Fragment-specific fixation for complex intra-articular fractures of the distal radius: results of a prospective single-centre trial

Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-Specific Fixation

Background  Treatment of intra-articular distal radius fractures (DRFs) rests on anatomic internal fixation. Fragment-specific fixation (FSF) is applied when fracture pattern is too complex for standard volar plating (SVP), oftentimes with potential increased risk of complications. We hypothesized that patients undergoing FSF would achieve less wrist range of motion (ROM) with higher risk of complications compared with SVP. Methods  We conducted a retrospective review of 159 consecutive patients undergoing DRF fixation from 2017 to 2020. Patients < 18 years old, < 8 weeks' follow-up, open fractures, ipsilateral trauma, and fractures requiring dorsal spanning plate were excluded. Patient demographics, specific construct type, AO fracture classification, ROM, and complications were assessed. ROM was calculated using average flexion, extension, supination, and pronation. t -Tests were used to determine differences in ROM among construct types. Results  Ninety-two patients met all inclusion criteria: 59 underwent SVP and 33 underwent FSF. Average wrist ROM for patients undergoing SVP was 57 degrees/50 degrees flexion-extension and 87 degrees/88 degrees supination-pronation; average ROM for patients undergoing FSF was 55 degrees/49 degrees flexion-extension and 88 degrees/89 degrees supination-pronation. No significant differences were identified when comparing final wrist flexion ( p  = 0.08), extension ( p  = 0.33), supination ( p  = 0.35), or pronation ( p  = 0.21). Overall reoperation rate was 5% and higher for FSF (12%) versus SVP (2%). Highest reoperation rate was observed in the double volar hook cohort (80%; N  = 4). Conclusion  Construct type does not appear to affect final ROM if stable internal fixation is achieved. SVP and FSF had similar complication rates; however, double volar hook constructs resulted in increased reoperations likely from fixation failure and plate prominence. Level of Evidence  Level IV, retrospective review.

Effect of the Articular Surface Incongruency on Surgical Outcome of the Distal Radius Fracture

Purpose

The aim of this study was to demonstrate the joint fragment that mostly affects the outcome of the distal radius fracture surgically treated with a volar locking plate (VLP).

Methods

The outcomes of 69 patients with the distal radius fractures were evaluated at their final follow-up. The articular surface was divided into six specific fragments, and computed tomography (CT) was used to evaluate the degree of mismatch of each fragments. A plain radiograph was also obtained for evaluation of the distal radius alignment. Clinical outcomes were measured by using the Disabilities of the Arm, Shoulder and Hand (DASH) and Modified Mayo Wrist Score (MMWS). Univariate analyses were performed, with subsequent multiple logistic regression analyses.

Results

The mean follow-up period was 14.8 (range, 12 to 52) months. The group with a worse DASH score showed significantly greater mismatch in the volar and dorsal lunate facets, as well as the central depression of the distal radius (p = 0.042, 0.031, and 0.023, respectively). There was a significant positive correlation between the DASH score and degree of mismatch of the dorsal lunate facet and central depression of the distal radius (p = 0.040 and 0.011, respectively). Groups with worse MMWS showed significantly greater mismatch in the dorsal lunate facet (p = 0.025). There was a significant negative correlation between MMWS and abnormal ulnar variance and mismatch of the dorsal lunate facet and central depression of the distal radius (p = 0.041, 0.004, and 0.018, respectively). The result of multiple logistic regression analysis demonstrated that a mismatch of the dorsal lunate facet is a significant predictor for a worse MMWS (odds ratio = 3.072, p = 0.043).

Conclusions

Articular surface mismatch of the dorsal lunate facet appears to mostly affect the surgical outcomes of the distal radius fractures using VLP. In cases where the dorsal lunate facet is heavily involved, surgeons should be cautious about its reduction and fixation.

Dorsal Cortical Breaks in Volar Barton Distal Radius Fractures

Background: Volar Barton fractures involve the volar articular margin of the distal radius with proximal and volar subluxation of the carpus. Although traditionally conceptualized as partial articular, some volar Barton fractures are complete articular injuries due to a dorsal cortical break in the distal radial metaphysis. While dorsal cortical breaks can affect surgical strategy, they may be difficult to identify on plain radiographs and their epidemiology remains poorly characterized. Some authors have hypothesized an association with osteoporosis; however, this hypothesis remains untested. To better characterize volar Barton fractures, we analyzed fracture geometry on pre-operative computed tomography (CT) scans to: (1) determine the frequency of a dorsal cortical break; and (2) test the null hypothesis that a dorsal cortical break is not associated with age or gender. Methods: We retrospectively reviewed adults with a volar Barton distal radius fracture and an available pre-operative CT who underwent surgical fixation. Using multivariable logistic regression, we assessed whether age or gender was an independent predictor of a dorsal cortical break. Results: Forty patients (mean age 52 years, 57% female) were identified. Including the shaft as a fragment, 32 (80%) had 3 or more discrete fracture fragments. Thirty patients (75%) had a dorsal cortical break. Dorsal cortical breaks were not associated with either age or gender (P > 0.05). Conclusions: Most (75%) patients with volar Barton distal radius fractures had a dorsal cortical break. Dorsal cortical breaks were not statistically associated with age or gender, suggesting these fracture patterns may not be associated with osteoporosis as previously hypothesized.

Articular reductions - how close is close enough? A narrative review

Intra-articular fractures are a unique subset of fractures as they involve a varying extent of damage to cartilage. The impact of this articular fracture causes significant microscopic and macroscopic changes, as well as biomechanical irregularities, which can lead to further cartilage damage, and ultimately cascade down the dreaded path to arthritis. It is generally believed that an anatomic reduction of an articular fracture is the necessary goal of treatment for these injuries, however it yet to be delineated how perfect this reduction has to be. A comprehensive literature review was carried out to create a best available evidence guide to the acceptability of upper extremity and lower extremity articular fracture reductions. Ultimately, a perfect anatomic reduction is the best strategy to minimize abnormal loading and wear patterns, however this should be balanced with the realistic factors of each individual case, such as the level of difficulty, joint involved, surgical timing, and patient activity levels.

The Declining Use of Wrist-Spanning External Fixators

Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.

A Sandwich Method Using Kapandji Intrafocal Pinning to Facilitate Palmar Plating of Displaced Distal Radius Fractures

The use of palmar plating in the treatment of dorsally displaced distal radius fracture is very common, and can result in a good functional outcome. We present an easy "sandwich method" to reduce the fracture and to facilitate osteosynthesis. Firstly, the dorsal Kapandji intrafocal wire was applied to achieve the reduction of the dorsally displaced fracture and provide a volar-directed force. Then the intra-articular fractures were reduced or the metaphyseal defect is stuffed with bone graft if necessary. Finally, the anatomical plate is used to buttress and push back the distal fragment to complete the osteosynthesis. The postoperative radiographic parameters, comparing with the contralateral noninjured side, could achieve similar radial height, radial inclination, volar tilt, and ulnar variance without significant difference.

Intra-articular comminution worsens outcomes of distal radial fractures treated by open reduction and palmar locking plate fixation

We studied 50 patients with AO type C2 distal radial fractures and 35 with AO type C3 distal radial fractures treated by open reduction and palmar locking plate fixation. At 3-month clinical assessments, mean wrist flexion arcs, grip strengths and disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures. At 2-year post-operative clinical assessments, mean disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures than for AO type C3 fractures. At 2-year radiographic examinations, anterior angulations, ulnar variances and arthritis grades were also significantly better for AO type C2 fractures. This study showed that AO type C3 distal radial fractures, which have intra-articular comminution, had poorer clinical and radiographic outcomes than AO type C2 fractures, despite open reduction and palmar locking plate fixation.

LEVEL OF EVIDENCE

IV.

Fixation of intra-articular fractures of the distal radius using intramedullary nailing: a randomized trial versus palmar locking plates

BACKGROUND

Proposed benefits of intramedullary techniques include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial was that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of intra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, prospective randomized matched-pairs trial. Patients with intraarticular distal radius fractures with metaphyseal comminution and a sagittal fracture line (AO 23 C2.1) were randomized to receive volar locking plate fixation (n = 14) or intramedullary nailing (n = 14). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain at eight weeks. At the final follow up, patients in the nail group had regained more extension than in the plate group (98% of the unaffected side vs. 94%, this however, did not reach significance). Reduction was maintained in both groups; however volar tilt and ulnar variance were significantly better in the plate group. There was no significant difference in the complication rate between groups.

CONCLUSION

The present study suggests that intramedullary nail fixation is a reasonable alternative to volar plate fixation for the treatment of intra-articular distal radius fractures and both techniques can yield reliably good results.

The EFCR Approach and the Radial Septum-Understanding the Anatomy and Improving Volar Exposure for Distal Radius Fractures: Imagine What You Could Do With an Extra Inch

Locked volar plating is the most common surgical procedure to address distal radius fractures. The extended flexor carpi radialis approach continues to be an excellent method for visualizing distal radius fractures and applying a volar plate. A new understanding of the anatomy allows for better visualization and reduction of the many different distal radius fracture patterns surgeons commonly see. Within the extended flexor carpi radialis approach, we describe the radial septum in further detail including the anatomy which comprises the radial septum triangle. Knowledge of this area allows for better visualization, more anatomic reductions, and fewer complications.

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

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

Distal radius fractures in athletes: approaches and treatment considerations

Fractures of the distal radius are common injuries in both athletes and nonathletes. Management is dictated by the nature of the fracture and the patient's level of competition, age, and sport-specific demands. Treatment strategies range from nonoperative treatment for stable injuries to primarily operative treatment for unstable fractures, particularly in active athletes. Once the decision has been made to treat a distal radius fracture operatively, a wide variety of fixation options are available. However, no technique has proven superior to all others, and no single method of fixation will lead to acceptable results in all types of distal radius fractures. This study will highlight important considerations when treating distal radius fractures in athletes, describe the various fixation options available, and discuss our method for determining the fixation needs of each fracture.

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.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

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.