Operative treatment of distal radius fractures

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model

PURPOSE

Distal radius (DR) fracture repair using the volar locked plating technique typically involves indirect fracture reduction, assessed using fluoroscopy, without direct visualization of the articular surface. This method of fracture repair may be guided by the rationale that volar radiocarpal ligament disruption may cause radiocarpal instability, although direct articular visualization may facilitate improved fracture reduction. This study investigated anatomical feasibility and articular surface visualization using volar ligament-sparing radiocarpal arthrotomy pertinent to DR fracture repair.

METHODS

Ten fresh-frozen cadaveric specimens of the upper extremity underwent volar arthrotomy via the standard flexor carpi radialis approach with partial longitudinal sectioning of the long radiolunate and partial transverse sectioning of the short radiolunate ligaments to visualize the articular surface of the DR. Following arthrotomy, the visible surface of the DR was analyzed using digital photography. The wrist was disarticulated, and the fully exposed articular surface was photographed. The visible area of the articular surface was quantified using digital imaging software by calculating the ratio of the surface area visualized using the arthrotomy to the total articular surface area.

RESULTS

The percentage of the articular surface area of the DR visualized using the volar arthrotomy was 76% ± 7.6% (range, 69%-90%), including both the scaphoid facet, lunate facet, and scapholunate ridge.

CONCLUSIONS

Volar radiocarpal arthrotomy allows clinically relevant visualization of the articular surface of the DR, including the scaphoid and lunate facets.

CLINICAL RELEVANCE

Radiocarpal arthrotomy may facilitate improved articular reduction during DR fracture repair via the volar approach.

Prospective Descriptive Study of Radiological and Functional Outcomes of Volar Barton’s Fracture Fixed by Volar Locked Plate

BACKGROUND: Volar Barton’s fracture is a shearing mechanism of injury that results in fracture and subluxation of distal end radius in which volar rim of the distal radius is displaced with hand and carpus. Open reduction and volar plate fixation ensure more stable change of displacement, preservation of reduction, and early mobilization. AIM: This study aims to assess the functional and radiological outcome results of volar Barton’s fracture treated by volar buttress plate using the demerit points system of Gartland and Werley. PATIENTS AND METHODS: This study is a prospective descriptive observational study on 32 patients who were treated with ORIF by volar buttress plate for isolated volar Barton’s fractures between February 2018 and June 2020 in Alkindy teaching hospital/Baghdad/Iraq. All volar Barton’s fracture cases satisfying the inclusion criteria which included patient over 18 years, isolated fracture, medically fit, and <5 days old injuries, while fractures extend to radius shaft, compound fractures, and associated with other injuries were excluded from the study. All fractures are fixed by volar locked plate followed up for 12 week’s duration for functional and radiological assessment using the Demerit points system of Gartland and Werley. RESULTS: Most cases were in the age group below 40 years, average age 38 years (range 19–64 years), male patient was 69%, side of involvement was right wrist in 75% of cases, falling on an outstretched hand account 50%, while roads traffic accidents in 37.5%, fall from a height in 6.25%, and direct trauma in 6.25%. The final sequel of the results was average volar tilt was 11.1°, the radial shortening average was 4 mm, the radial inclination average was 19.9°, and the ulnar variance was 0.3 mm. Functional outcomes depending on Gartland and Werley’s score were 50% as excellent results, 43.75% as good results, 6.25% as fair results, and no poor results in this study. CONCLUSIONS: Volar locking buttress plate provides fracture stability and early mobilization, therefore, recovery of daily live activity in a short time.

Introducing and Prospective Efficacy Comparison of an Innovative and Affordable Technique for the Treatment of Distal Radius Fractures

Background

There are different treatments as well as controversies surrounding the adequate treatment for Distal Radius Fractures (DRF). In the absence of enough evidence[HYPHEN]base data regarding clinical effectiveness of available treatments, cost should be considered as an essential factor in selecting the surgical technique for DRF treatment. The goal of this study is introducing an improved and modified pin[HYPHEN]and[HYPHEN]plaster (MP&P) technique as an affordable alternative for treatment of DRF. This study also assesses and compares the outcomes of DRF treatment by using the introduced method versus external fixation (EF) technique.

Methods

In this clinical cohort study, 98 patients presenting with closed DRF Types III or IV, randomly were classified into two modified P&P (50 patients) and EF (48 patients) groups and assessed for functional, clinical, radiographic and overall outcome at the time, 2, 10 and 22 months after surgery. They were also followed[HYPHEN]up for up to 3 years to determine the rate of complications.

Results

Eighty one percent of EF and 86% of MP&P group were female. The average ages in the EF and MP&P groups were 44.9 ± 12.4 and 46.1 ± 5.4, respectively. Around 70% of the patients in each group had a Type III fracture, and 30% had Type IV. The rate of complications was higher among EF group patients (seven major and seven minor complications) compared to the MP&P (only 4 minor complications), however the difference between two groups regarding the complications and treatment outcome were insignificant, except in extension ROM and the quick[HYPHEN]dash score (only in two and four months follow up visits) and also returning to work (only in two month follow up visit).

Conclusion

This study introduces a modified P&P technique that protects the transverse palmar curvature, prevents the collapse of the distal radius, and simplifies casting, thereby obviating a full arm cast and mitigating elbow stiffness in patient outcomes. This modified technique could be considered as a more cost[HYPHEN]conscious alternative to external fixation for patients with distal radius fractures.

Corrective osteotomy of distal radius malunion after IIIB open fracture: Palmar approach - Case report

BACKGROUND

Despite the fact that distal radius fractures are the most common, open fractures are relatively uncommon. The aim of this study is to present the case with severe malunion of extra-articular left distal radius after open fracture grade IIIB (Gustillo). The treatment was done with open correctuve osteotomy and ostosynthesis with volar low profile plate.

CASE PRESENTATION

A 32-years old man was admitted to our departement because of severely malunited left distal radius extra-articular metaphyseal fracture after treatment of an open fracture. He was primary treated in a Regional Hospital with irrigation, debridement, antimicrobial cover, and immediate skeletal management through fixation with Kirschner's wires. No external fixator was used. He developed volar metaphyseal angulation after loss of primary reduction of K-wires fixation; therefore it required corrective surgical treatment. Because of malunion, open corrective osteotomy and bone grafting of distal radius with volar plating were done. Follow-up 20 months after surgery show deformity correction of radial volar inclination, height, and restitution of distal radioulnar joint.

CONCLUSION

This case report offers an informative overview on this uncommon case of distal radius open fracture malunion treated successfully with volar approach corrective osteotomy. Corrective surgery is the primary therapy of choice in the this case. This method have shown to be safe and effective in treatment of distal radius malunion with volar angulation.

Dorsal or Volar Plate Fixation of the Distal Radius: Does the Complication Rate Help Us to Choose?

BACKGROUND

Internal fixation with plates is a reliable fixation technique for the treatment of distal radius fractures. An ongoing discussion exists whether volar or dorsal plating is the appropriate technique. In clinical practice, volar plate fixation is usually preferred because of the assumed lower complication frequency. However, recent studies with the newer generation low-profile dorsal plates reported lower complication rates.

PURPOSE

The aim of our study was to evaluate the differences in complication rates between volar and dorsal plate for the treatment of distal radius fractures in adult patients.

PATIENTS AND METHODS

A total of 214 patients with acute distal radius fractures were included in this retrospective study with a minimum 2 years of follow-up. In total, 123 patients were treated with dorsal plate fixation and 91 patients with volar plate fixation. Our primary study outcome was complication rate.

RESULTS

The overall risk for complications was 15.4% in the dorsal group and 14.3% in the volar group (p = 0.81). A total of 19 patients had implant removal due to complications: 11 patients in the dorsal group and 8 patients in the volar group (p = 0.97).

CONCLUSION

There is no preferred plate fixation technique based on these study results. In our opinion, decision for type of plate fixation should be based on fracture type and surgeon's experience with the specific approach and plate types.

LEVEL OF EVIDENCE

Therapeutic level III.

A prospective study of a modified pin-in-plaster technique for treatment of fractures of the distal radius

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.

Methods

Fifty-four patients with fractures of the distal radius were followed for one year post-operatively. Patients were excluded if they had type B fractures according to AO classification, multiple injuries or pathological fractures, and were treated more than seven days after injury. Range of movement and functional results were evaluated at three and six months and one and two years post-operatively. Radiographic parameters including radial inclination, tilt, and height, were measured pre- and post-operatively.

Results

The average radial tilt was 10.6° of volar flexion and radial height was 10.2 mm at the sixth month post-operatively. Three cases of pin tract infection were recorded, all of which were treated successfully with oral antibiotics. There were no cases of pin loosening. A total of 73 patients underwent surgery, and three cases of radial nerve irritation were recorded at the time of cast removal. All radial nerve palsies resolved at the six-month follow-up. There were no cases of median nerve compression or carpal tunnel syndrome, and no cases of tendon injury.

Conclusion

Our modified technique is effective to restore anatomic congruity and maintain reduction in fractures of the distal radius.

Cite this article: Bone Joint Res 2015;4:176–180

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review

Background Unstable distal radius fractures are a popular research subject. However, to appreciate the findings of studies that enrolled patients with unstable distal radius fractures, it should be clear how the authors defined an unstable distal radius fracture. Questions In what percentage of studies involving patients with unstable distal radius fractures did the authors define unstable distal radius fracture? What are the most common descriptions of an unstable distal radius fracture? And is there one preferred evidence-based definition for future authors? Methods A systematic search of literature was performed to identify any type of study with the term unstable distal radius fracture. We assessed whether a definition was provided and determined the level of evidence for the most common definitions. Results The search yielded 2,489 citations, of which 479 were included. In 149 studies, it was explicitly stated that patients with unstable distal radius fractures were enrolled. In 54% (81/149) of these studies, the authors defined an unstable distal radius fracture. Overall, we found 143 different definitions. The seven most common definitions were: displacement following adequate reduction; Lafontaine's definition; irreducibility; an AO type C2 fracture; a volarly displaced fracture; Poigenfürst's criteria; and Cooney's criteria. Only Lafontaine's definition originated from a clinical study (level IIIb). Conclusion In only half of the studies involving patients with an unstable distal radius fracture did the authors defined what they considered an unstable distal radius fracture. None of the definitions stood out as the preferred choice. A general consensus definition could help to standardize future research.

Displaced intra-articular fractures involving the volar rim of the distal radius

PURPOSE

To describe the features of displaced intra-articular fractures confined to the volar rim of the distal radius and compare outcomes after their operative fixation to complete intra-articular and extra-articular fractures treated with operative fixation.

METHODS

A total of 627 distal radius fractures were treated over a 6-year period. Twenty-eight patients had volar rim fractures (type 23-B3, as classified by the Orthopaedic Trauma Association [OTA]), all treated with operative reduction and fixation using a volar buttress plate. Clinical outcome information including radiographs, Short Form-36 health survey, and Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at regular postoperative intervals. Patients with volar rim fractures were compared with patients who sustained other types of operatively managed distal radius fractures (OTA types 23-A, 23-B1/B2, and 23-C).

RESULTS

The most common type of volar rim fracture consisted of a single large fragment (OTA 23-B3.2; 46%), followed by comminuted fractures (OTA 23-B3.3; 36%). Restoration of radiographic parameters was similar between groups except for an increased volar tilt in volar rim fractures compared with group 23-B1/B2. Active wrist and finger motion improved in all groups except for wrist extension, which was less in the 23-B1/B2 groups. The 23-B1/B2 group had the greatest pain and worst Short Form-36 scores. Disabilities of the Arm, Shoulder, and Hand questionnaire scores were similar and without differences between groups.

CONCLUSIONS

Our data suggest that patients with volar rim distal radius fractures can expect a rapid return to function with minimal risk for complications and have outcomes similar to other types of operatively treated distal radius fractures. Further investigation of type 23-B fractures (23-B1/B2) is warranted owing to evidence of diminished outcomes.

A new building block: costo-osteochondral graft for intra-articular incongruity after distal radius fracture

Even with the invention of locking plates, intra-articular fractures of distal radius with extreme comminution remain a challenge for orthopaedic surgeons. Osteochondral graft is a potential choice to reconstruct the articular defect. We report a patient who had a fracture of distal radius with costo-osteochondral graft for articular reconstruction which has not yet been described in the English literature. At nine-year follow-up, he was pain free and had full range of movement of the wrist. The authors suggest that costo-osteochondral graft could be an option with satisfactory result.

A new volar plate DiPhos-RM for fixation of distal radius fracture: preliminary report

We analyzed the efficiency of a new plate DiPhos-RM in CFR-PEEK [carbon-fiber-reinforced poly (etheretherketone)] for the volar fixation of distal radius fractures. The new plate's composition has the advantage of x-ray absolute transparency, therefore allowing to monitor the healing of the fracture. The desired combination of high strength and low rigidity is obtained through the use of the polymer composites CFR-PEEK. In this preliminary study (from March 2012 to June 2012), 10 cases of intra-articular distal radius fractures were treated with DiPhos-RM produced by Lima Corporate (Italy). The fractures were classified according to the AO classification, 4 fractures were type C1, 3 type C2, and 3 were A2. A preoperative computed tomography scan was carried out in all patients. One patient also underwent a postoperative computed tomography scan. Grip strength, range of motion, and DASH score were evaluated at follow-up. There were no cases of hardware failure. Specifically, no loss of position or alignment of fixed-angle locking screws or breakage of the plate were observed. Radiographic union was present at an average of 6 weeks (range, 5 to 8 wk). The overall preliminary experience with this new plate is favorable. The new plate is easy to apply and provides the surgeon dual options of fixed-angle or variable-angle screws. It was rigid enough to maintain the reduction also in AO type C articular fractures.

How placement affects force and contact pressure between a volar plate of the distal radius and the flexor pollicus longus tendon: a biomechanical investigation

Open reduction and internal fixation of a distal radius fracture can leave a volar plate in close proximity or touching the tendons of the wrist. This cadaveric study examines the how volar plate position changes contact pressure and force against the flexor pollicis longus (FPL) tendon in multiple wrist extension positions. This study suggests that moving the plate from an ideal position (distal edge at the watershed line) to a malposition (5 mm distal to the watershed line) significantly increased the force by 72.7% and contact pressure by 33.5% on the FPL. Multiple clinical case reports have described rupture of the flexor tendons associated with distally positioned plates or protruding screw heads, creating prominent or sharp edges. This study illustrates that in order to minimize contact pressure on the flexor tendons, plating distal to the watershed line should be avoided when possible.

Type C distal radial fractures treated with conventional AO plates: an easy and cost-saving solution in a locking plate era

PURPOSE

C-type distal radial fractures remain challenging fractures. Currently locking plates are very popular because of their length preserving, stability. A considerable drawback is the high cost. Since 2003 we have been using mini AO plates (2.7 mm) as an alternative. We analysed our results and performed a cost analysis.

METHODS

Retrospective analysis was performed of all patients operated upon between 2003 and 2008 for C type distal radius fractures. Reduction was achieved with mini AO plates, applied in a buttress fashion, with ligamentotaxis. Rehabilitation consisted of immediate mobilisation. Pre- and postoperative X-rays, operative results and patient charts were reviewed. Furthermore, we prospectively evaluated the functional results using VAS, DASH and Mayo wrist scores. Lastly, we assessed the implant costs and compared them to locking plates.

RESULTS

Thirty-four patients were treated with a mean age of 49 years. Mean radial shortening improved 2 mm; dorsal and radial angulation improved 23 and 4°, respectively. At consolidation (eight weeks) the average radial shortening was 0.75 mm, a volar angulation of 3°, and 21° of radial angulation. Functional results were excellent, demonstrated by a mean VAS score less than 1, a DASH score of 12 and a Mayo wrist score of 87. Compared to locking plates, there was an overall reduction in material costs of 15,300 Euro.

CONCLUSIONS

Our technique has excellent biomechanical stability, enabling immediate functional rehabilitation, good anatomical and functional outcome with significantly lower costs.

Therapeutic effects of volar anatomical plates versus locking plates for volar Barton's fractures

Volar Barton's fractures are uncommon and extremely unstable. Various surgical techniques have been reported in the literature, but open reduction and internal fixation using a volar plate system is currently advocated for the treatment of volar Barton's fractures. The purpose of this study was to compare the therapeutic effects of volar anatomical plates and volar locking plates in the treatment of volar Barton's fractures. A retrospective comparative study was performed of 33 patients with volar Barton's fractures treated between October 2005 and November 2010. One group was treated with a volar anatomical plate (n=16) and the other with volar locking plates (n=17). Radiological and functional results were compared between groups. All patients' fractures healed. Mean union time in the anatomical plate group was 12.93 weeks and in the locking plate group was 11.76 weeks (P>.05). No significant difference was noted between the 2 groups in terms of radial inclination, volar tilt, and ulnar variance. No significant differences were noted between the 2 groups in Disabilities of the Arm, Shoulder and Hand scores; however, according to Sarmiento's modification of the Gartland and Werley score, the excellent and good rate was 75% in the anatomic plate group and 94.1% in the locking plate group, which was statistically significant (P<.05). Anatomical and locking plates give satisfactory results in the treatment of volar Barton's fractures, but locking plates may provide better wrist function recovery.

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience

BACKGROUND

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction.

RESULTS

Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10 days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction.

DISCUSSION

The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.

Variable-angle locking screw volar plating of distal radius fractures

Surgical treatment options for distal radius fractures are many and commonly involve volar locked plating. More recently, newer volar locking plates have been introduced to the market that allow the placement of independent distal subchondral variable-angle locking screws to better achieve targeted fracture fixation. This article reviews this new technology and presents the authors' experience with the Aptus (Medartis, Kennett Square, Pennsylvania) variable-angle volar locking plates.