and case report.

RESULTS

Positive ulnar variance is the most common sequelae of pediatric distal forearm fractures. A positive variance of as little as >2 mm frequently causes ulnar-sided wrist pain and loss of motion, as is also shown in our case.

CONCLUSIONS

Careful follow-up is advisable beyond fracture union following pediatric distal forearm fractures, especially after transphyseal osteosynthesis or growth plate involvement. Reconstructively corrective osteotomy of the ulna should be considered in patients with corresponding clinical symptoms, radiological findings and a positive ulnar variance of >2 mm.

Finite element investigation into the use of carbon fibre reinforced PEEK laminated composites for distal radius fracture fixation implants

Carbon fibre reinforced PEEK (CF/PEEK) laminates provide mechanical advantages over homogenous metal osteo-synthesis implants, e.g. radiolucency, fatigue strength and strength to weight ratio. Implants can be designed with custom anisotropic material properties, thus enabling the engineer to tailor the overall stiffness of the implant to the specific loading conditions it will experience in vivo. In the current study a multi-scale computational investigation of idealised distal radius fracture fixation plate (DRP) is conducted. Physiological loading conditions are applied to macro-scale finite element models of DRPs. The mechanical response is compared for several CF/PEEK laminate layups to examine the effect of ply layup design. The importance of ply orientation in laminated DRPs is highlighted. A high number of 0° plies near the outer surfaces results in a greater bending strength while the addition of 45° plies increases the torsional strength of the laminates. Intra-laminar transverse tensile failure is predicted as the primary mode of failure. A micro-mechanical analysis of the CF/PEEK microstructure uncovers the precise mechanism under-lying intra-laminar transverse tensile crack to be debonding of the PEEK matrix from carbon fibres. Plastic strains in the matrix material are not sufficiently high to result in ductile failure of the matrix. The findings of this study demonstrate the significant challenge in the design and optimisation of fibre reinforced laminated composites for orthopaedic applications, highlighting the importance of multi-scale modelling for identification of failure mechanisms.

The Effect of Dorsal Angulation on Distal Radioulnar Joint Arthrokinematics Measured Using Intercartilage Distance

Background  The effects of dorsal angulation deformity on in vitro distal radioulnar joint (DRUJ) contact patterns are not well understood. Purpose  The purpose of this study was to utilize intercartilage distance to examine the effects of forearm rotation angle, distal radius deformity, and triangular fibrocartilage complex (TFCC) sectioning on DRUJ contact area and centroid position. Methods  An adjustable implant permitted the creation of simulated intact state and dorsal angulation deformities of 10, 20, and 30 degrees. Three-dimensional cartilage models of the distal radius and ulna were created using computed tomography data. Using optically tracked motion data, the relative position of the cartilage models was rendered and used to measure DRUJ cartilage contact mechanics. Results  DRUJ contact area was highest between 10 and 30 degrees of supination. TFCC sectioning caused a significant decrease in contact area with a mean reduction of 11 ± 7 mm ² between the TFCC intact and sectioned conditions across all variables. The position of the contact centroid moved volarly and proximally with supination for all variables. Deformity had a significant effect on the location of the contact centroid along the volar-dorsal plane. Conclusion  Contact area in the DRUJ was maximal between 10 and 30 degrees of supination during the conditions tested. There was a significant effect of simulated TFCC rupture on contact area in the DRUJ, with a mean contact reduction of 11 ± 7 mm ² after sectioning. Increasing dorsal angulation caused the contact centroid to move progressively more volar in the sigmoid notch.

Life has become troublesome - my wrist bothers me around the clock: an interview study relating to daily life with a malunited distal radius fracture

Purpose: The aim of this study was to explore the everyday life experiences of people suffering from a symptomatic, malunited, distal radius fracture.Method: Qualitative interviews were conducted with twenty respondents, median age 59 [16-85] years. The interviews were subjected to qualitative content analysis.Results: The result, presented as one main theme with categories and subcategories, describes the impact of the injury. Everyday life was affected in all participants, very much in a few highly valued activities such as sports and work, whenever the hand was used, or even at rest. This study indicates that the injury has an impact on the ability to move around, other parts of the body, sleep, emotions, self-perception and relationships. It also shows that the patients used several strategies to manage the situation.Conclusion: The malunion of a distal radius fracture has a negative impact on a wide range of daily activities, as well as other aspects of daily life. There is a need for information between caregivers and patients, and clear routines, once a malunion has occurred.Implications for rehabilitationThe symptomatic malunion of a distal radius fracture should be acknowledged as a complex condition requiring comprehensive interventionsTechnical equipment, braces and new solutions on practical problems was necessary to manage everyday life and should be a focus of intervention for this patient groupThe consequences of the injury was not only restricted activity performance but also affected social relationships and emotionsInformation about fracture healing and how a malunion can occur, as well as information on how much the wrist can be loaded at different time points, is important to reduce anxiety.

Effect of decrease in radial inclination of distal radius fractures on distal radioulnar joint stability: a biomechanical study

We investigated the relationship between the radial inclination of the distal radius and distal radioulnar joint stability. Six fresh-frozen upper extremities were used. Radial inclination was decreased by 10° and 20° and increased by 10° from the original radial inclination. Distal radioulnar joint stiffness was assessed with an intact radioulnar ligament and after partial and then complete sectioning of the radioulnar ligament. Radial angulation deformities significantly increased distal radioulnar joint stiffness when the radioulnar ligament is totally or partially attached to the ulnar fovea. After complete sectioning of the radioulnar ligament, distal radioulnar joint stiffness decreased significantly; additional radial angulation deformity slightly increased distal radioulnar joint stiffness, but the distal radioulnar joint never recovered to the original stiffness. Based on the results, radial angulation deformities of the distal radius should be corrected within 10° when the radioulnar ligament is intact, to reduce the risk of symptomatic distal radioulnar joint instability.

Comparison of volarly and dorsally displaced distal radius fracture treated by volar locking plate fixation

INTRODUCTION

In case of distal radius fractures (DRF) the distal fragment generally displaces either dorsally or volarly. Scientific literature however, seldom differentiates between volarly and dorsally displaced DRFs when reporting results. It is no clear, if the direction of displacement has an influence on the clinical and radiological outcome. This study was intended to evaluate the influence of displacement direction in adult patients with surgically treated Colles or Smith type fractures.

PATIENTS AND METHODS

After a mean follow up (FU) time of above 5 years, 50 patients who underwent open reduction and internal fixation for DRFs (25 Smith type fractures, 25 Colles type fractures) were included. Upon FU, standard X-rays and a clinical evaluation as well as evaluation scores were raised and analysed.

RESULTS

Clinical evaluation showed no difference between the Colles and the Smith group. Radiologic and clinical results for the Colles group showed diminished flexion compared to the healthy wrist, decreased radial inclination and dorsal tilt during FU and progression of osteoarthritis. For the Smith group decreased grip strength compared to the healthy wrist and osteoarthritis-progression was found. For both groups there was no correlation between radiologic values, grip strength, arthrosis grading, disability of arm, shoulder and hand score and patient rated wrist evaluation score.

DISCUSSION

Decreased flexion in combination with a decreased dorsopalmar tilt might hint towards a mechanical inhibition in the Colles group. Altogether, the study showed good clinical outcome with satisfactory radiological result. As all patients showed arthrosis progression, the fracture per se is to be seen as a prearthrotic factor. It still remains unclear which measures could be taken to prevent this.

Intramedullary nailing for correction of post-traumatic deformity in late-diagnosed distal radius fractures

BACKGROUND

Post-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius.

MATERIALS AND METHODS

From July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months.

RESULTS

All fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8.

CONCLUSION

Surgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius.

LEVEL OF EVIDENCE

IV.

Distal radius fractures-Design of locking mechanism in plate system and recent surgical procedures

Recently, many studies have emphasized the importance of the comprehension of detailed functional anatomy of the distal forearm and wrist joint, and their biomechanics. A significant contribution which yields good functional outcomes of surgical treatment was the development of the locking plate technology; this technology has facilitated the improvement of the surgical technique for the fixation of fractures. This article reviews the locking mechanism and design of the fixation screws and plate, and the details of the surgical technique including the double-tired subchondral support procedure as it is applied to common fractures. Arthroscopic-assisted surgical procedures can be used to reduce the intra-articular fracture fragments after realignment of the distal radius with the locking plate. This technique is also useful at the time of fixation to assess soft tissue injury. The combination of arthroscopic-assisted reduction and locking plate fixation is now indicated for AO type C2 and C3 intra-articular comminuted fractures.

A Simple 3-Dimensional Printed Aid for a Corrective Palmar Opening Wedge Osteotomy of the Distal Radius

The reconstruction of malunited distal radius fractures is often challenging. Virtual planning techniques and guides for drilling and resection have been used for several years to achieve anatomic reconstruction. These guides have the advantage of leading to better operative results and faster surgery. Here, we describe a technique using a simple implant independent 3-dimensional printed drill guide and template to simplify the surgical reconstruction of a malunited distal radius fracture.

Effect of volar angulation of extra-articular distal radius fractures on distal radioulnar joint stability: a biomechanical study

The relationship between increased volar tilt of the distal radius and distal radioulnar joint stability was examined. Distal radioulnar joint stiffness was recorded at 10° intervals from 10° dorsal angulation to 20° of volar angulation from the anatomical position of the radius. Tests were performed with the intact radioulnar ligament and repeated after partial and then complete sectioning of the radioulnar ligament at the ulnar fovea. With the intact radioulnar ligament, distal radioulnar joint stiffness increased significantly at 10° and 20° of volar angulation. Partial sectioning of the radioulnar ligament resulted in an approximate 10% decrease of distal radioulnar joint stiffness compared with the intact state, but distal radioulnar joint stiffness still increased significantly with greater volar tilt. Complete sectioning of the radioulnar ligament significantly decreased distal radioulnar joint stiffness, and increasing the volar tilt did not result in increased distal radioulnar joint stiffness. These results suggest that volar angulation deformities of the distal radius should be corrected to 10° of volar tilt when the triangular fibrocartilage complex is intact. Level of evidence: N/A.

Volar subluxation of the ulnar head in dorsal translation deformities of distal radius fractures: an in vitro biomechanical study

OBJECTIVES

To quantify the effects of dorsal translation deformities of the distal radius with and without dorsal angulation on volar displacement of the ulnar head during simulated active forearm rotation, both with the triangular fibrocartilage complex (TFCC) intact and sectioned conditions.

METHODS

Eight fresh-frozen cadaveric upper extremities were mounted in an active forearm motion simulator, and distal radial deformities of 0, 5, and 10 mm of dorsal translation with 0, 10, 20, and 30 degrees of dorsal angulation were simulated. Volar displacement of the ulnar head at the distal radioulnar joint as a result of each distal radial deformity was quantified during simulated active supination. The data were collected with the TFCC intact and after sectioning the TFCC at its ulnar insertion.

RESULTS

Increasing isolated dorsal translation deformities increased volar displacement of the ulnar head when the TFCC was intact (P < 0.001). Increasing dorsal translation combined with dorsal angulation increased volar displacement of the ulnar head compared with isolated dorsal angulation deformities (P < 0.001). Sectioning the TFCC increased the volar displacement of the ulnar head caused by each distal radial deformity (P = 0.001).

CONCLUSIONS

These results emphasize the clinical importance of evaluating the magnitude of both dorsal translation and dorsal angulation when managing displaced distal radius fractures and malunions.

Load transfer at the distal ulna following simulated distal radius fracture malalignment

PURPOSE

To measure the effects of distal radius malalignment on loading at the distal ulna.

METHODS

Using an adjustable mechanism to simulate angulated and translated malalignments, clinically relevant distal radius deformities were simulated in a cadaveric model. A custom-built load cell was inserted just proximal to the native ulna head to measure the resultant force and torque in the distal ulna. Loads were measured before and after transecting the triangular fibrocartilage complex (TFCC).

RESULTS

There was an increase in distal ulna load and torque with increasing dorsal translation and angulation. Combined conditions of angulation and translation increased force and torque in the distal ulna to a greater extent than with either condition in isolation. Transecting the TFCC resulted in a reduction in distal ulna load and torque.

CONCLUSIONS

A progressive increase in load at the distal ulna was observed with increasing severity of malalignment, which may be an important contributor to residual ulnar wrist pain and dysfunction. However, no clear-cut threshold of malalignment of a dorsally angulated and translated distal radius fracture was identified. These observations suggest that radius deformities cause articular incongruity, which increases TFCC tension and distal radioulnar joint load. Cutting of the TFCC decreased distal ulna loading, likely by releasing the articular constraining effect of the TFCC on the distal radioulnar joint, allowing the radius to rotate more freely with respect to the ulna.

CLINICAL RELEVANCE

Anatomical reduction of a distal radius fracture minimizes the forces in the distal ulna and may reduce residual ulnar wrist pain and dysfunction.

Ulnar shortening osteotomy for distal radius malunion

Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis.

LEVEL OF EVIDENCE

 Level IV.

Intramedullary nail versus volar plate fixation of extra-articular distal radius fractures. Two year results of a prospective randomized trial

BACKGROUND

Intramedullary techniques for stabilization of displaced distal radius fractures are now available. Purported benefits include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial is that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of unstable dorsally displaced extra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, parallel-group trial, with unrestricted randomization. Patients with dorsally displaced extra-articular distal radius fractures were randomized to receive volar locking plate (n=72) fixation or intramedullary nailing (n=80). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks, 6 months, 1 year and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain during the entire follow-up period (p>0.05). There was no significant difference between treatment groups with respect to volar tilt or ulnar variance (p>0.05). There was no significant difference in the complication rate between groups (p>0.05).

CONCLUSIONS

The present study supports the view that intramedullary nail fixation and volar plate fixation for the treatment of displaced extra-articular distal radius fractures have equivalent radiographic and functional outcomes.

LEVEL OF EVIDENCE

Level I therapeutic study.

The effects of dorsally angulated distal radius fractures on distal radioulnar joint stability: a biomechanical study

Relationship between dorsal tilt of the distal radius and distal radioulnar joint stability was examined. Stiffness in dorsopalmar displacement of the radius (distal radioulnar joint stiffness) was recorded at 10° intervals until 30° of dorsal angulation from 10° of palmar tilt. Tests were repeated after partial sectioning of the radioulnar ligament, then after complete sectioning of the radioulnar ligament. All data were compared with control (intact triangular fibrocartilage complex, 10° of palmar tilt). The distal radioulnar joint stiffness in dorsal translation decreased significantly with dorsal tilt 10° and 20° in pronation. Partial sectioning of the radioulnar ligament indicated a decrease of the distal radioulnar joint stiffness in the dorsal translation at neutral tilt to 20° of dorsal tilt in the neutral position and in pronation. Distal radioulnar joint stiffness decreased significantly in both dorsal and palmar translations in all forearm positions at 10° and 20° of dorsal tilt. From these findings, the dorsal angulation of the radius should be corrected to less than 10° of dorsal tilt.

Changes in length of the radioulnar ligament and distal oblique bundle after Colles' fracture

The purpose of this study was to investigate changes in length of the radioulnar ligament and distal oblique bundle (DOB) within the distal interosseous membrane after Colles' fracture and correlate the magnitude of the changes in length with clinical features. This study investigated 10 patients with malunion of a Colles' fracture. In three-dimensional computed tomography, the paths of the four limbs of the radioulnar ligament (superficial and deep, dorsal, and palmar limbs) and DOB were modelled and each path length was computed. Differences in length between the affected and contralateral unaffected side were calculated and correlated with the radiographic parameters of deformity on plain X-ray, subluxation of the DRUJ on CT, and limited range of forearm rotation in the clinical examination. In the malunited radius, the superficial and deep dorsal limbs of the radioulnar ligament were significantly elongated and DOB was significantly shortened compared with the contralateral side. These length changes correlated with radiographic radial shortening, subluxation of the DRUJ, and inversely correlated with limited range of forearm pronation. This study suggests that the dorsal radioulnar ligament would be overstretched and disrupted in Colles' fracture with severely increased radial shortening, producing laxity of the distal radioulnar joint that could negate limitation of pronation.

Isolated ulnar shortening osteotomy for the treatment of extra-articular distal radius malunion

PURPOSE

To report the clinical outcomes and complications for a cohort of patients who had extra-articular distal radius malunions treated with isolated ulnar-shortening osteotomy (USO). A second purpose was to define the dorsal angulation limit that would still result in clinical and functional improvement after isolated USO for distal radius malunion. We postulated that patients with up to 20° dorsal or volar tilt could be successfully treated with isolated USO.

METHODS

We conducted a retrospective chart review for all patients who had an isolated USO for the treatment of ulnar impaction syndrome after distal radius malunion between January 1990 and December 2011. A total of 18 patients underwent isolated USO after distal radius malunion. The mean age of the patients was 53 years and the mean duration of follow-up was 34 months. We used Wilcoxon signed-rank tests to compare preoperative and postoperative range of motion; pain; Quick Disabilities of the Arm, Shoulder, and Hand scores; and radiographic measurements.

RESULTS

Average intraoperative ulna shortening was 5.6 mm. Average flexion-extension arc improved from 79° preoperatively to 105° postoperatively. Average pronation-supination arc improved from 121° preoperatively to 162° postoperatively. Average visual analog scale pain score improved from 4.1 to 1.9. Average Quick Disabilities of the Arm, Shoulder, and Hand score improved from 43 to 11.

CONCLUSIONS

This case series demonstrated a significant improvement in pain score and range of motion after isolated USO for distal radius malunion. Patients with up to 20° dorsal tilt and radial inclination as low as 2° demonstrated improved clinical and functional outcomes after isolated USO. Given the comparable functional outcomes with shorter operative times and lower complication rate requiring fewer secondary surgeries, isolated USO is an attractive alternative to distal radius osteotomy for the management of distal radius malunion in patients with up to 20° dorsal tilt.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature

BACKGROUND

Flexor tendon rupture is a rare but major complication associated with volar plate fixation of distal radius fractures.

MATERIALS AND METHODS

We performed a systematic review to evaluate the demographics, clinical profile, treatment and outcome of flexor tendon rupture following volar plate fixation of distal radius fracture. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases for systematic reviews and conference proceedings were performed. Studies were included if they reported flexor tendon rupture (partial or complete) as a complication of distal radius fracture plating (all levels of evidence).

RESULT

Our search yielded 21 studies. There were 12 case reports and 9 clinical studies. A total of 47 cases were reported. There were 11 males and 23 females (n = 16 studies). The mean age was 61 years old (range 30-85). The median interval between the surgery and flexor tendon rupture was 9 months (interquartile range, 6-26 months). Twenty-nine plates were locking and 15 were nonlocking (n = 20 studies). FPL was the most commonly ruptured tendon (n = 27 cases, 57 %), with FDP to index finger being the second most common (n = 7 cases, 15 %). Palmaris longus tendon graft and primary end-to-end repair were the most common surgical methods used in cases of FPL tendon rupture.

CONCLUSION

Flexor tendon rupture is a recognised complication of volar plating of distal radius fracture. Positioning of the plate proximal to the "watershed" line and early removal of the plate in cases with plate prominence or warning symptoms can reduce the risk of this complication.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Outcomes of pin and plaster versus locking plate in distal radius intraarticular fractures

Background

Distal radius fractures are among the most prevalent fractures predictive of probable occurrence of other osteoporotic fractures. They are treated via a variety of methods, but the best treatment has not been defined yet.

Objectives

This study was performed to compare the results of open reduction and internal fixation with locking plates versus the pin and plaster method.

Materials and Methods

In this prospective study, 114 patients aged 40 to 60 years with Fernandez type III fracture referring to Imam-Reza and Mehr hospitals of Mashhad from 2009 to 2011, were selected randomly; after obtaining informed consent, they were treated with pin and plaster fixation (n = 57) or internal fixation with the volar locking plate (n = 57). They were compared at the one year follow up. Demographic features and standard radiographic indices were recorded and MAYO, DASH and SF - 36 tests were performed. Data was analyzed by SPSS software version 13, with descriptive indices, Mann-Whitney and Chi-square tests.

Results

SF-36 test demonstrated a better general health (P < 0.001), mental health (P = 0.006), physical functioning (P < 0.001), social functioning (P < 0.001) and energy/fatigue (P < 0.001) in LCP group. However, pain (P = 0.647) was not significantly different between the groups. Physical limitation (P < 0.001) and emotional limitation (P < 0.001) were greater in the pin and plaster group. Also, in the LCP group mean MAYO score (P < 0.001) was more than pin and plaster group. Mean DASH score was not different between the groups (P = 0.218). The rate of acceptable results of radiographic indices (P < 0.001), grip strength (P < 0.001) and range of motion in supination-pronation (P < 0.001) in LCP method were better than the pin and plaster method.

Conclusions

In treatment of intra-articular distal radius fractures in middle-aged patients internal fixation with locking plates may be prefered to pin and plaster as the treatment of choice.

Correction of dorsally-malunited extra-articular distal radial fractures using volar locked plates without bone grafting

Malunion is the most common complication of the distal radius with many modalities of treatment available for such a problem. The use of bone grafting after an osteotomy is still recommended by most authors. We hypothesised that bone grafting is not required; fixing the corrected construct with a volar locked plate helps maintain the alignment, while metaphyseal defect fills by itself. Prospectively, we performed the procedure on 30 malunited dorsally-angulated radii using fixed angle volar locked plates without bone grafting. At the final follow-up, 22 wrists were available. Radiological evidence of union, correction of the deformity, clinical and functional improvement was achieved in all cases. Without the use of bone grafting, corrective open wedge osteotomy fixed by a volar locked plate provides a high rate of union and satisfactory functional outcomes.

The biomechanical effects of a deepened articular cavity during dynamic motion of the wrist joint

BACKGROUND

A deepened articular cavity of the distal radius due to a metaphyseal comminution zone is associated with early osteoarthritis and reduced joint motion. As this deformity has not been investigated biomechanically, the purpose of this study was to evaluate the effects of a deepened articular cavity on contact biomechanics and motion range in a dynamic biomechanical setting.

METHODS

Six fresh frozen cadaver forearms were tested in a force controlled test bench during dynamic flexion and extension and intact mean contact pressure and contact area as well as range of motion were evaluated. Malunion was then simulated and intraarticular as well as motion data were obtained. Intact and malunion data were compared for the scaphoid and lunate facet and the total radial joint surface.

FINDINGS

Due to malunion simulation, cavity depth increased significantly. Motion decreased significantly to 54-69% when compared to the intact state. Malunion simulation led to a significant decrease of contact area in maximum extension for all locations (by ~50%). In maximum flexion and neutral position, contact area decrease was significant for the scaphoid fossa (by 51-54%) and the total radial joint surface (by 47-50%). Contact pressure showed a significant increase in maximum extension in the scaphoid fossa (by 129%).

INTERPRETATION

Already a small cavity increase led to significant alterations in contact biomechanics of the radiocarpal joint and to a significant range of motion decrease. This could be the biomechanical cause for degenerative changes after the investigated type of malunion. We think that restoration of the normal distal radius shape can minimize osteoarthritis risk post trauma and improve radiocarpal motion.

Corrective Radial and Ulnar Osteotomies for Distal Radial Fracture Malunion

Introduction

We describe a technique consisting of simultaneous radial closing-wedge and ulnar shortening osteotomy to treat malunion of distal radial fractures.

Step 1 Preoperative Planning

Plan the radial closing-wedge osteotomy to correct the volar tilt angle to 8.5° to 15.5° and the ulnar shortening osteotomy to restore ulnar variance to -2.5 to 0.5 mm.

Step 2 Radial Closing-Wedge Osteotomy

Remove the wedge of bone from the radius and reduce the distal fragment, keeping the dorsal cortex as a hinge.

Step 3 Distal Ulnar Shortening Osteotomy

Resect the section of the ulna equivalent to the positive ulnar variance with transverse osteotomies.

Step 4 Plate Fixation of the Radial Osteotomy Site

Hold together the two fragments of the radius with a Kirschner wire and fix the osteotomy site with a volar locking plate.

Step 5 Proximal Ulnar Shortening Osteotomy

Evaluate residual ulnar positive variance with fluoroscopy and restore the ulnar variance to within a normal range by removing additional bone from the proximal fragment.

Step 6 Plate Fixation of the Ulnar Osteotomy Site

Use a compression device to close and fix the ulnar osteotomy site.

Step 7 Postoperative Management

Allow early motion immediately after the operation.

Results

We retrospectively evaluated forty-two patients at a minimum of one year after treatment of an extra-articular distal radial malunion with a radial corrective osteotomy.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

[Long-term results after Kirschner wire pinning of distal radius fractures]

BACKGROUND

The purpose of this study was to investigate the outcome after K-wire pinning of distal radius fractures with a minimum follow-up period of 5 years.

PATIENTS AND METHODS

A total of 189 patients with an isolated fracture of the distal radius were treated between 1998 and 2002 and 100 were evaluated at an average of 5.6 years after the surgery. At the final follow-up examination all patients were assessed clinically and bilateral radiographs were taken.

RESULTS

Of the patients 37 had an A type fracture, 8 a B type and 55 a C type according to the AO classification and 86% achieved good to excellent results based on the Gartland and Werley and Disability of Arm, Shoulder, Hand (DASH) scores. Patients were divided in to two groups. Group A included patients with fractures with a primary palmar inclination greater than -20° (range -20° to 10°) and group B with fractures with a primary palmar inclination less than -20° (range -45° to -20°). Secondary loss of reduction was significant higher in group B compared to group A (group B: 8.3°, group A: 1.6°, p <0.05). In 8 out of 11 patients of group B an osteoporosis was found. Functionally no difference was detected between the two groups. Radial shortening of over 4 mm resulted in a significant reduction (36%) of prosupination and supination. No other influence of the radiological results on the functional or subjective outcome was found. Superficial infection of the K-wire occurred in 6 cases, whereas early K-wire removal was performed in 2 cases, 8 patients complained of dysesthesia in the area of the superficial radial nerve and 5 patients developed an early stage of the complex regional pain syndrome.

CONCLUSION

K-wire pinning cannot be routinely recommended. However, in cases of A2, A3 and C1 fractures, a primary dorsal dislocation of less than -20° and in patients without low bone mineral density, K-wire pinning leads to a high rate of radiological, functional good results.

Management of the distal radioulnar joint and ulnar styloid fracture

Fractures of the distal radius and ulnar styloid have the potential to disturb the normal function of the distal radioulnar joint (DRUJ), resulting in loss of motion, pain, arthritis, or instability. The DRUJ can be adversely affected by several mechanisms, including intra-articular injury with step-off, shortening, and angulation of an extra-articular fracture; injury to the radioulnar ligaments; ulnar styloid avulsion fracture; and injury of secondary soft tissue stabilizers. This article discusses the management of the DRUJ and ulnar styloid fracture in the presence of a distal radius fracture.

Clinical outcomes of corrective osteotomy for distal radial malunion: a review of opening and closing-wedge techniques

BACKGROUND

Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is ongoing discussion over whether an opening or closing-wedge osteotomy should be employed. The purpose of the present study was to retrospectively compare the clinical and radiographic results of conventional opening-wedge osteotomy with those of our closing-wedge technique.

METHODS

We retrospectively evaluated forty-two patients with extra-articular distal radial malunion who were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients were managed with radial opening-wedge osteotomy and interpositional bone graft or bone-graft substitute, and twenty were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The mean duration of follow-up was thirty-six months (range, twelve to 101 months) for the opening-wedge cohort and twenty-eight months (range, twelve to eighty-seven months) for the closing-wedge cohort. The two techniques were comparable in terms of complications. Postoperative volar tilt and ulnar variance improved significantly compared with the preoperative status in each cohort (p < 0.05). Restoration of ulnar variance to within defined criteria (-2.5 to 0.5 mm) was significantly more frequent in the closing-wedge cohort than in the opening-wedge cohort (p < 0.001). The postoperative mean extension-flexion arc of the wrist (p < 0.001) and Mayo wrist score (p = 0.008) were significantly better in the closing-wedge cohort. Differences between the two cohorts in terms of the pronation-supination arc, grip strength, pain-rating score, and DASH scores were not significant.

CONCLUSIONS

The closing-wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

The effect of multiplanar distal radius fractures on forearm rotation: in vitro biomechanical study

PURPOSE

Many patients develop distal radioulnar joint (DRUJ) pain and loss of forearm rotation after distal radial fractures. Residual distal radial deformity is one potential cause of DRUJ dysfunction; however, the parameters of distal radial fracture alignment that lead to an acceptable functional outcome are poorly defined in the literature.

METHODS

We used 8 fresh-frozen cadaveric specimens in this in vitro study to examine the effect of simulated distal radius fracture misalignment on forearm rotation. A distal radial osteotomy was performed just proximal to the DRUJ and a custom-made, 3-degrees-of-freedom modular implant designed to simulate distal radius fracture deformities was secured in place. This allowed for accurate simulation of dorsal angulation, dorsal translation, and radial shortening, both independently and in combination. We examined the effects of distal radius deformity in the setting of both an intact and sectioned triangular fibrocartilage complex.

RESULTS

Pronation was not significantly affected until dorsal angulation reached 30 degrees . Dorsal translation of up to 10 mm or radial shortening up to 5 mm had no effect on forearm rotation. Combined deformities had a greater effect on forearm motion than isolated malpositions. Dorsal angulation of > or =20 degrees combined with 10 mm of dorsal translation or 20 degrees of angulation with 2.5 mm of radial shortening resulted in a significant decrease in forearm pronation. There was no effect of distal radial deformities, either isolated or combined, on the magnitude of forearm rotation after sectioning the triangular fibrocartilage complex.

CONCLUSIONS

This study demonstrates that a broad range of distal radius fracture malpositions can be tolerated before a notable loss in forearm range of motion is evident. Combined deformities are more likely to result in a clinically important loss of forearm rotation, and this should be considered when choosing the optimal management of patients with displaced distal radial fractures. Disruption of the triangular fibrocartilage releases the tether on the DRUJ, allowing for preservation of forearm motion even in the setting of marked osseous deformities.

Treatment of distal radius malunions with an intramedullary nail

Malunion of the distal radius are the most common complications of distal radius fractures. Increased angulation of the distal radius can result in altered load concentrations on the wrist, decreased range of motion, decreased grip strength, and residual incongruence of the radiocarpal and distal radioulnar joints. Multiple options exist for fixation of corrective osteotomies of the distal radius, including intramedullary nails. The use of an intramedullary nail provides the benefits of a percutaneous insertion technique, low-profile implant, load-sharing design, and fixed-angle locking screws in the distal fragment. We describe an innovative technique for intramedullary fixation for corrective osteotomies of extraarticular distal radius malunions.

Corrective osteotomy for deformity of the distal radius using a volar locking plate

Dorsally angulated malunions of the distal radius have historically been corrected with an opening wedge osteotomy fixed with a dorsal plate. Volar locking plates may facilitate a less morbid approach to corrective osteotomies of the wrist. Eight consecutive patients with an average age of 40 years (range, 15-52 years) underwent correction of a distal radius deformity through a volar approach. Clinical follow-up averaged 17.4 months (range, 7-41 months). Preoperative radiographs revealed an average of 24 degrees of dorsal tilt in patients with dorsal deformity. Postoperatively, their average measurement was <3 degrees of volar tilt. Patients were initially ulnar-positive with an average of 4 mm ulnar-positive variance (range, 2-7 mm). This corrected to less than 1 mm postoperatively. Postoperative disabilities of the arm, shoulder, and hand (DASH), SF-12, and Mayo Wrist scores averaged 10.8, 40.5, and 82.5, respectively. There were no nonunions, and no plates required removal. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate.

[Distal radius fracture. Correlation between radiological and functional results]

BACKGROUND

The purpose of the present study was to investigate the influence of the radiological parameters on the functional outcome of patients with a fracture of the distal radius and to find out to which extent a deformity can be tolerated.

PATIENTS AND METHODS

A total of 344 patients with an isolated fracture of the distal radius were treated during a 3-year period; 211 of them were evaluated at an average of 16 months after the accident according to the score of Gartland and Werley as modified by Sarmiento. Furthermore, we developed our own score for evaluating the influence of radiological parameters on the functional outcome.

RESULTS

According to the AO classification, there were 20 patients with an A2, 71 an A3, 11 a B, 35 a C1, 44 a C2, and 30 a C3 fracture. Of 211 patients, 28 (13%) had a step-off in the articular surface of over 1 mm, resulting in a 24% reduction of the range of motion compared to the non-injured wrist (p<0.05). Patients with a radial shortening of more than 3 mm (n=12) had a 21% reduction of pro- and supination compared to the non-injured side (p<0.05). The radial tilt and the palmar inclination did not have a direct influence on the functional outcome. Patients treated with K-wire pinning and with an initial palmar inclination of less then -15 degrees had a significantly higher secondary loss of palmar inclination of 9 degrees compared to all others (p<0.05) at the final follow-up.

CONCLUSION

The main radiological factors influencing the functional outcome of fractures of the distal radius are radial shortening and a step-off in the articular surface.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Malunion of the distal radius

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

The treatment of severely comminuted intra-articular fractures of the distal radius

Comminuted fractures of the distal end of the radius are caused by high-energy trauma and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments. The force of the impact and the position of the hand and carpal bone determine the pattern of articular fragmentation and their displacement and the amount and the extent of frequent concommitant ligament and carpal bone injury. The result of the osseous lesion in comminuted fractures was termed "pilon radiale", which emphasizes the amount of damage to the distal radius and the difficulties to be expected in restoring the articular congruity. Besides this the additional injury, either strain of disruption of the ligaments and the displacement of the carpus and/ or the triangular fibrocartilage complex will equally influence the functional outcome. This review will expand on the relevant anatomy, correct classification and diagnosis of the fracture, diagnostic tools and operative treatment options. Current treatment concepts are analysed with regard to actual literature using the tools of evidence based medicine criteria. A new classification of severely comminuted distal radius fractures is proposed using CT data of 250 complex intraarticular radius fractures. Finally a standardized treatment protocol using external fixation in combination with minimal invasive internal osteosynthesis is described.

[Functional outcome after corrective osteotomy of the distal radius]

BACKGROUND

Malunited fractures of the distal radius frequently show disabling and painful reductions in active range of motion (AROM) of the wrist and forearm with reduced grip strength. Shortening and three-dimensional torsion of the distal radius occur with relative ulnar lengthening. Corrective osteotomy of the distal radius is indicated in these conditions.

METHODS

We examined 24 of 30 patients after corrective osteotomy with respect to AROM, grip strength, DASH, and pain perception (visual analogue scale). The mean age of the population was 49 years (18-69 years), and the mean follow-up period was 22 months (6-63 months).

RESULTS

Preoperative extension/flexion was 65 degrees , postoperative 92 degrees (p<0.05). Forearm rotation improved from 129 degrees preoperative to 160 degrees postoperative (p<0.01). The DASH score could be reduced from 40 (n=9) to 18 (n=24). Grip strength increased from 17 kg to 27 kg postoperative (p<0.01). Radioulnar inclination increased from 15 degrees preoperative to 24 degrees postoperative (p<0.05). Relative ulnar lengthening could be minimized from 4.3 mm to 0.7 mm (p<0.05).

CONCLUSION

Data show that reconstruction of the distal radius improves grip strength and range of motion significantly with simultaneous reduction of pain perception and DASH scores.

Distal radius fractures: a comparison of tension band wiring versus ulnar outrigger external fixation for the management of distal radioulnar instability

PURPOSE

To retrospectively compare the results of immobilization of the forearm in supination with the results of tension band fixation of the ulnar styloid in 35 patients with distal radius fractures, fracture of the base of the ulnar styloid, and distal radioulnar joint instability treated with external fixation.

METHODS

Thirty-five patients with fractures of the distal radius, fracture of the base of the ulnar styloid, and unstable distal radioulnar joint had external fixation with adjunctive percutaneous pins and allograft bone to reduce and stabilize the distal radius fracture anatomically. Only those patients with an associated ulnar styloid base fracture displaced over 2 mm with gross distal radioulnar joint instability relative to the contralateral wrist were included in this study. Group 1 consisted of patients in whom the ulnar styloid base fracture was treated with conventional tension band wiring techniques. Group 2 patients were treated with a supplemental outrigger from the external fixator to the ulna and locked in 60 degrees of forearm supination. Groups 1 and 2 had an average follow-up period of 40 and 36 months, respectively.

RESULTS

Group 2 had significantly better supination than group 1. In terms of functional outcome it was found that there was no significant difference for the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scores between the 2 treatment groups. There was a lower rate of complications and fewer secondary procedures were required in group 2. The incidence of distal ulna resection was 4 of the 35 patients (2 patients in each group).

CONCLUSIONS

Our results indicate that patients in whom the ulnar styloid can be reduced and maintained in supination can be treated effectively with fixed supination outrigger external fixation. This method resulted in a statistically significant improvement in supination and a lower rate of distal radioulnar joint complications, and it required fewer secondary procedures.

[Salvage operations and their differential indication for the distal radioulnar joint]

The most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.