Combined volar and dorsal plating for complex comminuted distal radial fractures

Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases

PURPOSE

The optimal way to stabilize intra-articular distal radius fractures is unclear despite recent advances in surgical management. Volar plating is the most common treatment but may not be sufficient for more complex intra-articular AO type C fractures. The purpose of this randomized controlled study was to evaluate the radiographic and clinical outcomes following surgical treatment of AO type C distal radius fractures, comparing volar with combined plating.

METHODS

In this study, 150 patients were randomized to volar locking plate (n = 75) or combined plating (n = 75) following a distal radius fracture AO type C. The 1-year follow-up included radiographic outcome (Batra score), visual analog scale pain score, hand grip strength, wrist range of motion, Patient-Rated Wrist Evaluation score, and Quick Disabilities of the Arm, Shoulder, and Hand score.

RESULTS

Overall, 147 patients (median age 61 years) completed the 1-year follow-up (73 patients with volar plate and 74 with combined plating). No difference was found in radiographic outcome between the treatment groups. The volar plate group had significantly better Patient-Rated Wrist Evaluation scores, Quick Disabilities of the Arm, Shoulder, and Hand scores, hand grip strength, visual analog scale scores during activity, and flexion, extension, ulnar and radial deviation than the combined plate group. Hardware removal was performed in 10% in the volar plate group and in 31% in the combined plate group. There was no postoperative infection in the volar plate group but 3 cases in the combined plate group.

CONCLUSIONS

In patients with complex AO type C intra-articular fractures, volar and combined plating yielded the same radiographic result. The differences in Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores between the groups did not reach the thresholds for minimal clinically important differences, suggesting similar clinical outcome. The combined plating group had a considerably higher frequency of hardware removal and postoperative infections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Radiological, Clinical and Functional Outcomes of Combined Dorsal and Volar Locking Plate Osteosynthesis for Complex Distal Radius Fractures

PURPOSE

The purpose of this study was to assess the short- to mid-term radiologic, clinical, and functional outcomes of patients treated with combined dorsal and volar locking plating for internal fixation of complex, comminuted, intra-articular, distal radius fractures.

METHODS

We performed a retrospective review of 34 patients treated with combined dorsal and volar locking plates for the internal fixation of complex, comminuted, intra-articular distal radius fractures. Radiographic and clinical parameters were recorded at a mean of 48 months after surgery. Activities of daily living and quality of life were assessed by the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation questionnaires.

RESULTS

Compared with the contralateral wrist, the treated wrist regained 73% of flexion, 81% of extension, 86% of ulnar deviation, 90% of radial deviation, 98% of pronation, 99% of supination, and 93% of grip strength. Mean Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 11 (range, 0-78) and 11 (range, 0-77), respectively. Radial height and radial inclination were restored anatomically in 24% and 41% of patients, respectively, while volar tilt and ulnar variance were restored in 68% of patients.

CONCLUSION

The overall functional and radiologic outcome of patients with comminuted intra-articular complex distal radius fractures treated with the combined dorsovolar plate osteosynthesis was good to excellent.

LEVEL OF EVIDENCE

Therapeutic IV.

Combined Approach for Intra-articular Distal Radius Fracture: A Case Series and Literature Review

Background

The purpose of this study was to classify the possible indications for a combined approach to distal radius fractures (DRFs) by investigating surgical outcomes of patients treated according to our treatment algorithm.

Methods

A combined approach was performed in 32 patients. Patients who were thought to need a combined approach were classified into three types according to the combined injuries associated with loss of volar cortical buttresses in DRFs. The classifications included the following: type 1, free intra-articular fragments; type 2, distally migrated dorsal fragments located beyond the wrist joint; and type 3, centrally impacted articular fragments and displaced dorsal fragments, not reduced by indirect methods.

Results

Seven patients had type 1 fractures treated with volar plates and excision of the intra-articular fragments. Fourteen patients had type 2 fractures: 12 were treated with volar plates and excision of dorsal fragments, and 2 with relatively large unstable dorsal fragments were treated with combined volar and dorsal plates. The remaining 11 patients had type 3 fractures treated with combined volar and dorsal plates. At the latest follow-up, the radiographs revealed an average of 16.9° of radial inclination, an average of 4.2° of volar tilt, and an average of 7.5 mm of radial height. According to the Garland and Werley scores, the functional results were excellent for 3 patients, good for 25, and fair for 4.

Conclusions

The classification system indicated when an additional dorsal approach was needed in unstable DRFs, and it may establish useful guidelines for appropriate surgical decision-making.

Single volar locking plating for the intra- and extra-articular distal radius fractures with dorsal metaphyseal comminution

BACKGROUND

Volar locking plating remains a popular method for the surgical management of distal radius fractures. Dorsal metaphyseal comminution (DMC) is a common fracture pattern which weakens the stability during fracture fixation. In this study, we aimed to compare the radiographic and functional outcome of the intra- and extra-articular distal radius fractures with DMC following single volar locking plate fixation.

MATERIALS AND METHODS

Patients suffered from a distal radius fracture with DMC were reviewed in the clinical database of the authors' institution between Jan 2016 and Jan 2020. The included patients were classified into the extra-articular (A3) group or the intra-articular (C2 and C3) group according to the AO/OTA system. The radiological parameters, wrist range of motion, and functional outcomes were evaluated following open reduction and volar locking plate fixation.

RESULTS

A total of 130 patients were included in this study with a mean follow-up length of 17.2 months. Compared with the A3 fracture group, no significant fracture re-displacement or reduced wrist ROMs was observed in the C2 fractures after 12-month's follow-up. However, significantly decreased volar tilt (P = 0.003) as well as the extension/flexion ROMs were observed in the C3 fractures comparing to the A3 fractures. Most of the patients achieved an excellent (n = 75) or good (n = 51) Gartland and Werley wrist score. Four patients with C3 fractures resulted in a fair functional outcome due to a significant loss of volar tilt during follow-up.

CONCLUSIONS

The single volar locking plate fixation provided sufficient stability for distal radius fractures with DMC, and resulted in similar radiological and functional outcomes in the intra-articular distal radius fractures with a simple articular component (C2 fractures) as those in the extra-articular fractures. Considering the intra-articular fractures with multifragmentary articular component (C3 fracture), despite of the subsequent loss of volar tilt, the majority of the patients achieved good to excellent wrist function following single volar locking plating.

TRIAL REGISTRATION

This study has been registered on the ClinicalTrials.gov.

A modified intrafocal pinning technique with three-dimensional planning to facilitate volar plating in dorsally comminuted AO/OTA C2 and C3 distal radius fractures

Backgrounds

Theaim of this study was to assess the efficacy of a modified intrafocal pinningtechnique with three-dimensional (3D) planning to facilitate volar plating in dorsally comminuted intra-articular distal radius fractures.

Methods

Intotal 35 AO/OTA type C2 and C3 fractures were finally included.The 3D digital model of the fracture was reconstructed based on preoperative computedtomographic (CT) images, with the displacement of the comminuted dorsalfragment and the intra-articular fragment analyzed for preoperative planning. During operation, amodified intrafocal pinning technique was applied percutaneously from thedorsal aspect of the radius to reduce the collapsed intra-articular fragmentfollowing volar plating. Adequate reduction was confirmed in all of patientsconsidering radial height, radial inclination and volar tilt in postoperativeradiographs.

Results

No significant fracture re-displacement wasobserved in most of the cases during a mean follow-up period of 17.4 months, exceptfor two patients withthe C3 fracture. All of the patients achieved adequate clinicalROMs at 12 months postoperatively, with a mean DASH score of 12.0. Most of the patients achievedan excellent (n = 21) or good (n = 12) Gartland and Werley wrist score.

Conclusions

Ourmodified intrafocal pinning technique with 3D planning contributes to a satisfactoryclinical and radiological outcome in dorsally comminuted intra-articular distalradius fractures fixed with a volar locking plate.

Trialregistration

Notapplicable because the design of the study is retrospective.

Management of Distal Radius Fractures: Comparison of Three Methods

Introduction

Distal radius fractures are the most common type of all extremity fractures. It is generally accepted that fractures with more than 2 mm step-off in the radiocarpal joint and greater than 10 degrees dorsal tilt should be treated surgically. However, the ideal technique for surgical management is still a point of debate. We performed cross-sectional data analysis to compare the results of three treatments methods - volar locking plate (VLP), external fixation (EF), Kirschner wire (K-wire) - in patients with distal radius fractures, and compared the clinical, functional, and radiological results

Materials and methods

Forty-four patients with distal radius fractures who underwent fixation with VLP, K-wire or EF between 2011 and 2013 were included in the study. All fractures were classified according to the Müller’s Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Frykman's classifications. Routine radiographs were taken at the postoperative three weeks, six weeks, and three months. Radial inclination, volar tilt, radial length and ulnar variance were assessed on the follow-up visits and additionally at the follow -up for the study. The patient-based Disabilities of the Arm, Shoulder and Hand (DASH) score system and the physician-based MAYO scale were used to evaluate functional outcomes. Radiological and functional outcomes between three surgical modalities were compared and statistically analyzed.

Results

The average age at the time of surgery was 52 years (range = 35-69 years). Of a total of 44 patients, 28 were operated with VLP, 11 were with K-wire and five with EF. Satisfactory reduction was achieved in all fractures, and all of the fractures healed. DASH and MAYO scores were similar in all groups. Regarding radiographic parameters, there was no significant difference in radial inclination, volar tilt, radial length and ulnar variance between the treatment modality groups. When evaluated based on fracture geometry, the DASH score was significantly higher in the patients with AO23A type fracture compared to the patients with AO23B and AO23C type fractures. As for MAYO score, all AO23 groups had similar outcomes.

Conclusions

Surgical treatment options VLP, EF, and K-wire provide adequate fixation, satisfactory radiological, and functional results for the management of distal radius fractures of various severities. The optimal treatment approach depends on individual features, and the choice for an internal fixation or closed reduction method for the restoration of wrist function should be evaluated thoroughly by the operating surgeon considering the patient-related variations.

Management of High Energy Distal Radius Injuries

PURPOSE OF REVIEW

High energy distal radius are commonly multi-fragmentary with significant comminution and/or bone loss. They can also be associated with ligamentous and soft tissue injury and neurovascular compromise. As such, reconstruction of these injuries can be challenging. This paper will review the relevant anatomy, different methods of fixation, and present techniques for difficult fractures.

RECENT FINDINGS

Volar locked plating is a successful, very common method of treatment for distal radius fractures, but dorsal plating, fragment specific fixation, spanning bridge plating, and external fixation are sometimes necessary, particularly in higher energy injuries characterized by metaphyseal comminution, small volar fragments, intra-articular free fragments or lunate facet subsidence. Extended flexor carpi radialis (FCR), dorsal, and flexor carpi ulnaris (FCU) exposures can assist in visualizing the fracture site. There are many different modes of fixation for distal radius fractures, and successful outcome depends on selection of appropriate fixation based on the fracture pattern and status of the soft tissues.

A novel surgical approach for treating distal radial extraarticular malunion: Oblique osteotomy with buttress plate stabilization

PURPOSE

Distal radial extraarticular malunions are not uncommon. However, requirements of surgical correction depend on multiple conditions. Traditionally, surgical techniques include closing or opening wedge osteotomies. Each has unique advantages and disadvantages. An oblique osteotomy was developed to simplify the revision surgery.

METHODS

Forty-eight consecutive adult patients with 48 malunions were surgically treated. An oblique osteotomy of 45° vertical to the radial longitudinal axis was performed from medio-distally to latero-proximally. Consequently, the osteotomized fragments were compressed with a bone clamp. The proximal part of the distal fragment was pushed backward to correct the dorsal tilt. A 7-hole buttress plate was inserted volarly and cancellous bone graft was packed. Postoperatively, a short-arm splint or brace without restriction of all five metacarpophalangeal joints was applied for 6 weeks.

RESULTS

Forty-one patients were followed for an average of 2.8 years (range, 1.1-5.8 years). All malunions healed within 6 weeks. The union rate was 100% and no complications occurred. Radiographically, ulnar variance, volar tilt of radial articulation, and radial inclination restored to acceptable criteria in all patients. Patients with Modified Mayo Wrist Score (MMWS) improved from 17% to 80% ( p < 0.001) and Disability of Arm, Shoulder and Hand (DASH) Score improved from 0% to 80% ( p < 0.001). The relationship between MMWS and DASH Score was highly correlated (correlation coefficient = -0.90).

CONCLUSION

The described approach may be an excellent alternative for treating distal radial extraarticular malunions. The technique is not difficult but the satisfactory rate is high.

Use of Volar Plate for Indirect Coronal Plane Reduction in an Intraarticular Distal Radius Fracture

Management of intraarticular distal radius fractures requires precise reconstruction of the articular surface to optimize outcomes. Treatment goals also include restoration of alignment, rotation, and angulation in both the coronal and sagittal planes of the metaphyseal component of these fractures. Surgical management with open reduction and internal fixation with a volar plate is often the preferred method of open treatment. However, a variety of different techniques have been described, and the preferred technique may be determined on an individual basis by the fracture characteristics, patient-dependent factors, or surgeon experience.

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.