Carpal Alignment: A New Method for Assessment

Validation of radiographic assessment of radiocarpal (mal)alignment in a normal population

We measured radiocarpal alignment in 150 standard lateral radiographs of normal wrists. In 84% of the cases, the lines of the long axis of the capitate and radius did not cross within the carpus.

[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.

Concomitant ligament injuries can be left untreated during surgery of distal radial fractures

Instability of the distal radioulnar joint and scapholunate dissociation may cause pain, functional impairment and subsequent arthrosis. There is no consensus about whether these injuries should be treated acutely in patients undergoing surgery for distal radial fractures. We conducted a prospective cohort study to determine whether concomitant distal radioulnar joint instability or scapholunate dissociation negatively influence patient-related outcomes in these patients. The primary outcome was the patient-reported wrist/hand evaluation at 6 and 12 months after surgery. Out of 62 patients, 58% and 27% had intraoperative distal radioulnar joint instability and scapholunate dissociation, respectively. No significant differences were found in patient-reported scores at follow-up between patients with stable and unstable distal radioulnar joints, nor between patients with and without scapholunate dissociation. Sixty-three per cent of patients with an unstable distal radioulnar joint during surgery were stable on retesting after 6 months. Our study suggests that a wait-and-see policy in these patients therefore seems reasonable.Level of evidence: III.

Comparison of extra-articular radiographic parameters of distal radius fractures on plain radiographs and CT scans

The aim of this study was to compare extra-articular radiographic parameters of distal radial fractures measured on plain radiographs and CT scans. Two researchers independently measured four extra-articular radiographic parameters (dorsal tilt, carpal alignment, radial inclination and ulnar variance) on both radiographs and CT scans in 85 patients. Inter-observer reliability for both techniques was assessed, along with the agreement between CT scans and radiographs using the intraclass correlation coefficient and Bland-Altman plots. The results showed that dorsal tilt, carpal alignment, radial inclination and ulnar variance can be measured reliably on both radiographs and CT scans. At a patient level, carpal alignment, radial inclination and ulnar variance CT scan measurements are an acceptable alternative to plain radiograph measurements in the vast majority of patients. In contrast, dorsal tilt CT scan measurements are not comparable with radiographs in 40% of the cases. Therefore, caution should be taken in measuring dorsal tilt on CT scans.

Radiography of the Distal Radius

Imaging of the distal radius is of paramount importance in diagnosing injuries, indicating patients for operative or nonoperative treatment, and appropriately following patients for associated injuries and complications. Plain radiographs and fluoroscopy are the dominant imaging modalities in all settings because they are readily available and provide valuable information about the osseous structures and any instrumentation. Computed tomography can offer more information about implant placement and the level of comminution of the articular surfaces but is more expensive and exposes patients to higher doses of radiation. Magnetic resonance imaging is less commonly used but is useful for occult fractures and other associated injuries. Ultrasonography is gaining popularity in evaluating implant placement, especially regarding tendon impingement and subsequent tendon injury.

Scaphoid alignment in dorsally displaced distal radial fracture: a radiographic study

We aimed to establish if fracture reduction will correct scapholunate angle in dorsally displaced distal radial fractures and to identify the relationship with other measures of distal radial position and carpal alignment. Radiographs of 131 patients with a distal radial fracture and of 50 patients with normal radiographs were reviewed. We measured the scapholunate, radiolunate, capitolunate and metacarporadial angles on the lateral views. Linear regression modelling showed that all parameters measured were significantly associated with scapholunate angle on the first radiograph following injury. Scapholunate angle increased following distal radial fracture. Reduction of the fracture improved scapholunate angle, and this was most strongly related to change in dorsal tilt. We conclude that scaphoid flexion is likely to compensate for the dorsal tilt of the lunate as an attempt to counter its dorsal tilt, and to stabilize the wrist to maintain hand function.Level of evidence: IV.

Plate Fixation for Unstable Displaced Distal Radius Fractures in Children

Background  Distal radius fractures in children are normally treated by plaster immobilization. For displaced unstable distal radius fractures, closed reduction and Kirschner wire (k-wire) fixation can be performed. Disadvantages of k-wire fixation are the need for postoperative plaster treatment for several weeks, which may induce stiffness, and the risks of complications such as tendon irritation and pin-track infections. More invasive volar plate fixation is less popular, although this allows for direct mobilization and enhances anatomical reduction. Purpose  To present the functional outcomes of pediatric patients treated with volar plate fixation for unstable displaced distal radius fractures. Patients and Methods  A retrospective cohort study of all consecutive pediatric patients between September 2010 and July 2017 was performed. A total of 26 patients with a median age of 12.5 years were included. The primary objective was functional outcome determined by the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary objectives were range of motion, grip strength, radiological parameters, complications, and incidence of plate removal. Results  Median PRWE score was 3 after a median follow-up of 29 months. Range of motion and grip strength did not differ significantly between the injured and uninjured wrists. No wound infections were found. Plate removal was performed in 15 patients (58%). Conclusion  Volar plate fixation for unstable displaced distal radius fractures in children provides good functional and radiological outcomes with minor complications. Level of evidence  This is a Level IV cohort study.