Management of Complex Distal Radius Fractures: Review of Treatment Principles and Select Surgical Techniques

Analyzing the reduction quality of the distal radioulnar joint after closed K-wire transfixation in a cadaver model: is supination or neutral position superior?

INTRODUCTION

Distal radioulnar joint (DRUJ) instabilities are challenging and their optimal treatment is controversial. In special cases or when reconstruction of the stabilizing triangular fibrocartilage complex (TFCC) fails, K-wire transfixation can be performed. However, no consensus has been reached regarding the rotational position of the forearm in which this should be done. Therefore, it was investigated whether anatomical reduction would best be achieved by transfixation in neutral position or supination of the forearm.

MATERIALS AND METHODS

Twelve cadaveric upper limbs were examined before dissection of the DRUJ stabilizing ligaments and after closed transfixation in both positions by C-arm cone-beam CT. Whether this was first done in neutral position or in supination was randomized. The change in the radioulnar ratio (RR) in percentage points (%points) was analyzed using Student's t-test. RR was used since it is a common and sensitive method to evaluate DRUJ reduction, expressing the ulnar head's position in the sigmoid notch as a length ratio.

RESULTS

The analysis showed an increased change in RR in neutral position with 5.4 ± 9.7%points compared to fixation in supination with 0.2 ± 16.1%points, yet this was not statistically significant (p = 0.404).

CONCLUSIONS

Neither position leads to a superior reduction in general. However, the result was slightly closer to the anatomical position in supination. Thus, transfixation of the DRUJ should be performed in the position in which reduction could best be achieved and based on these data, that tends to be in supination. Further studies are necessary to validate these findings and to identify influential factors.

Dorsal wrist plating for the management of intra-articular distal radius fractures

The aim of the study was to evaluate the results of Dorsal Wrist Plating in intra-articular distal radius fractures with a dorsal displacement. In this prospective study, a single surgeon treated 20 patients with a (partially) intra-articular distal radius fracture with a dorsal rim avulsion or a dorsal Barton's type fragment. They all underwent an open reduction and internal fixation by Dorsal Wrist Plating. A total of 17 patients had a follow-up period of at least 12 months (mean follow- up of 17 months) and these patients were included in the study. Both functional and radiological outcome parameters were measured. The total range of motion was 92 % of the contralateral side. The mean grip strength and key pinch were 24.6 kg and 6.9kg respectively compared to 29.5 kg and 7.4 kg on the non-operated side. The average Mayo Wrist Score was 89.7 (range 80-100) and the mean Disability of the Arm, Shoulder and Hand score was 4.5 (range 0-9.2). An articular step-off was only noted in 2 patients (1 and 2 mm respectively). Radial inclination was restored in all patients. Palmar tilt was anatomically restored in five patients. In all other patients, the palmar tilt was acceptably restored. There was no significant radial shortening in any of the patients. No infections, no tendon ruptures, no Complex Regional Pain Syndrome, or union problems were observed. Dorsal wrist plating seems to be a safe and reliable procedure in the treatment of intra-articular distal radius fractures with dorsal displacement.

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.

Using Trident distal radial locking plate to fix the fracture of distal radius volar rim

BACKGROUND

The volar locking plates have been widely used in a variety of distal radius fractures, but they still have several limitations when dealing with small fragments located around the watershed line with widely reported complications. The volar rim fragments play a critical role in radiocarpal joint stability and failing to secure the volar rim fragment usually results in carpal instability, subluxation, or even dislocation. This study investigates clinical outcomes in the use of a novel implant, the Trident distal radial (TDR) locking plate to treat distal radius fracture with the intermedium column edge (lunate fossa volar rim) fragment involvement.

METHODS

A retrospective study of 25 patients was conducted, all patients had intermedium column fractures with lunate fossa volar rim involvement and treat with the TDR between January 2016 and December 2019. The clinical assessment outcomes included VAS Pain, PRWE, and DASH scores. Objective measurements included ROM of the injured wrist and grip strength. Final radiographs were used to evaluate radial inclination, volar tilt, ulnar variance, and distal radioulnar joint instability. Secondary operations related to hardware complications were also recorded.

RESULTS

The outcome revealed that the mean VAS Pain Score was 1.3, mean DASH score was 10.5, and mean PRWE score was 9.3. Objective measurements revealed good ROM recovery and an 89% gripping strength recovery compared with contralateral hand. Radiographic measurements revealed good maintenance of volar tilt, radial inclination, and mean ulnar variance. There were no complications related to the implant and all fracture sites were union.

CONCLUSION

We believe that the TDR provided more stable fixation among distal radial fractures that predominantly involved the intermedial column and volar rim fragment, and allowing early rehabilitation. We could obtain excellent results in the wrist ROM, gripping power, and Pain Score (VAS).

Volar Lunate Facet Rim Fractures: K-I Classification and Technique

Background and Purpose  It is difficult to capture and safely support a small volar lunate facet (VLF) fragment and obtain sufficient initial fixation. The challenge in treating VLF rim fractures has resulted in various management options. The purpose of this study was to evaluate the clinical and radiological outcomes of a consecutive series of VLF rim fractures of the distal radius treated surgically and to report the Kondo-Imatani (K-I) classification of these fractures, using computed tomography (CT) images and surgical technique, which is termed the Plate buttress and Double tiered subchondral support (PD) technique. Patients and Methods  A retrospective review was conducted on 35 patients with VLF rim fractures that included postoperative clinical evaluations, CT images, and radiographs. Description of Technique  The PD technique to stabilize the VLF fragment with an anatomical and low-profile volar locking plate (VLP). Results  All fractures healed at the final follow-up; Mayo wrist performance score average was 81.7 points (45-100), and the quick disabilities of the arm, shoulder, and hand (quick-DASH) score average was 9.5 points (0-31.8), showing relatively good clinical results. Conclusion  VLF rim fragments are not amenable to standard VLP fixation. Unstable fixation may result in postoperative correction loss, aseptic necrosis, malunion, radiocarpal subluxation, and wrist dysfunction. This report described the K-I classification for VLF rim fractures of the distal radius and surgical technique, termed the PD technique, to stabilize the VLF rim fragment with an anatomical and low-profile VLP. Level of Evidence  This is a Level IV, case series study.

Comparison between Surgical and Conservative Treatment for Distal Radius Fractures in Patients over 65 Years

BACKGROUND

Fractures of the distal radius (DRF) are the most common orthopedic injuries, representing one of the typical fractures indicating underlying osteoporosis. The aim of the study was to compare conservative and surgical treatment, analyzing quality of life and clinical outcome in an over 65 years old population.

METHODS

Ninety one patients were divided into two groups: the ORIF group (39 patients) underwent surgery, and the conservative group (52 patients) was treated conservatively. The clinical and functional outcomes of all patients were evaluated using Short Form 36 (SF36), Modified Mayo Wrist Score (MMWS), Disability of the Arm Shoulder Hand (DASH), and Visual Analogue Scale (VAS). Range of motion at the joint was measured and compared with the contralateral healthy wrist.

RESULTS

No significant difference was found between the overall SF36 score, DASH score, MMWS, and VAS results. Role limitation was significantly better in the surgical group (p < 0.05), and complication incidence was significantly higher (p < 0.05) in the conservative group.

CONCLUSION

The results of this study conform to recent literature, suggesting that a surgical reconstruction of the radius articular surface in an elderly population provides no clear clinical advantage. Treatment decisions must arise from careful diagnoses of the fracture and communication with the patient.