Dorsal Bridge Plating versus External Fixation for Distal Radius Fractures

Systematic review: dorsal bridge plating in distal radius fractures

PURPOSE

Distal radius fractures are the most common upper limb fractures in adults (up to 18% of all fractures in the Emergency Department). Conservative management is possible for the majority, the preferred surgical technique being volar plate fixation. Dorsal bridge plating (DBP) is an alternative method of treatment for complex fractures. DBP acts as an internal fixator and can be used in patients needing early rehabilitation. This systematic review assesses the demographics, functional and radiological outcomes and complications of using DBP in patients with distal radius fractures compared to volar plate fixation.

METHODS

A literature search of PubMed, Cochrane, EMBASE and Google Scholar was performed according to PRISMA guidelines. Seven hundred and sixty-one articles were found; 11 articles met the inclusion criteria. Cadaveric studies and case studies of less than five patients were excluded. Primary outcome measures were functional and radiological outcomes. Complications were recorded as secondary outcomes.

RESULTS

Three hundred and ninety-four patients were included in the study with an average age of 54.8 years (53.9% male and 46.1% female). Weighted mean follow-up was 55.2 weeks; the mean time to plate removal was 17.3 weeks with a mean DASH score of 25.7. The weighted range of movement was 46.9° flexion, 48.8° extension, 68.4° pronation and 67.5° supination. The radiological parameters show satisfactory outcomes with a mean radial height of 10mm, volar tilt of 3.1°, ulnar variance of 0.5mm and radial inclination of 18.8°. The complication rate was 11.4%. Digital stiffness was the most common complication but improved if tenolysis was performed at plate removal.

CONCLUSIONS

DBP is a good alternative to volar plating for complex distal radius fractures. The functional outcomes showed a slight loss of range of movement, whereas the radiological outcomes were within recommended limits. A significant disadvantage of the plate is the need for further surgical removal.

The Role of External Fixation in the Treatment of Distal Radius Fractures

There are numerous internal fixation (IF) options available for distal radius fractures (DRFs). The choice of fixation method depends on factors such as fracture morphology, soft tissue integrity, the patient's clinical status, and the surgeon's training. While volar plate fixation has become the primary approach for addressing these fractures, alternative IF methods like K-wire fixation, fragment-specific fixation, and dorsal bridge plating continue to be effective. Despite the versatility of IF, there are certain clinical situations where prompt and conclusive management through open reduction and internal fixation (ORIF) is not suitable. These instances include the treatment of polytraumatized patients, individuals with compromised soft tissues, or those medically unstable to tolerate lengthy anesthesia. In such cases, proficiency in closed reduction and external fixation (EF) proves invaluable. Being able to identify these clinical scenarios and comprehend the efficacy and safety of EF in addressing DRFs is valuable for any surgeon handling such injuries.

Bridge Plate Distraction for Complex Distal Radius Fractures: A Cohort Study and Systematic Review of the Literature

Background  Dorsal bridge plating (DP) of the distal radius is used as a definitive method of stabilization in complex fracture configurations and polytrauma patients. Questions/Purposes  This review aims to summarize the current understanding of DP and evaluate surgical outcomes. Methods  Four databases were searched following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO. Papers presenting outcome or complication data for DP were included. These were reviewed using the National Institutes of Health Quality Assessment and Methodological Index for Non-Randomised Studies tools. Results were collated and compared to a local cohort of DP patients. Results  Literature review identified 416 patients with a pooled complication rate of 17% requiring additional intervention. The most prevalent complications were infection/wound healing issues, arthrosis, and hardware failure. Average range of motion was flexion 46.5 degrees, extension 50.7 degrees, ulnar deviation 21.4 degrees, radial deviation 17.3 degrees, pronation 75.8 degrees, and supination 72.9 degrees. On average, DP removal occurred at 3.8 months. Quality assessment showed varied results. There were 19 cases in our local cohort. Ten displayed similar results to the systematic review in terms of range of motion and radiographic parameters. Higher QuickDASH scores and complication rates were noted. Local DP showed earlier plate removal at 2.9 months compared to previous studies. Conclusion  DP is a valid and useful technique for treating complex distal radius fractures. It displays a lower risk of infection and pain compared to external fixation which is commonly used to treat similar injuries. Patients can recover well following treatment both in function and range of motion. Further high-quality studies are required to fully evaluate the technique.

Distal Radius Fracture Therapy Utilization Following Traditional Open Reduction and Internal Fixation and Dorsal Bridge Plate Fixation

Background Many distal radius fractures are treated with a volar locking plate, but a minority undergo dorsal bridge plate fixation. This study's primary purpose was to compare therapy utilization following distal radius fractures treated with traditional open reduction and internal fixation (ORIF) versus dorsal bridge plate fixation. Secondary outcomes were time to first and last therapy visits and therapy costs. Methods Patients over 18 years old who underwent distal radius ORIF between January 2021 and August 2022 at a single regional orthopedic practice were identified. Patients who underwent post-operative hardware removal were retrospectively reviewed to identify dorsal bridge plate fixation patients. This resulted in "traditional ORIF" and "dorsal bridge plate" groups. Therapy visit number, cost, and payor (insurance type including Medicare, private insurance, worker's compensation, automobile policy, and private pay) were collected. Results In total, 1,376 patients met the inclusion criteria. Of these, 713 of the 1,283 (55.6%) patients in the traditional ORIF group and 25 of the 44 patients (56.8%) in the dorsal bridge plate group attended therapy at our institution. Traditional ORIF and dorsal bridge plate patients averaged 12.6(±10) and 24(±18.7) therapy visits in the one-year following ORIF, respectively. Time to last therapy visit was 90.9(±60) and 175.2(±72.1) days in the traditional ORIF and dorsal bridge plate groups, respectively. Total therapy cost was $1,219(±$1,314) and $2,015(±$1,828) in the traditional ORIF and dorsal bridge plate groups with similar out-of-pocket costs. Conclusions Dorsal bridge plate fixation patients attended a greater number of therapy sessions, had a longer time from surgery until therapy end, and had a higher therapy total cost relative to traditional ORIF, but both groups had similar patient out-of-pocket therapy costs.

The Role of External Fixation in the Management of Upper Extremity Fractures

External fixation is a powerful tool in the armamentarium of the active orthopaedic surgeon. The upper extremity, however, poses unique challenges in the techniques of external fixation because of the smaller soft-tissue envelope and the proximity of neurovascular structures, which may be entrapped in fracture fragments or traversing in line with pin trajectories. This review article summarizes the indications, techniques, clinical outcomes, and complications of external fixation of the upper extremity in the setting of proximal humerus, humeral shaft, distal humerus, elbow, forearm, and distal radius fractures.

COMBINED PLATE VERSUS EXTERNAL FIXATION FOR DISTAL RADIUS FRACTURES

Objectives

This study aimed to compare the functional and radiological results of patients who had intra-articular comminuted distal radius fractures and were operated on with external fixation percutaneous pinning or the volar-dorsal combined plate osteosynthesis.

Methods

In this study, 49 patients operated on and followed up for the comminuted distal radius fractures between May 2015 and January 2019 were retrospectively evaluated. The surgical outcomes of the patients, who were operated on with combined dorsal-volar plate osteosynthesis or external fixation percutaneous pinning, were compared in this study. Functional and radiological scores were evaluated and analyzed statistically.

Results

There was no statistical difference between external fixation and volar-dorsal combined plate groups regarding the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Visual Analog Scale (VAS), the Mayo scoring system, range of motion, and grip strength values.

Discussion

Although the combined volar-dorsal plate osteosynthesis technique had a longer operation time and a more complicated surgical procedure, the combined volar-dorsal plate osteosynthesis had lower complication rates and permitted early mobilization. The combined volar-dorsal plate osteosynthesis could be an alternative to external fixation percutaneous pinning. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Radiographic Outcomes following K-Wire Augmentation of Dorsal Spanning Plate Fixation for Intra-Articular Fractures of the Distal Radius

Background  Restoration of articular surface alignment is critical in treating intra-articular distal radius fractures. Dorsal spanning plate fixation functions as an internal distraction mechanism and can be advantageous in the setting of highly comminuted fracture patterns, polytrauma patients, and patients with radiocarpal instability. The addition of K-wires to support articular surface reduction potentially augments fracture repair stability. Questions/Purposes  We examined the radiographic outcomes and maintenance of reduction in patients with comminuted intra-articular distal radius fractures treated with K-wire fixation of articular fragments followed by dorsal spanning plate application. Patients and Methods  We reviewed 35 consecutive patients with complex intra-articular distal radius fractures treated with dorsal spanning plate and K-wire fixation between April 2016 and October 2019. AO classification was recorded: B1 (3), B3 (2), C2 (2), C3 (28). A two-tailed paired t -test was used to compare findings immediately post-dorsal spanning plate surgery and at final follow-up after dorsal spanning plate removal. Results  Mean patient age was 43.3 years (19-78 years). Mean follow-up was 7.8 months (SD 4.3 months) from surgery and 2.5 months from pin removal (SD 2.6 months). All patients achieved radiographic union. Radial height (mean interval change (MIC) 0.2 mm, SD 2.2, p  = 0.63), articular step-off (MIC 0.1 mm, SD 0.6 mm, p  = 0.88), and radial inclination (MIC -1.1 degrees, SD 3.7 degrees, p  = 0.10) did not change from post-surgery to final follow-up. Ulnar variance (MIC -0.9 mm, SD 2.0 mm, p  = 0.02) and volar tilt (MIC -1.5 degrees, SD 4.4 degrees, p  = 0.05) were found to have decreased. Conclusion  Dorsal spanning plate augmented with K-wire fixation for comminuted intra-articular distal radius fractures in polytrauma patients allows for immediate weightbearing and maintains articular surface alignment at radiographic union and may provide better articular restoration than treatment with dorsal spanning plate alone. Level of Evidence  This is a Level IV , therapeutic study.

Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures

INTRODUCTION

Distal radius fractures are the most frequent upper limb injuries encountered by orthopedic surgeons. Surgical treatment of distal radius fractures is preserved for unstable and displaced fractures. A randomized controlled trial was conducted to compare the radiological and functional outcomes of bridge plating (BP) to external fixation (EF) in comminuted intra-articular distal radius fractures.

METHODS

Sixty patients with distal radius fractures were eligible for treatment by means of ligamentotaxis using either a dorsal bridge plate (30 patients) or an external fixator (30 patients) with or without supplementary Kirschner wires (K-wires). Radiological evaluation was done using the radial inclination angle, radial length, and the volar tilt. Clinical evaluation was performed using ranges of wrist motion, grip strength, Visual Analogue Scale (VAS), and a validated Arabic version of the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire RESULTS: Patients were followed up for 12 months. No significant difference was found in terms of radiographic parameters or ranges of wrist motion. At 3-months follow-up, bridge plating group had stronger grip strength, lower Disability of the Arm, Shoulder, and Hand scores, and lower Visual Analogue Scale. However, both groups had similar functional outcomes at last follow-up. External fixation group had a higher rate of postoperative complications.

CONCLUSION

In comparison to external fixation, bridge plating may provide earlier functional recovery with lower complication rates. However, no functional or radiological superiority were demonstrated at 12-months follow-up.

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE

Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome.

METHODS

The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°.

RESULTS

A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups.

CONCLUSION

According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

Early Retrieval of Spanning Plates Used for Fixation of Complex Fractures of the Distal Radius

Background  Spanning plates are being increasingly used for the treatment of complex fractures of the distal radius. The traditional recommendation is to leave the hardware in place for at least 12 weeks. Questions/Purpose  This study assesses the comparative outcomes of spanning plates removed at or before 10 weeks. We hypothesized that acceptable healing and functional outcomes can be achieved with earlier hardware removal to allow for earlier range of motion, rehabilitation, and return to function. Patients and Methods  All patients treated for a comminuted, intra-articular distal radius fracture with a temporary spanning plate were identified. Outcomes of bridge plates removed before 10 weeks were compared with plates removed after 12 weeks. Twenty patients in the short duration cohort were compared with 40 patients in the long duration cohort. Results  All fractures healed and there were 10 complications (4 short duration, 6 long duration) and 2 reoperations (1 short duration, 1 long duration) in the study population. There were no significant differences in final Quick-DASH scores (27.4 short duration, 20.9 long duration) or radiographic alignment. Mean values for wrist extension and ulnar deviation were significantly worse in the long duration cohort, although these differences are of unclear clinical significance. Conclusion  It may be safe to remove spanning bridge plates earlier than what is traditionally recommended. Plate removal at or before 10 weeks did not detract from healing or radiographic alignment. Prospective investigations assessing the optimal duration of fixation for this technique are needed. Level of Evidence  This is a Level IV study.

Temporary spanning plate wrist fixation of complex distal radius fractures: a systematic review of 353 patients

PURPOSE

Temporary spanning plate fixation of the wrist has been described as an alternative treatment method for complex distal radius fractures (DRfs). This systematic review aims to gain insight on clinical and radiological outcomes of this technique currently published in literature.

METHODS

A comprehensive literature search of Pubmed, Embase, CENTRAL and CINAHL databases was conducted on November 5th 2020. All studies reporting on complications, functional, patient-rated and radiological outcomes of temporary spanning plate wrist fixation of DRFs in adult patients were included.

RESULTS

Two prospective and eight retrospective cohort studies were included encompassing 353 patients with of 357 DRFs. The overall mean age was 53 years (range 19-95 years). Overall mean follow-up ranged from 6 months to 8.8 years. The union rate was 99.4%. Plate removal was performed on average 4.5 months after initial operation (range 1.1-28.9 months). The most frequently reported complication was implant failure with an incidence of 3.1%. Mean flexion/extension, pronation/supination and radial/ulnar inclination arc averaged 96.6°, 151.5° and 36.5°, respectively. Grip strength averaged 79.7% of the contralateral side. Mean DASH and PRWE scores were 22.9 and 16 points, respectively. Radiological indices were all within the acceptable limits.

CONCLUSIONS

Temporary spanning plate wrist fixation is a safe method for the treatment of complex DRFs. This technique can exploit the advantages of temporary wrist immobilization without the disadvantages of external fixation. With these aspects in mind, the spanning plate can serve as a valuable tool in the treatment of complex intra-articular DRFs.