Four-Corner Concept: CT-Based Assessment of Fracture Patterns in Distal Radius

[Diagnostics and classification of distal radius fractures]

Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X‑ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

[Distal radius fracture-tactic and approach]

OBJECTIVE

The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare.

INDICATIONS

Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement.

CONTRAINDICATIONS

The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation.

SURGICAL TECHNIQUE

The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen.

POSTOPERATIVE MANAGEMENT

In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization.

RESULTS

Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

Three Column Fixation Through a Single Incision in Distal Radius Fractures

Purpose  The purpose of this study was to evaluate the clinical and functional results of 67 patients with distal radius fracture (DRF), treated with a modified surgical technique that allows three-column fixation through the same palmar approach. Patients and Methods  Between 2014 and 2019, we treated 67 patients using a particular surgical technique. All patients suffered DRF, classified using the universal classification system. Two different intervals were developed palmary: the first ulnarly to the flexor carpi radialis tendon for direct visualization of the distal radius and the second one radially to the radial artery for direct visualization of the styloid process. An anatomic volar locking compression plate was applied to all patients. The radial styloid process was fixed and stabilized either with Kirschner-wires or an anatomic plate through the same incision. Functional results were evaluated based on the Disabilities of the Arm, Shoulder and Hand and Mayo wrist scores. Range of motion and grip strength of the injured wrist were statistically compared with the opposite side. Results  The mean follow-up was 47 months (13-84). All fractures were united, and all patients recovered to the preinjury level of activity. The mean flexion-extension range was 73.8° to 55.2° and the supination-pronation range 82.8° to 67°. No infection or nonunion occurred. No major complications were reported. Conclusion  Open reduction and internal fixation, under specific indications, is the best treatment option in DRF. The described technique provides excellent visualization to the distal radius surfaces and allows the internal fixation of the radial columns through the same skin incision. Therefore, it can constitute an efficient choice in the treatment armamentarium of DRF.

Minimally Invasive Fixation with Dorsal Suspension Button and Volar Plate in Distal Radius Fractures with Dorsal Die Punch Fragments: A Preliminary Study

Objective  The objective of the study is to analyze the clinical and radiological results obtained using a minimally invasive fixation technique with a volar locking plate and a suspension system with a dorsal button in distal articular radius fractures with dorsal comminution. Materials and Methods  Six patients with distal radius fractures, between 19 and 68 years of age, were included in the study. Mean follow-up was of 15 weeks. Range of motion (ROM) in flexion, extension, radial deviation, ulnar deviation, pronation, supination, the strength in kilograms, and values on the Visual Analog Scale (VAS), Disabilities of Arm, Shoulder and Hand (DASH), and Mayo Wrist Score (MWS) scales were evaluated at 4, 8, and 12 weeks postoperative. Correction of anteroposterior diameter of the radius and concordance between postoperative anteroposterior diameter and the contralateral wrist diameter were evaluated radiologically. Results  The following mean values were obtained at 12 weeks postoperative: ROM in flexion: 40.5°, ROM in extension: 49.5°, ROM in radial deviation: 24.5°, ROM in ulnar deviation: 15°, ROM in pronation: 87°, ROM in supination: 89°, strength: 37.5 kg, pain in VAS scale: 2 points, DASH: 54.5 points, and MWS: 67.5 points. At 12 weeks postoperative, the mean correction of anteroposterior diameter was 0.49 mm. The anteroposterior diameter and that of the contralateral wrist were strongly correlated. Conclusion  Fixation with the volar locking plate and dorsal suspension button could be considered an alternative to dorsal plate fixation for treatment of distal radius fractures with comminution or associated dorsal die punch fragments.

Open Reduction and Internal Fixation by Volar Locking Plates and the "Poking Reduction" Technique in Distal Radius Fractures with Displaced Dorsal Ulnar Fragments: A Retrospective Study

Objective

To investigate the clinical and radiological outcomes of distal radius fractures (DRFs) with displaced dorsal ulnar fragments treated with volar locking plate (VLP) and the “poking reduction” technique.

Methods

Between January 2014 and January 2019, 78 unilateral DRFs with displaced dorsal ulnar fragment (AO type C3) treated with VLP were conducted. According to the reduction technique of the dorsal ulnar fragment, the patients were divided into the conventional reduction (CRG) group (33 patients, 14 males and 19 females, mean age 57.2 ± 12.1 years old) and the “poking reduction” (PRG) group (45 patients, 11 males and 34 females, mean age 60.1 ± 12.4 years old). According to the AO classification, there were 21 cases of C3.1 and 12 of C3.2 in the CPG group, 27 cases of C3.1 and 18 of C3.2 in the PRG group. Clinical and radiographic data were extracted from the electronic medical record system. These data were reviewed for clinical outcomes (range of motion, grip strength), radiological outcomes (volar tilt, radial inclination, radial height, step of articular surface), and postoperative complications. The final functional recovery was evaluated by the disabilities of the arm, shoulder, and hand (DASH) score.

Results

The mean duration of follow‐up was 27 months (range from 12 to 56). The average operation time and intraoperative blood loss did not significantly differ between groups (p > 0.05). Postoperative CT examination showed that the step of articular surface in CPG group (0.8 ± 0.3 mm) was larger than that in PRG group (0.5 ± 0.2 mm) (p < 0.001). The DASH score did not significantly differ between groups (26.1 ± 4.6 in CRG and 24.7 ± 4.0 in PRG, p > 0.05) at 3 months postoperatively. At 6 months and 12 months postoperatively, the DASH score was better in PRG group (11.8 ± 2.5 and 10.4 ± 2.0) than in CRG group (13.6 ± 2.7 and 12.2 ± 2.5) (p = 0.004, p = 0.001, respectively). At 12 months postoperatively, wrist range of motion did not significantly differ between groups (p > 0.05). There was no significant difference in radiological parameters between the two groups (p > 0.05). The incidence of complications was higher in the CRG group (7/33) than in the PRG group (2/45) (p = 0.009).

Conclusion

The “poking reduction” technique is a wise option for reduction of dorsal ulnar fragment in DRFs. This innovative technique could restore smoothness of the radiocarpal joint effectively, and the dorsal ulnar fragment could be fixed effectively combined with the volar plate.

Routine x-rays after the osteosynthesis of distal radius and ankle fractures—a prospective randomized controlled trial on the necessity of routine imaging

BACKGROUND

The utility of routine x-rays after the osteosynthesis of distal radius fractures and ankle fractures is questionable. We performed a trial to determine whether such x-rays are justified in patients who have undergone standardized imaging with C-arm fluoroscopy during surgery.

METHODS

Patients requiring surgery for a distal radius fracture or an ankle fracture were candidates for inclusion in this prospective, randomized, controlled, non-blinded trial. Standardized intraoperative images were obtained with C-arm fluoroscopy and stored at the end of the operation. The next day, patients in the control group underwent imaging with a standard postoperative x-ray, while those in the intervention group did not. The primary endpoint was a change in the treatment plan, defined as additional imaging or a second operation. The secondary endpoints included the range of motion, pain as rated on the Visual Analog Scale, and a functional outcome analysis (PRWE/FAOS).

RESULTS

316 patients were included in the trial (163 in the control group, 153 in the intervention group), of whom 202 (64%) had radius fractures and 114 (36%) had ankle fractures. The treatment plan changed in twelve patients (3.8%; four in the control group and eight in the intervention group), seven of whom (2.2%; three in the control group and four in the intervention group) underwent a second operation. The frequency of changes in the treatment plan and of reoperations was comparable in the two groups (p = 0.36). On follow-up at six weeks and one year, the results with respect to functional outcomes and pain were comparable.

CONCLUSION

In this trial, routine postoperative x-rays after the osteosynthesis of distal radial fractures and ankle fractures did not improve the care of patients who had undergone standardized intraoperative imaging.

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

PURPOSE

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

MATERIAL

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

RESULTS

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

CONCLUSION

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

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

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

Inducing life-like distal radius fractures in human cadaveric specimens: a tool for enhanced surgical training

INTRODUCTION

Surgical education consists often times of a discrepancy between necessary amount of provided operative teaching and amount of organizational and ward duties. Operative education is often cut to a minimum. As public awareness toward surgical competence raises, so must the educational system. Courses that provide pre-fractured cadaveric specimens can facilitate surgical teaching realistically, prior to operating on living patients. The aim of this study is to introduce a realistic distal radius fracture simulation setup.

MATERIALS AND METHODS

12 cadaveric specimens (3 male, 9 female) were fixed onto a custom drop-test-bench in the hyperextension of the wrist. The forearm was cut midway between elbow and carpus. The distal part of the forearm was potted, and the specimen was exposed to a high energetic impulse. CT imaging was performed after fracture simulation to detect the exact fracture patterns. We used the AO/ASIF recommendations and four-corner concept to classify the achieved fractures by two independent trauma surgeons.

RESULTS

All cadaveric specimens could be successfully fractured. 11 fractures were classified as type 23C3.2 and one was classified as type 23C3.3, as additional fracture of diaphysis occurred. Subclassification according to the four-corner concept showed all fractures to be type C. A concomitant ulnar styloid fracture was observed in 4 cases. Furthermore, all cases showed at least one fragment involving the sigmoid notch. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age (p value 0.402), as well as HU and required kinetic energy (p value 0.063).

CONCLUSION

A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic distal radius fractures in cadaveric specimens with intact soft tissue. Furthermore, these pre-fractured specimens can be utilized in surgical education to provide a teaching experience as realistic as possible without harming living patients.

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Prevalence of posttraumatic arthritis following distal radius fractures in non-osteoporotic patients and the association with radiological measurements, clinician and patient-reported outcomes

INTRODUCTION

Outcomes of non-osteoporotic patients who sustained a distal radius fracture (DRF) have not gained much attention in recent literature. The aims of this study were to determine the prevalence of posttraumatic arthritis (PA), to analyze associations of radiological measurements, clinician-reported and patient-reported outcomes (CROs and PROs) with PA and gain insight into employment changes after DRF in non-osteoporotic patients.

METHODS

Non-osteoporotic patients following a DRF were selected. Radiographs of both wrists were obtained at follow-up and the degree of PA was determined. Radiological measurements consisted of grading of PA, ulnar variance, radial length, radial inclination, dorsal tilt, distal radio-ulnar joint width, scapholunate dissociation, step-off and gap. Active range of motion and grip strength measurements were performed and all patients filled in four questionnaires to assess pain, upper extremity functioning, and health status (Disability of Arm, Shoulder and Hand; Patient Reported Wrist Evaluation; Michigan Hand Questionnaire; Short Form-36).

RESULTS

Seventy-three patients (32 women, 41 men) with a mean age of 33.5 (SD 9.2) years were included. Prevalence of PA was 32% at a median follow-up of 62.0 months. Patients with PA had statistically significant longer radial length (1.1 mm, 95% CI - 2.1; - 0.0, p = 0.045). Patients with PA had a statistically significant diminished flexion/extension arc of motion (12.0°, p = 0.008) and ulnar/radial deviation arc of motion (6.3°, p = 0.018). When corrected for dominance, all grip strength measurements were not statistically significantly different between patients with and without PA. Statistically significant poorer PROs in patients with PA were the MHQ subscales general functioning (65 versus 75, p = 0.018), esthetics (94 versus 100, p = 0.037), satisfaction (75 versus 92, p = 0.042) and total score of the MHQ (83 versus 91, p = 0.044), as well as the SF-36 subscale physical functioning (95 versus 100, p = 0.028). In regression analyses the DASH, PRWE function and PRWE total were statistically significantly associated with flexion/extension arc of motion. Seven patients (10%) changed or left their occupation because of the DRF.

CONCLUSION

Non-osteoporotic patients had a considerably high prevalence of PA following DRFs, despite a relatively short follow-up time. Patients with longer radial length more often had PA. Irrespective of AO/OTA fracture type, patients with PA had diminished range of motion, but no altered grip strength measurements. Non-osteoporotic patients following DRFs perceived diminished general functioning and dissatisfaction, which was impacted by the diminished active range of motion. Pain or impaired general health status was not reported. The PRO MHQ might be a valuable evaluation tool in this patient group. Change of occupation following DRFs should receive attention in further research.

[Distal radius fracture of the adult : Diagnostics and therapy]

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

Image classification for Die-punch fracture of intermediate column of the distal radius

OBJECTIVE

The aim of the study was to analyze the imaging findings of Die-punch fracture of intermediate column of the distal radius, and to explore the clinical application value of image classification.

METHODS

The clinical data of 45 patients who were admitted to our hospital from May 2010 to October 2016 were analyzed retrospectively. All patients met the inclusion criteria for Die-punch fracture. X-ray and CT scan were performed to examine the fracture, and the results were assessed by two doctors in a double blind method. Finally, the image classification of Die-punch fracture was formulated.

RESULTS

According to the imaging features of Die-punch fracture, it was divided into four types: type I (dorsal type, 15 cases), type II (volar type, 8 cases), type III (splitting type, 10 cases), type IV (collapsed type, 12 cases). The accuracy rate of CT was 100% (45/45). The misclassification rate of X-ray was 15.6% (7/45) and the missed diagnosis rate was 11.1% (5/45).

CONCLUSIONS

CT examination could accurately diagnose Die-punch fracture and perform preoperative image classification.

[Biomechanics of distal radius fractures : Basics principles and GPS treatment strategy for locking plate osteosynthesis]

Fractures of the distal radius are most commonly caused by hyperextension injuries of the wrist. Tensile forces and force vectors, strength of impact, bone strength and soft tissue tension create individually different fracture patterns. Metaphyseal comminution, loss of cortical support, ligament avulsion and shear fragments are defining parameters for fracture instability. The dislocation of the articular fragment follows the force vectors of the extrinsic forearm muscles bridging the joint. The goal-plan-standardized (GPS) treatment strategy has proven to be helpful in choosing the ideal individual treatment. It is based on individual patient demands on wrist function and an analysis of fracture instability in computed tomography (CT) scans. The "goal" is a realistic expectation assessed by patient and surgeon. The "plan" includes a benefit-risk analysis and selection of an appropriate treatment modality. The "standardized treatment" of surgical and follow-up treatment is based on biomechanical knowledge. Locking plate osteosynthesis aims to neutralize dislocating force vectors and to allow early active mobility. Unidirectional instability can be indirectly neutralized by palmar locking plate systems. A multidirectional instability can be addressed by multiple plating following the column theory. Distal shear and avulsion fractures may require a fragment-specific osteosynthesis approach.