Screw prominences related to palmar locking plating of distal radius

Cause of Extensor Pollicis Longus Ruptures After Distal Radius Fracture Fixation Using a Volar Plate

BACKGROUND

This research sought to analyze a cohort of patients with extensor pollicis longus (EPL) ruptures after volar locked plating of a distal radius fracture (DRF) to characterize the incidence of ruptures that are unlikely to be related to dorsal screw prominence.

METHODS

This is a retrospective, observational, descriptive cohort study of adults with operative fixation of a closed DRF and an EPL rupture between 2002 and 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. The cohort consisted of 66% women with an average age of 57.5 years. Median follow-up was 14.5 months.

RESULTS

The incidence of EPL rupture was 0.4% (18/4768). The average time from DRF and DRF fixation to EPL rupture was 3.7 and 3.4 months, respectively. Based on the operative record, in 2 of the 18 patients (11%), the rupture was directly attributable to prominent hardware; however, in 4 of the 18 patients (22%), the rupture was not related to prominent hardware, and the cause was indeterminate in 12 patients (67%). Radiologic analysis of those in the indeterminate group demonstrated that 5 of the 12 patients had screws that had a high probability of being prominent.

CONCLUSIONS

The incidence of EPL rupture after volar plating of DRF is between 0% and 1% and usually occurs about 3 months after fixation. Approximately 50% of EPL ruptures are attributable to prominent dorsal screws. Although screw prominence is an important cause of EPL rupture, it is not the sole cause of rupture.

Avoiding screw overlength using dorsal horizon view in palmar plate osteosynthesis of distal radius fractures: a prospective randomized trial

INTRODUCTION

Distal radius fractures are the most commonly reported fractures in adults. Treatment has changed in recent years to open reduction and palmar plate fixation. Penetration of the dorsal screw, however, is a well-known complication. Intraoperative anteroposterior and lateral radiographs lack the exact assessment of dorsal screw length and intraoperative measurement is therefore very likely to be inaccurate in a comminuted dorsal radial cortex. Secondary extensor tendon ruptures are reported in up to 6% following palmar plate fixation of distal radius fracture.

MATERIALS AND METHODS

A prospective randomized trial was performed to assess the value of the dorsal horizon view. The hypothesis was that the traditional anteroposterior and lateral fluoroscopic views aided by an axial view of the dorsal part of the radius, named dorsal horizon view, could prevent dorsal screw penetration. A total of 40 patients, 6 male and 34 female, were included in the study. Standardized anteroposterior and lateral radiographs were performed intraoperatively in 18 patients (standard group = control group). In 22 patients, intraoperative axial fluoroscopic views (dorsal horizon view) were added to anteroposterior and lateral images (horizon group). Numbers of intraoperative screw changes due to the two different radiological examinations were analyzed as well as exact postoperative CT guided measurement of screw length.

RESULTS

The total numbers of intraoperative screw changes were significantly higher in the horizon group. Forty-two screws were changed in 15 patients in the horizon group while only 8 screws were changed in 3 patients in the standard group. Postoperative computed tomography scans showed significantly lower total numbers of perforating screws in the horizon group with 11 screws in 22 patients compared to 20 screws in 18 patients in the standard group (p = 0.02).

CONCLUSIONS

Based on the results of this study, the dorsal horizon view improves the assessment of the correct screw length and should routinely be used in palmar plate osteosynthesis of distal radius fractures. Since screw protrusion cannot be absolutely ruled out using the dorsal horizon view, monocortical drilling or screw downsizing is still mandatory.

TRIAL REGISTRATION

This clinical trial was not registered because it was a clinical examination without any experimental techniques.

LEVEL OF EVIDENCE: 2

Is ultrasound superior to fluoroscopy in distal radius volar fixation?

OBJECTIVES

In volar distal radius fixation, conventional and additional fluoroscopic views could not be sufficient to assess dorsal screw penetration. Ultrasound (US) has been suggested as a technique to improve this assessment. The objective was to determine the agreement between these two explorations in a clinical study. Quantify time-consuming of intraoperative US was the secondary objective.

MATERIAL AND METHODS

A prospective descriptive study was performed. Thirty patients with a surgical distal radius fracture were treated with volar fixation by five consultant surgeons in a level I Trauma Centre. Final intraoperative fluoroscopic views: AP, lateral, 20º tilted lateral and Dorsal Tangential views (DTV) were performed assessing for dorsal screw protrusion. Then, ultrasound was performed to reassess dorsal cortex integrity. Those protruding screws were registered and changed.

RESULTS

A total of 153 screws were examined. Four protruding screws were observed with no multiple protruding screws in the same fixation. Intraoperative ultrasound detected a dorsal screw protrusion in one fixation, assessed as correct by radiological projections. Almost perfect agreement was found between DTV and US examination k = 0.83 (p < 0.001). The mean surgical time was 63 ± 20.3 min while the addition of the ultrasound, supposed an average of 4 ± 1 min more.

CONCLUSION

Ultrasound did not show a clinically significant improvement in the assessment dorsal screw penetration in distal radius fixation. A high agreement was observed between US and the described fluoroscopic views. The addition of intraoperative US was a non-significant time-consuming procedure.

Comparison of ultrasound and dorsal tangential view for dorsal cortex screw penetration in volar plating of the distal radius

We compared the accuracy of the fluoroscopic dorsal tangential view (DTV) and an ultrasound (US) examination in detecting dorsal screw penetration during volar distal radius plating. In six fresh cadaveric distal radii, seven periarticular locking screws in two rows for each plate were inserted according to the measured length using a depth gauge and then replaced with another that was 1 and 2 mm longer, respectively. The actual protruded length of each screw was determined using computed tomography (CT) images. The accuracy of US and DTV measurements was determined using the intraclass correlation coefficient (ICC), as both measurements were compared with CT measurements. The ICC of US and DTV was 0.96 and 0.75, respectively, for all screws. After excluding the data for proximal-row screws, the ICC of US remained unchanged at 0.96, and that of DTV improved to 0.86. The ICC of US was significantly higher than that of DTV (p < 0.01). US had a 100% detection rate for screw protrusion of more than 1.0 mm. US examination showed excellent consistency with CT measurements and its accuracy was not affected by screw location. US might thus be a practical tool for detecting dorsal cortex screw penetration during volar distal radius plating.

Diagnostic ultrasound of tendon injuries in the setting of distal radius fractures

OBJECTIVE

Describe tendon injuries and their structural causes seen on ultrasound in wrists with distal radius fractures and estimate the accuracy of ultrasound and its impact on clinical management.

MATERIALS AND METHODS

Ultrasounds of 226 wrists (221 patients) with distal radius fractures were retrospectively reviewed. Ultrasound findings of tendon injuries and their structural causes were correlated with surgery and clinical outcome. Accuracy and inter- and intra-observer reproducibilities were calculated.

RESULTS

Twenty-five wrists were treated non-operatively while 201 underwent surgery. Ultrasound demonstrated hardware contact with flexor pollicis longus (FPL) in 76 wrists, extensor pollicis longus (EPL) in 21, and other tendons in 94. Ultrasound identified tendon ruptures in 23 wrists (13 EPL/8 FPL/2 extensor indicis proprius (EIP)), most of which were surgically confirmed. Among 12 wrists with confirmed EPL ruptures, distal radius fracture had been treated with volar plating in 6 and non-operatively in 6, and ultrasound showed osseous irregularity at the rupture site in 8. All FPL ruptures occurred in wrists with volar plating. Ultrasound findings were concordant with subsequent clinical management in most. In 2, ultrasound findings led to the decision to remove hardware despite lack of symptoms. Ultrasound had sensitivity/specificity/accuracy of 88/99/98% for identifying a specific tendon as ruptured and 88/87/88% for tendon abnormalities in general. Inter- and intra-observer reproducibilities were excellent (kappa = 0.85 ~ 1.0).

CONCLUSION

Certain wrist tendons, particularly EPL and FPL, are vulnerable after distal radius fractures. Ultrasound is accurate and useful for detecting tendon injury and sources of tendon irritation and can guide clinical management.

Optimal screw length in volar locking plate osteosynthesis for distal radius fractures: a systematic review

BACKGROUND

Fractures of the distal radius represent the most common fracture of the upper limb, and can be managed surgically with volar locking plate osteosynthesis (VLPO). Uncertainty remains regarding the optimal length of the distal locking screws. The aim of this study was to determine the optimal VLPO screw length which provided adequate stability while minimizing complications.

METHODS

A systematic review of relevant literature published within Cochrane, PubMed, MEDLINE and Embase, including studies up to April 2020, was performed using the Preferred Reporting Items for Systemic Reviews and Meta-analysis (PRISMA) guidelines. Studies were included if they investigated distal radius fracture fixation with VLPO, screw lengths, complications, and associated imaging.

RESULTS

Search results identified 664 relevant studies, of which 14 studies examining 926 radii were included for review. Synthesis revealed that unicortical locking fixation with screws ~75% the depth of the radius, or 2 mm short of the dorsal cortex, provided equivalent stability to bicortical fixation. The lunate may be used as a proxy to determine radial depth at each quartile column. Inadvertent screw protrusion can be assessed by taking four images intra-operatively; anteroposterior (AP), lateral, 45° supinated and dorsal tangential views (DTVs). Radial shaft screws can have up to 2 mm prominence with no clinical significance.

CONCLUSION

Unicortical locking fixation at least 75% the depth of the distal radius provides equivalent stability to bicortical fixation in extra-articular fractures with lower complication rates. Imaging should be used to confirm that penetration of the dorsal cortex has not occurred.

Comparison of a ceiling-mounted 3D flat panel detector vs. conventional intraoperative 2D fluoroscopy in plate osteosynthesis of distal radius fractures with volar locking plate systems

Objectives

To compare intraoperative 3D fluoroscopy with a ceiling-mounted flat panel detector in plate osteosynthesis of distal radius fractures (AO/OTA 2R3C1.2) with volar locking plate systems to conventional 2D fluoroscopy for detection of insufficient fracture reduction, plate misplacement and protruding screws.

Methods

Using a common volar approach on 12 cadaver forearms, total intraarticular distal radius fractures were induced, manually reduced and internally fixated with a 2.4 distal radius locking compression plate. 2D (anterior-posterior and lateral) and 3D (rotational) fluoroscopic images were taken as well as computed tomographies. Fluoroscopic images, Cone Beam CT (CBCT), 360° rotating sequences (so called “Movies”) and CT scans were co-evaluated by a specialist orthopedic surgeon and a specialist radiologist regarding quality of fracture reduction, position of plate, position of the three distal locking screws and position of the three diaphyseal screws. In reference to gold standard CT, sensitivity and specifity were analyzed.

Results

“Movie” showed highest sensitivity for detection of insufficient fracture reduction (88%). Sensitivity for detection of incorrect position of plate was 100% for CBCT and 90% for “Movie.” For intraarticular position of screws, 2D fluoroscopy and CBCT showed highest sensitivity and specifity (100 and 91%, respectively). Regarding detection of only marginal intraarticular position of screws, sensitivity and specifity of 2D fluoroscopy reached 100% (CBCT: 100 and 83%). “Movie” showed highest sensitivity for detection of overlapping position of screws (100%). When it comes to specifity, CBCT achieved 100%. Regarding detection of only marginal overlapping position of screws, 2D fluoroscopy and “Movie” showed highest sensitivity (100%). CBCT achieved highest specifity (100%).

Conclusion

As for assessment of quality of fracture reduction and detection of incorrect position of plate as well as overlapping position of the three diaphyseal screws CBCT and “Movie” are comparable to CT – especially when combined. Particularly sensitivity is high compared to standard 2D fluoroscopy.

3D virtual pre-operative planning may reduce the incidence of dorsal screw penetration in volar plating of intra-articular distal radius fractures

Purpose

To evaluate the effect of three-dimensional virtual pre-operative planning (3DVP) on the incidence of dorsal screw penetration after volar plating of distal radius fractures.

Methods

A cross-sectional diagnostic imaging study was performed. Twenty out of 50 patients were randomly selected from our index prospective cohort (IPC): a prior study evaluating dorsal tangential views (DTVs) in reducing dorsal screw penetration in internal fixation of intra-articular distal radius fractures using post-operative CT scans to quantify screw protrusion. Pre-operative CTs from this cohort were now used for 3DVP by three experienced orthopaedic trauma surgeons (supplementary video). 3DVP was compared with the corresponding post-operative CT for assessing screw lengths and incidence of dorsal penetration. The Wilcoxon Signed Ranks test was used to compare screw lengths and the Fishers’ exact for incidence of penetration.

Results

Three surgeons performed 3DVP for 20 distal radius fractures and virtually applied 60 volar plates and 273 screws. Median screw length was shorter in the 3DVP when compared to IPC: 18 mm (range, 12–22) versus 20 mm (range, 14–26) (p < 0.001). The number of penetrating screws was 5% (13/273 screws) in the 3DVP group compared to 11% (10/91 screws) in the IPC (p = 0.047). Corresponding to a reduction in incidence of at least one dorsally penetrating screw in 40% of patients in the IPC group, to 18% in the 3DVP group (p = 0.069).

Conclusion

Three-Dimensional Virtual Pre-Operative Planning (3DVP) may reduce the incidence of dorsally penetrating screws in patients treated with volar plating for intra-articular distal radius fractures.

Level of evidence

II, diagnostic imaging study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01800-2.

Transmural supraspinatus tendon tear caused by suture anchor tip 19-month postacromioclavicular joint stabilisation

Rotator cuff injuries present rarely in paediatric patients due to the tendon strength at this age. There are reports of ruptures caused by either irritation of the lateral clavicle or acromioclavicular (AC) joint in fractures or after usage of hook plates. In this case report, we present a patient with an acute complete supraspinatus rupture caused by a suture anchor tip from a previously performed AC joint stabilisation. After the diagnosis of a new complete supraspinatus, the causative prominent suture anchor was removed, and the tendon subsequently repaired. This case highlights the close anatomic relation of the AC joint and the rotator cuff, which is imperative to adequately address in injuries to this anatomical location.

[Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]

BACKGROUND

Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists.

PATIENTS AND METHODS

We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured.

RESULTS

All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol.

CONCLUSION

Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.

A Prospective Cohort Study on Accuracy of Dorsal Tangential Views to Avoid Screw Penetration With Volar Plating of Distal Radius Fractures

OBJECTIVE

To assess diagnostic performance of dorsal tangential views (DTVs) to detect dorsal screw protrusion in clinical practice.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Fifty consecutive patients undergoing volar plating for 50 distal radius fractures were prospectively included.

INTERVENTION

Fluoroscopic DTVs were routinely obtained, and screw revision was documented. Multiplanar reconstructions of postoperative CTs allowed for detection and quantification of dorsal screw penetration using reproducible measuring techniques.

MAIN OUTCOME MEASUREMENTS

Diagnostic performance (sensitivity, negative predictive value, positive predictive value, and accuracy) of DTV.

RESULTS

Intraoperatively, in 16 of 50 patients (32%), screws were revised based on DTV, with 13 of 218 screws (6.0%) being revised due to dorsal prominence. One screw was changed because DTV showed it was in the distal radioulnar joint. Postoperatively, in 10 patients (20%), the computed tomography revealed 12 additional screws penetrating ≥1 mm with an average of 1.8 mm (range 1.0-4.5 mm). DTV had a sensitivity of 52%, a negative predictive value of 95%, and accuracy of 95%. No ≥1-mm protruding screw remained in the third compartment.

CONCLUSIONS

In one-third of our patients, the incidence of protruding screws that can cause iatrogenic extensor tendon rupture was reduced by obtaining additional DTVs. Although DTV reduces the incidence of dorsal screw penetration considerably, this study reveals limited sensitivity. Therefore, one should keep in mind that dorsal screw penetration may go unnoticed on DTVs, and proper surgical technique remains paramount of DTV.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis of dorsal screw penetration after volar plating of a distal radial fracture

Aims

The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging.

Methods

A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard.

Results

In order to detect dorsal screw penetration, the sensitivity of dorsal tangential views was 39% with a negative predictive value (NPV) of 91% and an accuracy of 91%; compared with a sensitivity of 25% for 3D fluoroscopy with a NPV of 93% and an accuracy of 93%. On the postoperative CT scans, we found penetrating screws in: 1) 40% of patients in the 2D fluoroscopy group; 2) in 32% of those in the 2D fluoroscopy group with AP, lateral, and dorsal tangential views; and 3) in 25% of patients in the 3D fluoroscopy group. In all three groups, the second compartment was prone to penetration, while the postoperative incidence decreased when more advanced imaging was used. There were no penetrating screws in the third compartment (extensor pollicis longus groove) in the 3D fluoroscopy groups, and one in the dorsal tangential views group.

Conclusion

Advanced intraoperative imaging helps to identify screws which have penetrated the dorsal compartments of the wrist. However, based on diagnostic performance characteristics, one cannot conclude that 3D fluoroscopy outperforms dorsal tangential views when used for this purpose. Dorsal tangential views are sufficiently accurate to detect dorsal screw penetration, and arguably more efficacious than 3D fluoroscopy. Cite this article: Bone Joint J 2020;102-B(7):874–880.

Evaluation of Flexor Pollicis Longus Tendon Rupture after Treatment of Distal Radius Fracture with the Volar Plate

Background  The aim of this study is to evaluate the frequency of flexor pollicis longus (FPL) tendon rupture and factors leading to this rupture during the follow-up of patients who underwent volar plate fixation because of distal radius fracture. Patients and Methods  A total of 109 distal radius fractures of 102 patients treated with volar plate fixation and periodically followed up for at least 1 year between January 2013 and May 2018 were evaluated. Fractures were categorized according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) Fracture-Dislocation Classification and Soong's grading was used for classifying volar plate position. All patients operated were inquired retrospectively in terms of flexor tendon rupture. Results  Gender distribution revealed 45 females and 57 males. Mean age was 47.9 (range: 17-88) years. Mean period of follow-up was 27 months. Distribution of fractures in accordance with the AO/OTA distal radius classification was 6, 8, 7, 12, 24, 33, 11, and 8 patients with types A2, A3, B1, B2, B3, C1, C2, and C3, respectively. When volar plate positions were analyzed with Soong's classification, it revealed that 79 (72.4%), 23 (21.1%), and 7 (6.5%) plates were grade 0, 1, and 2, respectively. In total, evaluating the three patients with FPL rupture, it revealed that the volar plate was positioned distally during fixation because the fracture line had advanced to the distal of the watershed line, the distal portion of the plate had lost complete connection with the bone, and at this portion, it was observed that the pronator quadratus muscle was not covering the plate entirely (Soong's classification grade 2). Patients did not have additional flexor tendon injury. Conclusion  FPL tendon rupture is a rare but serious complication of volar plate fixation performed for distal radius fractures. We believe that appropriate choice of implant and careful surgical technique, along with the close follow-up of patients, with Soong's classification grade-2 volar positions would help in preventing this complication. Level of Evidence  This is a Level 3a, differential diagnosis/symptom prevalence study.

Predicting epiphyseal screw length in anterior plating of distal radial fractures

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

The Effect of Radial Shaft Dorsal Screw Prominence in Volar Locking Plate Fixation of Distal Radius Fractures

Background: The purpose of this study was to determine whether prominent radial shaft screws in volar locked plating of distal radius fractures increase the risk of tendon irritation, tendon rupture, or hardware removal. Methods: Patients who underwent volar locked plating of distal radius fractures from April 2002 to March 2016 with at least 6 months of follow-up were evaluated. Variables examined included demographics, extensor tendon irritation, extensor tendon rupture, and hardware removal. The most prominent cortical screws on postoperative lateral radiographs were identified and measured from the dorsal cortex of the radial shaft to the tip of the screw. Results: In all, 261 distal radius fractures in 255 patients were identified. Thirty-nine patients (14.9%) underwent subsequent hardware removal at a mean 15.8 ± 18.6 months. Nine patients (3.45%) were found to have clinically significant extensor tendon irritation including one patient (0.38%) with extensor tendon rupture. The average screw was 1.48 mm proud of the dorsal radial cortex. In all, 22.6% of screws were greater than 2 mm proud. Comparing patients who underwent hardware removal with those who did not, there was no statistically significant difference in mean screw prominence or proportion of patients with screws greater than 2 mm. There was no statistically significant difference between shaft screw prominence and extensor tendon irritation. Conclusions: The effect of dorsal screw prominence of radial shaft screws is not significant. This study does not support the downsizing of prominent screws 2 mm or less.

Volar Plating: Imaging Modalities for the Detection of Screw Penetration

Background  Volar plating for distal radius fractures exposes the risk of extensor tendon rupture, mechanical problems, and osteoarthritis due to protruding screws. Purposes  The purpose of this review was to identify the best intraoperative diagnostic imaging modality to identify dorsal and intra-articular protruding screws in volar plating for distal radius fractures. Methods  The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed for this review. In vitro and in vivo studies that analyzed the reliability, efficacy, and/or accuracy of intraoperatively available imaging modalities for the detection of dorsal or intra-articular screw protrusion after volar plating for distal radius fractures were included. Results  Described additional imaging modalities are additional fluoroscopic views (pronated views, dorsal tangential view [DTV], radial groove view [RGV], and carpal shoot through [CST] view), three-dimensional (3D) and rotational fluoroscopies, and ultrasound (US). For detection of dorsal screw penetration, additional fluoroscopic views show better results than conventional views. Based on small (pilot) studies, US seems to be promising. For intra-articular screw placement, 3D or 360 degrees fluoroscopy shows better result than conventional views. Conclusion  Based on this systematic review, the authors recommend the use of at least one of the following additional imaging modalities to prevent dorsal protruding screws: CST view, DTV, or RGV. Tilt views are recommended for intra-articular assessment. Of all additional fluoroscopic views, the DTV is most studied and proves to be practical and time efficient, with higher efficacy, accuracy, and reliability compared with conventional views. Level of Evidence  The level of evidence is Level III.

MRI Study on the Distance between the Distal Radius and the Flexor and Extensor Tendons: Is There Any Room for Error/Hardware?

Purpose  This study aims to quantify the distances between the cortex of the distal radius and flexor and extensor tendons. Methods  We analyzed 50 magnetic resonance images (MRI) of intact wrist without pathology. The distances between the volar cortex and the flexor pollicis longs (FPL), index flexor digitorum profunduns (FDPi), flexor digitorum profundus (FDP), and flexor digitorum superficialis (FDS) were measured at the level of the watershed line and 3- and 6-mm proximal to this level. The distances between the dorsal cortex and the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor pollicis longus (EPL), extensor indicis proprius (EIP), and the extensor digitorum communis (EDC) were measured at the level of Lister's tubercle and 5-mm distal to this level. Analysis was descriptive. Results  At the watershed line, the FPL, FDPi, FDP, and FDS were located at an average of 3.1, 2.4, 3.6, and 5.1 mm, respectively, volar to the volar cortex. The distances of the FDP and FDS increased at 3-mm proximal to the watershed line and increased for all four tendons at 6-mm proximal to the watershed line. Dorsally, at Listers' tubercle the ECRL, ECRB, EPL, EIP, and EDC were identified at an average of 0.7, 0.5, 0.5, 2.6, and 3.2 mm, respectively, dorsal to the dorsal cortex of the distal radius. At 5-mm more distal, these tendons were located on average 1.2, 1.0, 0.7, 1.9, and 1.8 mm, respectively, dorsal to the dorsal cortex. Conclusion  On the volar side, on average there is enough room for a volar plate when staying proximal to the watershed line. On the dorsal side, there is virtually no room for protruding screws as physical anatomical space is limited to a maximum of 0.7 mm from cortex to the closest tendon (the FDP), with screw increments being 2 mm. Level of Evidence  This is a Level II Study.

Virtual guidance versus virtual implant planning system in the treatment of distal radius fractures

BACKGROUND

A virtual guidance framework is used to assist the conventional method of virtual implant planning system (VIPS). The study null hypothesis was that its screw placement accuracy is equal to that of conventional VIPS.

METHODS

In 34 distal radius sawbone models, 3D implant planning was performed. A camera attached to the surgical drill was used to support screw positioning. Differences of angles/tip distances between planned and placed screws were identified in intraoperative cone beam Computer tomography (CT) and compared with already existing data from 22 patients treated by conventional VIPS.

RESULTS

The virtual guidance group showed tip distances of 1.02 ± 0.56 mm, azimuth of 3.69° ± 4.34°, and inclination of 1.75° ± 1.37°, whereas the VIPS group showed tip distances of 2.23 ± 0.99 mm (P < 0.001), azimuth of 23.17° ± 33.50° (P < 0.001), and inclination angle of 4.18° ± 6.29° (P = 0.001).

CONCLUSIONS

The results reveal that using a guidance framework leads to a higher accuracy in screw placement compared with the conventional VIPS itself.

Ultrasonography or direct radiography? A comparison of two techniques to detect dorsal screw penetration after volar plate fixation

Background

Complications related to extensor tendons have begun to increase with the use of volar plates in the treatment of distal radius fractures. In this study, we aimed to compare four-plane radiography and ultrasonography in the evaluation of dorsal cortex screw penetration following volar plate fixation.

Methods

We recruited 47 patients (33 males, 14 females, mean age 37.4 years; range 18–58 years). To evaluate dorsal screw penetration in all patients, we performed radiographs at 45° pronation, 45° supination and obtained dorsal tangential graphs at maximum palmar flexion, and a wrist lateral radiograph. Wrist ultrasonography was performed in all patients.

Results

Dorsal screw penetration was detected in 12 of the 47 patients undergoing VLP application. While there was > 2 mm screw penetration in seven patients, there was < 2 mm screw penetration in five patients. On four-plane radiographs, screw penetration > 2 mm was detected in seven patients and screw penetration < 2 mm was detected in two patients. On four-plane radiography, dorsal screw penetration was not detected in three out of five patients, who were shown to have < 2 mm screw penetration by ultrasonography. In addition to perioperative four-plane radiographs are also required to detect dorsal cortex penetration in patients undergoing VLP due to distal radius fracture. However, the detection of screw penetrations < 2 mm is more likely with ultrasonography compared to four-plane radiography.

Conclusion

We recommend that dorsal cortex screw penetration should be evaluated with perioperative ultrasonography.

Trial registration

Research Registry, researchregistry3344, Registered 10 January 2017

Comparison of ultrasound and dorsal horizon radiographic view for the detection of dorsal screw penetration

OBJECTIVE

The aim of this study was to compare the efficiency of dorsal tangential fluoroscopy and ultrasonography in detecting dorsal screw penetration in distal radius volar locking plate applications.

METHODS

Ten cadaveric forearms were operated. The distal four screws were protruded 0, 1 and 2 mm into each of the second, third and fourth dorsal compartments of distal radius. Dorsal horizon views were taken using fluoroscopy. Each radiographic image was evaluated by two orthopedic surgeons who are blinded to procedure. Sonographic evaluations were performed by an orthopedic surgeon blinded to the procedure. Both dorsal horizon view and ultrasonography assessments were noted by the evaluators whether the tip of the screw penetrated or not the dorsal cortex for each compartment.

RESULTS

No significant difference was observed on correct detection of 0 mm, 1 mm and 2 mm screw penetrations at second and third compartments. In the fourth compartment, there was no difference with 0 mm and 2 mm penetrations but correct detection accuracy of 1 mm screw penetration was 87% in ultrasonography group and 71% in dorsal horizon view group.

CONCLUSIONS

The accuracy of ultrasonography on 1 mm penetration at the fourth compartment is better than dorsal horizon view. However, dorsal horizon view and ultrasonography accuracy is similar for the other compartments and penetration levels. Ultrasonography is a reliable and effective procedure for detection of dorsal screw penetrations.

LEVEL OF EVIDENCE

Level III, Diagnostic study.

Comparing Dorsal Tangential and Lateral Views of the Wrist for Detecting Dorsal Screw Penetration after Volar Plating of Distal Radius Fractures

BACKGROUND

The dorsal tangential (DT) view has been shown to improve the detection of dorsal screw perforation during volar distal radius fracture fixation. Here we performed a cadaveric imaging survey study to evaluate if the DT view was uniformly beneficial for all screws.

METHODS

Standardized placement of fixed-angle volar distal radius plates was performed on two cadavers. Fluoroscopic images depicting variable screw perforation of each of the four screw holes on the plate were generated. A 46-image survey was distributed at a large academic medical center. Respondents were asked to answer if the screw was perforating through the dorsal cortex in each image. Statistical analysis was performed using Fisher's exact test. A p value < .05 was considered significant.

RESULTS

The DT view offered a significantly more reliable determination of dorsal screw penetration than traditional lateral imaging for the radial-most screw at all degrees of perforation and the middle two screws at 2 mm of perforation. Residents and attendings had more accurate screw readings overall using the DT view.

CONCLUSIONS

The DT view is superior to traditional lateral imaging in the detection of small amounts of dorsal perforation of the radial-most three screws of a fixed-angle volar plate.

Results of geriatric distal radius fractures treated by intramedullary fixation

INTRODUCTION

Distal radius fracture are common injuries but no gold standard for their therapy exists. The aim of this study was to evaluate the quality of fracture care in distal radius fractures using an intramedullary implant (Targon DR interlocking nail). The nail had been developed to minimize the surgical exposure, increase fixation strength, to prevent tendon irritations and to allow for a fast return to activity.

PATIENTS AND METHODS

Prospective study reports the result of 43 patients with an age over 70 years (range 70-91 years) treated by closed reduction and intramedullary fixation. Inclusion criteria were displaced unilateral isolated AO A or C type fractures. The Targon DR interlocking nail was used for all patients. The minimum follow up was 12 months.

RESULTS

All fractures united within 2 months. At one-year follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial abduction of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and a grip strength of 91.5 ± 4.3% compared to the contralateral wrist. Pain score measured by a Visual Analogue Scale scored 0.0 ± 0.0 at rest and in activity 0.3 ± 0.3. The mean Castaing Score was good (1.06 ± 0.30) and the Gartland & Werley Score was excellent (1.50 ± 0.57). The mean radial shortening was 0.2 ± 0.1 mm and radial inclination was 3.1 ± 1.1° (range +15° to 0°). No deep soft-tissue or chronic osseous infections were observed. One patient developed a carpal tunnel syndrome. Paraesthesia or dysaesthesia of the superficial radial nerve was registered in seven patients and fully recovered in four patients. There were two cases of single screw loosening. We also found two cases of screw overlength and consecutive contact with the ulnar head, one patient underwent implant removal. Another patient developed CRPS (2.3%). We did not observe any case of hardware failure, tendon irritation or tendon rupture.

CONCLUSION

In geriatric patients intramedullary interlocking nailing of displaced extraarticular or intraarticular distal radius fracture with the Targon DR nail represents a viable treatment option and alternative to the use of volar interlocking plating in terms of fracture reduction, maintenance of reduction and functional outcome.

Assessment of penetration of dorsal screws after fixation of the distal radius using ultrasound: cadaveric study

INTRODUCTION

Volar locking plates are used to treat unstable and displaced fractures of the distal radius. Potential advantages of stable anatomical reduction (eg early mobilisation) can be limited by penetration of dorsal screws, leading to synovitis and potential rupture of extensor tendons. Despite intraoperative imaging, penetration of dorsal screws continues to be a problem in volar plating of the distal radius. Ultrasound is a well recognised, readily available, diagnostic tool used to assess soft-tissue impingement by orthopaedic hardware. In this cadaveric study, we wished to ascertain the sensitivity and specificity of ultrasound for identification of protrusion of dorsal screws after volar plating of the distal radius.

METHODS

Four adult, unpaired phenol-embalmed cadaveric distal radii were used. A VariAx™ Distal Radius Volar Locking Plate system (Stryker, Kalamazoo, MI, USA) was employed for instrumented fixation. A portable SIUI CTS 900 ultrasound machine (Providian Medical, Eastlake, OH, USA) was used to image the dorsal cortex to ascertain screw penetration.

RESULTS

Specificity and sensitivity of ultrasound for detection of screw protrusion through the dorsal cortex was 100%.

CONCLUSIONS

Ultrasound was found to be a safe and accurate method for assessment of dorsal-screw penetration through the dorsal cortex of the radius after volar plating of the distal radius. It also aids diagnosis of associated tendon disorders (eg tenosynovitis) that might cause pain and limit wrist function.

Design and evaluation of a portable intra-operative unified-planning-and-guidance framework applied to distal radius fracture surgery

PURPOSE

During a standard fracture reduction and fixation procedure of the distal radius, only fluoroscopic images are available for planning of the screw placement and monitoring of the drill bit trajectory. Our prototype intra-operative framework integrates planning and drill guidance for a simplified and improved planning transfer.

METHODS

Guidance information is extracted using a video camera mounted onto a surgical drill. Real-time feedback of the drill bit position is provided using an augmented view of the planning X-rays. We evaluate the accuracy of the placed screws on plastic bones and on healthy and fractured forearm specimens. We also investigate the difference in accuracy between guided screw placement versus freehand. Moreover, the accuracy of the real-time position feedback of the drill bit is evaluated.

RESULTS

A total of 166 screws were placed. On 37 plastic bones, our obtained accuracy was [Formula: see text] mm, [Formula: see text] and [Formula: see text] in tip position and orientation (azimuth and elevation), respectively. On the three healthy forearm specimens, our obtained accuracy was [Formula: see text] mm, [Formula: see text] and [Formula: see text]. On the two fractured specimens, we attained: [Formula: see text] mm, [Formula: see text] and [Formula: see text]. When screw plans were applied freehand (without our guidance system), the achieved accuracy was [Formula: see text] mm, [Formula: see text], while when they were transferred under guidance, we obtained [Formula: see text] mm, [Formula: see text].

CONCLUSIONS

Our results show that our framework is expected to increase the accuracy in screw positioning and to improve robustness w.r.t. freehand placement.

Using self-drilling screws in volar plate osteosynthesis for distal radius fractures: a feasibility study

Background

Symptomatic extensor tendon irritation is a frequent complication in volar plate osteosynthesis of distal radius fractures. It is typically caused by dorsal screw protrusion and overdrilling of the dorsal cortex. The use of self-drilling locking screws (SDLS) could overcome both causes. The practical applicability of SDLS depends on two prerequisites: (1) the feasibility of preoperative distal screw length determination, and (2) sufficient primary biomechanical stability of SDLS compared to standard locking screws (SLS).

Methods

We first assessed the feasibility of preoperative screw length determination (1): Distal radius width, depth and distal screw lengths were measured in 38 human radii. Correlations between distal radius width and depth were assessed, a cluster analysis (Ward’s method and squared Euclidean distance) for distal radius width conducted, and intra-cluster screw lengths analyzed (ANOVA). The biomechanical performance of SDLS (2) was assessed by comparison to SLS in a distal radius fracture model (AO-23 A3). 75 % distal screw length was chosen for both groups to simulate a worst-case scenario. Uniaxial compression tests were conducted to measure stiffness, elastic limit, maximum force and residual tilt. Statistics comprised of independent sample t-tests and a Bonferroni correction (p < 0.0125).

Results

(1) Distal radius width and depth showed a high correlation (R² = 0.79; p < 0.001). Three distal radius width clusters could be identified: small <34 mm; medium 34–36.9 mm; large >36.9 mm. ANOVA and Tukey post-hoc analysis revealed significantly different volar-dorsal depths (p < 0.05) for nearly all screws. (2) To assess biomechanical stability nine specimens were tested each; no significant differences were found between the SDLS and SLS groups.

Conclusions

This feasibility study demonstrates that (1) distal radius width can be used as a predictor for distal screw length and (2) that SDLS provides mechanical stability equivalent to SLS. These results highlight the feasibility of applying SDLS screws in volar plate osteosynthesis at least in extraarticular fractures.

Ultrasound Imaging Improves Identification of Prominent Hardware in the Surgical Treatment of Distal Radius Fractures: A Cadaveric and Prospective Clinical Study

Background Volarly applied locking plates are one of several current treatment options for displaced fractures of the distal radius. Presently, surgeons use intraoperative depth gauges and fluoroscopy to select and confirm proper screw length. The contour of the dorsal cortex beneath the extensor compartments along with fracture comminution may limit the accuracy of screw length selection. Question/Purpose To evaluate the accuracy of ultrasound (US) and fluoroscopy in the detection of dorsally prominent screws placed during volar plating of experimentally created distal radius fractures and extend this prospectively into the clinical setting. Patients and Methods Distal radius fractures were experimentally induced in fresh cadaveric arms. The fractures were then internally fixated with volar locking plates utilizing fluoroscopic imaging. US imaging of the dorsal surface of the radius was then performed followed by dorsal dissection and direct caliper measurements to quantitate screw tips as recessed, flush, or protruding from the dorsal cortex. A small, prospective clinical study was also conducted to validate the clinical usefulness of using US to provide additional information regarding screw tip prominence. Results Our study demonstrated that US was able to detect dorsally prominent screw tips not visible on fluoroscopy. Cadaveric dissection showed a higher statistical correlation between US imaging and actual prominence than between fluoroscopy and actual prominence. Conclusions US examination after volar plate fixation of comminuted distal radius fractures may detect dorsal screw tip prominence when screw lengths are selected to engage the dorsal cortex. Level of Evidence IV.

Ultrasonic Evaluation of the Flexor Pollicis Longus Tendon Following Volar Plate Fixation for Distal Radius Fractures

PURPOSE

To evaluate with ultrasound the thickness of the flexor pollicis longus (FPL) tendon and its relationship to the volar locking plate after the fixation of distal radius fractures.

METHODS

We evaluated 27 type C2 and C3 distal radius fractures with ultrasound to evaluate damage to the FPL tendon after volar plate fixation. The thickness of the FPL tendon and its distance to the volar plate in the involved wrists and to the volar rim in the contralateral uninjured wrist were measured on sonograms taken 12 months postoperatively. Measurements of the involved wrists were compared with those of the intact wrists.

RESULTS

The mean plate-tendon distance in the involved wrist was considerably shorter than the mean volar rim-tendon distance in the intact wrist, and the FPL tendon was considerably thicker in the involved wrist than in the intact wrist.

CONCLUSIONS

In distal radial fractures treated with volar locking plates, increases in the thickness of the FPL tendon and a consequent decrease in the distance between the tendon and the plate can be determined with ultrasonography. This finding is a warning that asymptomatic tenosynovitis may eventually cause tendon ruptures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Intraoperative evaluation of dorsal screw prominence after polyaxial volar plate fixation of distal radius fractures utilizing the Hoya view: a cadaveric study

BACKGROUND

The irregular nature of the dorsal surface of the distal radius makes it difficult to detect prominent screws with volar plate fixation for distal radius fractures using standard fluoroscopic images. This study evaluates the accuracy of a new radiographic method, the Hoya view, for the assessment of dorsal cortical screw penetration with volar plate fixation.

METHODS

Eight cadaveric upper extremities underwent application of a volar distal radius plate with polyaxial locking screws placed distally. Utilizing a mini C-arm, lateral and Hoya views were obtained with notation of any dorsal cortical screw prominence. Dissection of the cadavers was then performed for direct visualization of screw prominence. The screws were then exchanged sequentially for screws 2-mm longer than their initial measurements with repeated imaging and direct visualization.

RESULTS

The Hoya view revealed that 9.4 % of the screws penetrated the dorsal cortex with an average screw prominence of 1.08 mm (range 0.5-2 mm). None of the six prominent screws were detected with lateral views. With the Hoya view, six of six prominent screws were identified. With locking screws exchanged for screws 2-mm longer, 76.6 % of the screws had violated the dorsal cortex; of these, 24.5 % were detected with lateral imaging versus 100 % with the Hoya view.

CONCLUSIONS

This study supports the intraoperative use of the Hoya view to evaluate screw length and dorsal cortical screw penetration in volar plate fixation of distal radius fractures. However, this view may be difficult to obtain in patients with limitations in elbow or shoulder range of motion.

Complication rates and reduction potential of palmar versus dorsal locking plate osteosynthesis for the treatment of distal radius fractures

Background

The aim of this study was to evaluate the complication rates of volar versus dorsal locking plates and postoperative reduction potential after distal radius fractures.

Materials and methods

For this study 285 distal radius fractures (280 patients/59.4 % female) treated with locked plating were retrospectively evaluated. The mean age of the patients was 54.6 years (SD 17.4) and the mean follow-up was 33.2 months (SD 17.2). The palmar approach was used in 225 cases and the dorsal approach in 60 cases (95 % type C fractures).

Results

Adequate reduction was achieved with both approaches, regardless of fracture severity. In the dorsal group, the complications and implant removal rates were significantly higher and the operative time was also longer.

Conclusions

Based on these facts, we advocate the palmar locking plate for the vast majority of fractures. In cases of complex multifragmentary articular fractures where no compromise in reduction is acceptable, and with the biomechanical equality of palmar and dorsal plating remaining unproven, dorsal plating may still be considered.

Level of evidence

Therapeutic level IV.

Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events

OBJECTIVES

Determining the rate of specific adverse events after volar plating performed for distal radius fractures.

DESIGN

Retrospective.

SETTING

University level I trauma center.

PATIENTS

We searched the electronic database of all surgical procedures performed in our department using the following keywords: distal radius fracture, wrist fracture, and plate fixation. We identified 315 patients, 12 of whom were lost at follow-up.

INTERVENTION

Volar plate fixation for the treatment of distal radius fractures.

MAIN OUTCOME MEASUREMENTS

At an average follow-up of 5 years, 303 patients were evaluated through medical records and clinical and radiographic assessment for specific adverse events after volar plate fixation.

RESULTS

Adverse events were observed in 18 patients (5.9%). Implant-related adverse events, including tendon impairments, intra-articular screws, and screw loosening, were observed in 15 patients (5.0%). Extensor tendon impairments were represented by 5 cases of extensor tenosynovitis and 3 cases of rupture of the extensor pollicis longus due to screws protruding dorsally. Flexor impairments were represented by 2 cases of tenosynovitis and 2 cases of flexor pollicis longus rupture. Screw penetration into the radioulnar joint was observed in 1 case. Loss of reduction was identified in 3 cases. One patient had a deep postoperative infection treated with operative debridement. One patient experienced injury to the median nerve during routine implant removal unrelated to tendon issues.

CONCLUSIONS

The majority of adverse events after volar plate fixation were due to technical errors in implant placement. In our cohort, tendon impairments were the most frequently observed; among these, extensor tendon impairments were the most represented (50% of all adverse events). All 12 tendon-related adverse events were due to technical shortcomings with implant placement.

LEVEL OF EVIDENCE

Therapeutic level IV.

Intraoperative C-arm CT imaging in angular stable plate osteosynthesis of distal radius fractures

The purpose of this study was to analyze the practicability and benefit of intraoperative C-arm computed tomography (CT) imaging in volar plate osteosynthesis of unstable distal radius fractures. During a 1 year period, intraoperative three dimensional (3D) imaging with the ARCADIS Orbic 3D was performed in addition to standard fluoroscopy in 51 cases. The volar angular stable plate oesteosyntheses were analyzed intraoperatively and, if necessary, improved immediately. The duration of the scan and radiation exposure dose were measured. On average, performance of the scan and analysis of the CT dataset took 6.7 minutes. In 31.3% of the surgeries a misplacement of screws was detected and correction was done immediately. C-arm CT imaging can easily be integrated in the normal course of surgery. As a complement to the standard 2D-fluoroscopy, the C-arm CT is a useful tool to evaluate the quality of osteosynthesis.

Fixation of distal radius fractures in adults: a review

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

Complications of distal radius locking plates

Fixation of distal radius fractures via locking plates is an increasingly popular method. However, these plates include variety of complications, such as flexor and extensor tenosynovitis, tendon injury and intra articular screw or peg penetration. Although they offer superior stability and early mobility, if used improperly; they may cause serious complications related to the implant. Proper use of the implant with strict adherence to the fixation principles and close follow up of patients are very important in order to decrease the rate and severity of complications.

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.

The relationship between displacement and clinical outcome after distal radius (Colles') fracture

We reviewed 260 patients who had been treated non-operatively for a dorsally displaced distal radius fracture a mean 6.3 (range 2.5-12.7) years earlier, in an attempt to find the limits of displacement compatible with a good clinical outcome. We excluded patients with previous or later injuries to the same limb. Bivariate analysis revealed a highly statistically significant relationship between radiographic displacement at review and clinical outcome scores. Correlation coefficients varied between 0.14 and 0.30. However, multiple linear regression analysis using most factors commonly thought to be of importance in determining the clinical outcome as independent variables explained only 23% of the variability of the clinical outcome. Dorsal angulation, ulnar variance, and radial inclination together accounted for only 11% of the variability. We conclude that the final alignment of the distal radius as shown radiologically has only a minor influence on the clinical outcome of Colles' type distal radius fractures.

Corrective osteotomy for combined intra- and extra-articular distal radius malunion

PURPOSE

This study evaluated the functional outcome of corrective osteotomy for combined intra- and extra-articular malunions of the distal radius using multiple outcome scores.

METHODS

We evaluated 18 skeletally mature patients at an average of 78 months after corrective osteotomy for a combined intra- and extra-articular malunion of the distal part of the radius. The indication for osteotomy in all patients was the combination of an extra-articular deformity (≥ 15° volar or ≥ 10° dorsal angulation or ≥ 3 mm radial shortening) and intra-articular incongruity of 2 mm or greater (maximum stepoff or gap), as measured on lateral and posteroanterior radiographs. The average interval from the injury to the osteotomy was 9 months. The average maximum stepoff or gap of the articular surface before surgery was 4 mm.

RESULTS

All 18 patients healed uneventfully and the final articular incongruity was reduced to 2 mm or less. Final range of motion and grip strength significantly improved, averaging 89% and 84% of the uninjured side and 185% and 241% of the preoperative measures, respectively. The rate of excellent or good results was 72% according to the validated rating system Mayo Modified Wrist Score, and 89% according to the unvalidated system of Gartland and Werley. The mean Disabilities of the Arm, Shoulder, and Hand score was 11, which corresponds to mild perceived disability. Of the 18 cases, 11 normalized upper limb function. Five patients had complications; all were successfully treated. According to the rating system of Knirk and Jupiter, 4 had grade 1 and 1 had grade 2 osteoarthritis of the radiocarpal joint on radiographs. Two of those patients reported occasional mild pain. Radiographic osteoarthritis did not correlate with strength, motion, and wrist scores.

CONCLUSIONS

Outcomes of corrective osteotomy for combined intra- and extra-articular malunions were comparable to those of osteotomy for isolated intra- and extra-articular malunions. A successful corrective osteotomy for the treatment of complex intra- and extra-articular distal radius malunions can improve wrist function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.