PALMAR PLATING FOR AO/ASIF C3.2 FRACTURES OF THE DISTAL RADIUS WITH ARTHROSCOPICALLY ASSISTED REDUCTION

Wrist arthroscopy in the management of articular distal radius fractures

INTRODUCTION

Fractures of the distal radius account for 15% of all fractures. The use of arthroscopy is increasingly popular in the last years, with the goal to achieve a better anatomical reduction of the articular fragments.

SOURCES OF DATA

We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'wrist', 'distal radial fracture', 'distal radius fracture' and 'arthroscopy'. Twenty-eight studies were identified. The quality of the studies was assessed using the Coleman Methodological Score.

AREAS OF AGREEMENT

Arthroscopy allows to detect intra-articular, ligamentous and triangular fibrocartilage complex injuries in an acute setting with a better prognosis. Arthroscopy increases the quality of the intra-articular reduction compared to fluoroscopy.

AREAS OF CONTROVERSY

The main limitation of the selected studies is the short follow-up: the average follow-up in 20 studies was 12 months, a period long enough to assess functional outcomes, but not to assess the occurrence of post-traumatic degenerative changes and their impact on function. Better stratification of the fracture population is needed.

GROWING POINTS

The shorter recovery time and the low incidence of adverse effects are the main advantages of this new technology.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is need to perform randomized controlled trials reporting on the use of volar locking plates as, at the present time, they are the standard management for these fractures. In addition, the different pattern of fracture should be better classified to manage the patients who will benefit after the management.

External Fixator for Maintaining Reduction Before Volar Plating: A Simple Treatment Method for Association of Osteosynthesis Type C3 Distal Radius Fracture

Volar plating for Association of Osteosynthesis type C3 distal radius fractures involves more time and more radiation exposure because it is extremely difficult to simultaneously maintain the reduction and restore the congruity of the articular surface. The authors present a technique of maintaining the acceptable reduction by using an external fixator followed by open volar plating for restoring articular congruity. A consecutive series of 96 Association of Osteosynthesis type C3 distal radius fractures treated with the technique were retrospectively reviewed between January 2004 and December 2012. The technique makes surgery simpler and more effective, and reduces radiation exposure.

Arthroscopic reduction of comminuted intra-articular distal radius fractures with diaphyseal-metaphyseal comminution

PURPOSE

In the setting of severely comminuted diaphyseal-metaphyseal fractures of the distal radius, arthroscopic reduction of the joint surface is difficult and often results in shortening and collapse. Yet, several authors have shown the benefits of arthroscopy in articular distal radius fractures. We present a method that safely allows a combination of arthroscopic reduction and rigid fixation and describe the outcomes in a small group of patients.

METHODS

Four consecutive patients with severely comminuted diaphyseal-metaphyseal articular fractures of the distal radius were treated using the stable reference fragment technique. For all cases, we used an extra-long volar locking plate applied to the diaphysis of the radius. Preoperative computed tomography scanning was used to identify the largest articular fragment. This reference fragment was reduced and stabilized with locking pegs or screws to the volar plate under fluoroscopic guidance. The articular reduction continued arthroscopically, using the reference fragment as a guide. Once the articular reduction was complete, the comminuted metaphysis was addressed and secured to the plate.

RESULTS

All patients achieved excellent clinical and radiological results. Flexion-extension averaged 124° and pronation-supination averaged 174°. One patient showed minor signs of radiocarpal osteoarthritis on radiographs at 3 years.

CONCLUSIONS

By securing the reference fragment before addressing the metaphyseal comminution, a stable platform was created. Thus, intra-articular reduction was achieved while maintaining extra-articular alignment. Although the results were excellent, the number of cases was small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: is there an advantage of palmar plates in the long term?

Background

Current surgical approaches to the distal radius include dorsal and palmar plate fixation. While palmar plates have gained widespread popularity, few reports have provided data on long term clinical outcomes in comparison. This paper reports the result of a randomised clinical study comparing dorsal Pi plates and palmar, angle-stable plates for treatment of comminuted, intraarticular fractures of the distal radius over the course of twelve months.

Methods

42 patients with unilateral, intraarticular fractures of the distal radius were included and randomised to 2 groups, 22 were treated with a palmar plate, 20 received a dorsal Pi-plate. Results were evaluated after 6 weeks, 3, 6 and 12 months postoperatively focussing on functional recovery as well as radiological results.

Results

The palmar plate group demonstrated significantly better results regarding range of motion and grip strength over the course of 12 months. While a comparable increase in function was observed in both groups, the better results from the early postoperative period in the palmar plate group prevailed over the whole course. Radiological results showed a significantly increased palmar tilt and carpal sag in dorsal plates, with other radiological parameters being comparable. Pain levels were decreased in dorsal plates after hardware removal and failed to show significant differences after 12 months. However, complications such as tendon ruptures were more frequent in the dorsal plate group.

Conclusions

Functional advantage of palmar plates gained within the first 6 weeks prevails over the course of a year. Both groups demonstrate further gradual increase of function after 6 months, although dorsal plates did not catch up completely. Improved early postoperative function seems to be the cornerstone for the best possible results. Patients with dorsal plates benefit from hardware removal more than palmar plates in terms of reduction of pain levels. The advantage of palmar plates is a faster functional recovery with lower complication rates. This is especially important in the elderly population. Radiological results did not show a superiority of palmar plates over dorsal plates.

Locking palmar plate fixation for dorsally displaced fractures of the distal radius: a preliminary report

We reviewed a series of 62 consecutive patients with dorsally displaced fractures of the distal radius, including 20 extra-articular and 42 intra-articular fractures. All patients were treated with palmar locking plate systems at our institution between 2002 and 2006. After a minimum follow-up time of 12 weeks, the fractures had healed with satisfactory radiographic and functional results. According to the demerit point system of Gartland and Werley, 35 patients were rated excellent, 26 good, and one fair. In the good and fair groups, the demerit points were almost all for ulnar wrist pain. Our results suggest that palmar locking plate systems enable early functional mobilization with good reproducible radiographic and clinical outcomes. Since nine out of 62 patients had residual ulnar wrist pain at the final follow-up evaluation, further investigation of the pathogenesis of ulnar wrist pain is necessary to obtain better functional outcomes.

Distal radius fracture arthroscopic intraarticular displacement measurement after open reduction and internal fixation from a volar approach

BACKGROUND

The purpose of this study was to assess articular surface reduction arthroscopically after volar locked-plate fixation of distal radius fractures (DRFs) via fluoroscopyguided open reduction/internal fixation. We also aimed to develop preoperative radiographic criteria to help assist in determining which DRFs may need arthroscopic evaluation.

METHODS

A total of 31 consecutive patients with DRF were prospectively enrolled. Posteroanterior (PA) and lateral radiographs as well as axial, coronal, and sagittal CT scans were obtained just after attempted reduction of the DRF. The widest articular displacement at the radiocarpal joint surface of the distal radius (preopD) was then measured using a digital radiography imaging system. The DRF was reduced under fluoroscopy, and a volar locked plate was applied. The degree of residual articular displacement was then measured arthroscopically, and the maximum displacement (postopD) was measured with a calibrated probe.

RESULTS

Of the 31 patients, 7 had an arthroscopically assessed maximum postopD of > or = 2 mm after internal fixation. The correlation coefficients between each preopD and postopD of all radiographs and CTs were statistically significant. The cutoff values were 0.5 mm for PA radiographs, 2.10 mm for lateral radiographs, 2.15 mm for axial CT scans, 3.15 mm for coronal CT scans, and 1.20 mm for sagittal CT scans. All cutoff values for PA and lateral radiographs and for axial, coronal, and sagittal CT scans were unsuitable as screening criteria for arthroscopic reduction of DRF because of their low sensitivities and specificities. The cutoff value of the new preopD (the sum of the preopDs determined by lateral radiography and coronal CT scan) was 5.80 mm, and its sensitivity and specificity were 100% and 83.3%, respectively.

CONCLUSIONS

Because a new preopD cutoff value of 5.80 mm is a good indicator for residual articular displacement after internal fixation of >2 mm, it is also a good indicator for the need for arthroscopic evaluation after internal fixation.

Complex fractures of the distal radius treated with angular stability plates

Complex fractures of the distal radius are articular lesions and comminuted at the level of the epiphysis and metaphysis. Their treatment is difficult and in most cases surgical. Of all the different osteosynthesis methods available, internal fixation with plate and screws is the most commonly used. In particular, angular stability plates are superior in terms of rigidity and stability to conventional volar and dorsal plates. DVR plate has these mechanical characteristics, and its low profile has reduced frictions with surrounding soft tissues. For these reasons, this device implanted through a single volar approach, can stabilize the majority of volarly and dorsally displaced unstable distal radius fractures. In this study, 48 patients, affected by complex fractures of the distal radius treated with DVR volar plates, were assessed by the Mayo modified wrist score, the Italian version of the disability of the arm, shoulder and hand. The satisfactory results observed confirm the efficacy of this device.

A randomised clinical study comparing palmar and dorsal fixed-angle plates for the internal fixation of AO C-type fractures of the distal radius in the elderly

Current surgical treatments for distal radial fractures include dorsal and palmar plate fixation. We report results of a randomised study comparing these methods for AO C1-3 fractures. The emphasis was placed on the early postoperative functional recovery within the first 6 months as this interval is of decisive importance for elderly patients. Thirty patients with unilateral AO C1-3 fractures were enroled, 15 were treated with a palmar plate and 15 received a dorsal Pi-plate. Results were assessed 6 weeks, 3 months and 6 months postoperatively focusing on functional recovery. The palmar plate group demonstrated significantly better results in range of motion, grip strength and pain.

Arthroscopic assessment of intra-articular distal radius fractures after open reduction and internal fixation from a volar approach

PURPOSE

The volar approach with locked plating is a common treatment for intra-articular distal radius fractures. The purpose of this study was to arthroscopically assess the articular surface after internal fixation through the volar approach as a means to evaluate the ability of an extra-articular reduction to anatomically restore the joint surface.

METHODS

Sixteen patients with intra-articular distal radius fractures were prospectively enrolled. A volar approach and internal fixation using a locked volar plate was performed. Using a visual analog scale (VAS), the fracture reduction was clinically graded on the quality of reduction of the visible metaphyseal fracture lines, fluoroscopically graded, and arthroscopic graded. Maximum step and gap deformity were recorded from arthroscopy and plain radiograph.

RESULTS

The mean VAS score for the fracture reduction based on extra-articular fracture lines was 7.4. The mean VAS score for the fluoroscopic reduction was 8.2. The mean VAS score for the arthroscopic reduction was 6.4. The arthroscopic VAS score was significantly lower than the VAS score for fluoroscopy but was not significantly different than the VAS score for metaphyseal reduction. Mean arthroscopic measurement of maximum step and gap deformity were 1 mm and 2 mm, respectively. Mean postoperative radiographic maximum step and gap deformity were both less than 1 mm. The arthroscopic step and gap deformities were significantly greater than the radiographic deformities.

CONCLUSIONS

A volar approach, indirect reduction, and locked plate fixation is a useful technique in restoring articular congruity after distal radius fracture. The number of fracture lines and presence of step and gap deformity can be adequately assessed using clinical and fluoroscopic assessment. However, the magnitude of step and gap deformity may be underestimated.

Current concepts in wrist arthroscopy

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction-internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.