Factors affecting late displacement following volar locking plate fixation for distal radial fractures in elderly female patients

Small volar fragment in the lunate fossa leads to volar tilt loss after volar plate fixation for AO/OTA type-C distal radius fracture

OBJECTIVES

The relationship between volar fragment size and postoperative volar tilt loss in complete articular distal radius fracture is not well known. In this study, we measured precise radiological parameters to help identify other factors that might contribute to volar tilt loss.

MATERIAL AND METHODS

We retrospectively reviewed the radiological examinations and charts of 256 patients with distal radial fracture who underwent volar locking plate fixation between March 2014 and July 2022. Radiological parameters were measured based on preoperative CT and immediate postoperative radiographs. Univariate and multivariate linear regression analysis was performed to identify relevant factors associated with volar tilt loss following volar locking plate fixation. The receiver operating characteristic curve was used to identify the cutoff value of the independent parameters.

RESULTS

On univariate analysis, 2 radiologic parameters on preoperative CT (volar fragment length at the lunate fossa, and teardrop angle) and 4 on immediate postoperative X-ray (radial inclination, radial length, capitate shift, and volar tilt) were significantly associated with postoperative volar tilt loss. On multivariate linear regression analysis, the risk of volar tilt loss increased as the capitate moved toward the back of the radial shaft. The cut-off for anteroposterior length in the lunate fossa was 6.5 mm.

CONCLUSIONS

AO/OTA type-C distal radius fractures with <6.5 mm anteroposterior length in the lunate fossa had significantly higher rates of malunion with dorsal deformity. In addition, preoperative teardrop angle <37.2 ° and immediate postoperative volar tilt <3.7º are also predictors of postoperative volar tilt loss.

Factors predicting complications following open reduction and internal fixation of intra-articular distal radius fracture

Objective

This study aimed to determine the incidence and predictors of the complications after open reduction and internal fixation (ORIF) of intra-articular distal radius fracture (IADRF) with a minimum follow-up of 12 months.

Methods

Medical records and outpatient follow-up records were retrospectively reviewed to collect medical, surgical, and complication data on consecutive patients who had undergone an ORIF procedure for an IADRF between January 2019 and June 2022. Data included demographics, comorbidities, injury, surgical characteristics, and laboratory findings on admission. A multivariate logistic regression model was constructed to identify the significant predictors, with a composite of any complications occurring within 12 months after the operation as the outcome variable and potentially a range of clinical data as the independent variables. The magnitude of the relationship was indicated by the odds ratio (OR) and the 95% confidence interval (CI).

Results

During the study period, 474 patients were included, and 64 had documented complications (n = 73), representing an accumulated rate of 13.5%. Among them, carpal tunnel syndrome was the most common, followed by tenosynovitis caused by tendon irritation/rupture, superficial or deep wound infection, complex regional pain syndrome (CRPS) type 1, radial shortening (≥4 mm), plate/screw problems, and others. The multivariate results showed the following factors significantly associated with increased risk of complications: experience of DRF surgery with <30 cases (OR: 2.2, 95% CI: 1.6-3.5), AO type C fracture (OR: 1.7, 95% CI: 1.2-2.9), initial lunate facet collapse of ≥5 mm (OR: 4.2, 95% CI: 1.4-8.9), and use of temporary external fixation before index surgery (OR: 2.4, 95% CI: 1.5-4.3).

Conclusions

These findings may aid in patient counseling and quality improvement initiatives, and IADRF should be directed by an experienced surgeon.

Intraoperative use of impact microindentation to assess distal radius bone quality

Impact microindentation is a new technique that measures the resistance of a patient's bone to micro-indentation but has not yet been implemented in an intraoperative setting. To assess the technique's safety and utility, we acquired microindentation measurements of bone material strength index (BMSi) using the OsteoProbe prior to distal radius fixation with a volar locking plate. Subsequently, the patients received a dual-energy x-ray absorptiometry scan to measure the areal bone mineral density of the proximal femur, lumbar spine, and contralateral distal radius. By assigning the patients to low-energy, fragility fracture (n = 17) and high-energy fracture (n = 11) groups based on clinical history, we investigated whether intraoperative BMSi was sensitive to osteoporosis. Impact microindentation added a maximum of 10 min of operative time and did not result in any intraoperative or postoperative complications. There were, however, no significant differences in BMSi at the radius between these two groups. This study demonstrates the feasibility of performing intraoperative impact microindentation to directly assess a patient's bone quality, but additional research is necessary to establish whether intraoperative microindentation can identify patients with inferior bone matrix quality.

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.

Cartilage and subchondral bone distributions of the distal radius: a 3-dimensional analysis using cadavers

OBJECTIVE

To quantify the spatial distributions of cartilage and subchondral bone thickness of the distal radius.

DESIGN

Using 17 cadaveric wrists, three types of 3-dimensional models were created: a cartilage-bone model, obtained by laser scanning; a bone model, rescanned after dissolving the cartilage; and a subchondral bone model, obtained using computed tomography. By superimposing the bone model onto the cartilage-bone and the subchondral bone models, the cartilage and subchondral bone thickness were determined. Measurements along with the spatial distribution were made at fixed anatomic points including the scaphoid and lunate fossa, sigmoid notch and interfossal ridge, and compared at each of these four regions.

RESULTS

Cartilage thickness of the interfossal ridge (0.89 ± 0.23 mm) had a larger average thickness compared to that of the scaphoid fossa (0.70 ± 0.18 mm; p = 0.004), lunate fossa (0.75 ± 0.17 mm; p = 0.044) and sigmoid notch (0.64 ± 0.13 mm; p < 0.001). Subchondral bone was found to be thickest at the scaphoid (2.18 ± 0.72 mm) and lunate fossae (1.94 ± 0.93 mm), which were both thicker than that of sigmoid notch (1.63 ± 1.06 mm: vs scaphoid fossa, p = 0.020) or interfossal ridge (1.54 ± 0.84 mm: vs scaphoid fossa, p = 0.004; vs lunate fossa, p = 0.048). In the volar-ulnar sub-regions of the scaphoid and lunate fossa, the subchondral bone thickened.

CONCLUSIONS

Our data can be applied when treating distal radius fractures. Cartilage thickness was less than 1 mm across the articular surface, which may give an insight into threshold for an acceptable range of step-offs. The combined findings of subchondral bone appreciate the importance of the volar-ulnar corner of the distal radius in the volar locking plate fixation.

Evaluation and Management of Osteoporosis and Sarcopenia in Patients with Distal Radius Fractures

Distal radius fractures (DRFs) are one of the most common fractures seen in elderly people. Patients with DRFs have a high incidence of osteoporosis and an increased risk of subsequent fractures, subtle early physical performance changes, and a high prevalence of sarcopenia. Since DRFs typically occur earlier than vertebral or hip fractures, they reflect early changes of the bone and muscle frailty and provide physicians with an opportunity to prevent progression of frailty and secondary fractures. In this review, we will discuss the concept of DRFs as a medical condition that is at the start of the fragility fracture cascade, recent advances in the diagnosis of bone fragility including emerging importance of cortical porosity, fracture healing with osteoporosis medications, and recent progress in research on sarcopenia in patients with DRFs.

Incidence of complications and secondary procedure following distal radius fractures treated by volar locking plate (VLP)

Objective

To investigate the incidence of postoperative overall complications or secondary procedures following distal radius fractures treated by volar locking plate (VLP)

Methods

Electronic medical records (EMR) of 1152 patients with 1175 distal radius fractures treated by volar locking plate between January 2013 and September 2018 were retrospectively reviewed and the data were extracted. The picture archiving and communication system (PACS) was inquired to assess the fracture severity and to determine the fracture type. Univariate and multivariate logistic regression analyses were used to identify the associated risk factors.

Results

During the median follow-up period of 6 months, a total of 138 complications in 131 patients were determined, indicating the accumulated rate of 11.7%; there were 68 cases of secondary procedures, with the rate of 5.8%. The independent associated factors for postoperative overall complications were AO type C fracture (OR, 2.6; 95%CI, 1.2 to 4.0), open fracture (OR, 4.2; 95%CI, 1.9 to 6.5), and significant collapse of the lunate fossa (OR, 2.9; 95%CI, 13 to 4.3), and for secondary procedures were significant collapse of the lunate fossa (OR, 3.7; 95%CI, 1.7 to 6.4) and the low-volume of surgeons (OR, 95%CI, 1.2 to 3.6)

Conclusions

Identification of these factors is of importance for the risk assessment of postoperative complications and the additional need of surgery. For patients with the above factors, especially those with combined risk factors, optimized operation scheme and high-volume surgeon should be considered to prevent or reduce the complications.

Screw placement is everything: Risk factors for loss of reduction with volar locking distal radius plates

AIM

To determine factors correlated with postoperative radial shortening in patients with distal radius fractures treated with volar locking distal radius plates.

METHODS

A total of 250 patients with a distal radius fracture stabilised with volar locking plates between January 2010 and December 2014 were included in a multicentre retrospective cohort study. We measured the distance of the distal locking screws to the joint line immediately postoperatively and then measured radial shortening after six to eight weeks using the change in ulnar variance.

RESULTS

Multivariate linear regression analysis showed that there was a significant linear association between the distance of the screws from the joint line and radial shortening. No other patient, injury, or treatment-related characteristic significantly influenced radial shortening in multivariate analysis.

CONCLUSION

Distal locking screws should be placed as close as possible to the subchondral joint line to prevent postoperative loss of reduction.

Examination of Skill Acquisition and Grader Bias in a Distal Radius Fracture Fixation Model

OBJECTIVES

Primary: Assess the ability of faculty graders to predict the objectively measured strength of distal radius fracture fixation. Secondary: Compare resident skill variation and retention related to other knowable training data.

DESIGN

Residents were allowed 60 minutes to stabilize a standardized distal radius fracture using an assigned fixed-angle volar plate. Faculty observed and subjectively graded the residents without providing real-time feedback. Objective biomechanical evaluation (construct strength and stiffness) was compared to subjective grades. Resident-specific characteristics (sex, PGY, and ACGME case log) were also used to compare the objective data.

SETTING

A simulated operating room in our laboratory.

PARTICIPANTS

Post-graduate year 2, 3, 4, and 5 orthopedic residents.

RESULTS

Primary: Faculty were not successful at predicting objectively measured fixation, and their subjective scoring suggests confirmation bias as PGY increased. Secondary: Resident year-in-training alone did not predict objective measures (p = 0.53), but was predictive of subjective scores (p < 0.001). Skills learned were not always retained, as 29% of residents objectively failed subsequent to passing. Notably, resident-reported case-specific experience alone was inversely correlated with objective fixation strength.

CONCLUSIONS

This testing model enabled the collection of objective and subjective resident skill scores. Faculty graders did not routinely predict objective measures, and their subjective assessment appears biased related to PGY. Also, in vivo case volume alone does not predict objective results. Familiar faculty teaching consistency, and resident grading by external faculty unfamiliar with tested residents, might alter these results.

The Effect of Osteoporosis on the Outcomes After Volar Locking Plate Fixation in Female Patients Older than 50 Years With Unstable Distal Radius Fractures

PURPOSE

The aim of this study was to investigate the effect of osteoporosis on radiological and clinical outcomes after volar locking plate (VLP) fixation in women older than 50 years with unstable distal radius fractures (DRFs).

METHODS

We retrospectively reviewed data of 79 women older than 50 years with DRFs treated by VLP fixation. We collected patients' baseline data, including age and bone mineral density. We also measured the cortical thickness of the distal radius on plain radiographs and computed tomography to assess local bone density. Radiological outcomes included late displacement at 1 year after surgery, which was defined as a change in radiological parameters (radial inclination, volar tilt, and ulnar variance). Clinical outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) and modified Mayo wrist score at 1 year after surgery. We compared mean values between the nonosteoporotic (group 1, T score > -2.5) and the osteoporotic groups (group 2, T score ≤ -2.5). We conducted linear and logistic regression analysis to investigate factors associated with poor outcomes.

RESULTS

There were 49 patients in group 1 and 30 patients in group 2. Radiological outcomes were similar in both groups. The mean DASH score was 14.9 (SD, 16.4) for group 1 and 12.5 (SD, 13.5) for group 2, and the mean modified Mayo wrist score was 87.6 (SD, 8.8) for group 1 and 88.2 (SD, 11.4) for group 2. There were no significant differences in clinical outcomes between groups. Simple and multivariable linear regression analysis showed only older age was associated with the change in volar tilt. Osteoporosis and cortical thickness were not associated with poor clinical outcomes on simple logistic regression analysis.

CONCLUSIONS

Osteoporosis and cortical thickness of the distal radius did not affect clinical outcomes after VLP fixation in women older than 50 years with unstable DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Pearls and Pitfalls of the Volar Locking Plating for Distal Radius Fractures

Volar locking plate fixation has been widely accepted method for the treatment of unstable distal radius fractures. Although the results of volar locking plate fixation are encouraging, it may cause implant-related complications such as flexor or extensor tendon injuries. In depth understanding of anatomy of the distal radius is mandatory in order to obtain adequate fixation of the fracture fragments and to avoid these complications. This article will review the anatomic characteristics of the distal radius because selecting proper implant and positioning of the plate is closely related to the volar surface anatomy of the distal radius. The number and the length of distal locking screws are also important to provide adequate fixation strength to maintain fracture fixation. We will discuss the pros and cons of the variable-angle locking plate, which was introduced in an effort to provide surgeons with more freedom for fixation. Finally, we will discuss about correcting radial length and volar tilt by using eccentric drill holes and distal locking first technique.

Comparison of ceiling effects between two patient-rating scores and a physician-rating score in the assessment of outcome after the surgical treatment of distal radial fractures

We compared the ceiling effects of two patient-rating scores, the Disability of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE), and a physician-rating score, the Modified Mayo Wrist Score (MMWS) in assessing the outcome of surgical treatment of an unstable distal radial fracture. A total of 77 women with a mean age of 64.2 years (50 to 88) who underwent fixation using a volar locking plate for an unstable distal radial fracture between 2011 and 2013 were enrolled in this study. All completed the DASH and PRWE questionnaires one year post-operatively and were assessed using the MMWS by the senior author. The ceiling effects in the outcome data assessed for each score were estimated. The data assessed with both patient-rating scores, the DASH and PRWE, showed substantial ceiling effects, whereas the data assessed with MMWS showed no ceiling effect. Researchers should be aware of a possible ceiling effect in the assessment of the outcome of the surgical treatment of distal radial fractures using patient-rating scores. It could also increase the likelihood of a type II error.

Arthroscopic assistance does not improve the functional or radiographic outcome of unstable intra-articular distal radial fractures treated with a volar locking plate

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.

Does osteoporosis have a negative effect on the functional outcome of an osteoporotic distal radial fracture treated with a volar locking plate?

We performed a retrospective study to determine the effect of osteoporosis on the functional outcome of osteoporotic distal radial fractures treated with a volar locking plate. Between 2009 and 2012 a total of 90 postmenopausal women with an unstable fracture of the distal radius treated with a volar locking plate were studied. Changes in the radiological parameters of 51 patients with osteoporosis (group 1, mean age 66.9, mean T-score –3.16 (sd 0.56)) were not significantly different from those in 39 patients without osteoporosis (group 2, mean age 61.1, mean T-score –1.72 (sd 0.57)). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at final follow-up was 11.5 (sd 12.2) in group 1 and 10.5 (sd 13.25) in group 2. The mean modified Mayo wrist score at final follow-up was 79.0 (sd 14.04) in group 1 and 82.6 (sd 13.1) in group 2. However, this difference was not statistically significant (p = 0.35 for DASH score, p = 0.2 for modified Mayo wrist score). Univariable and multivariable logistic regression analysis showed that only the step-off of the radiocarpal joint was related to both a poor DASH and modified Mayo wrist score. Pearson’s correlation coefficient showed a weak negative relationship only between the T-score and the change in volar tilt (intraclass coefficient –0.26, p = 0.02).

We found that osteoporosis does not have a negative effect on the functional outcome and additional analysis did not show a correlation between T-score and outcome.

Cite this article: Bone Joint J 2015;97-B:229–34.

Evidence-based review of Colles’ fracture

Background

A Colles’ fracture occurs as a transverse fracture of the metaphyseal region of the distal radius, approximately 25–40 mm proximal to the radio-carpal joint, and is associated with dorsal displacement and angulation of the distal fragment. Other features include radial shortening and palmar tilt. Key radiological measurements usually noted are that of radial length (normally 11 mm), dorsal angulation of the distal radius (normally 10° volar angulation) and radial inclination (normally 22°). A Colles’ fracture is one of the most common types of osteoporotic fractures seen, especially in females above the age of 50. Incidence of men vs. women over the age of 35 was 9/10,000 vs. 37/10,000, respectively.

Management

Conservative management is commonly an option in stable or minimally displaced fractures which are described as ≤2 mm loss of radial height, ≤5° change in radial inclination and ≤10° of dorsal angulation. This can be managed in a plaster cast for five to six weeks. Furthermore, age of >60 years was found to be the most important factor in predicting whether a reduced unstable fracture would redisplace. Kirschner-wire fixation is a useful and simple operative method to help stabilise fragments that are not severely comminuted. This option was found to be better than plaster cast management alone, but was associated with surgical complications such as infection and nerve injuries. A more common management option utilised for unstable fractures today is open reduction and internal fixation using either dorsal or volar plates. Dorsal plates are less commonly used due to increased risk of volar collapse and tendon rupture with up to a 22% removal of implant rate due to tendon irritation. Volar plates are more popular as they allow a more stable fixation and thus early mobilisation with a better radiological outcome when compared against K-wire fixation. They are also associated with a lower incidence of tendon complications. External fixation management options may either be bridging or nonbridging in regards to the radio-carpal joint. Immobilising the wrist with a bridging external fixation device can be an option when managing a severely comminuted fracture without a large enough distal fragment to secure a distal pin. However, dorsal malunion was six times more likely when compared against a nonbridging option. Though studies showed external fixation devices provided better radiological outcomes when compared to conservative management, there is insufficient evidence to conclude that long-term functional outcomes are also improved.

Prevention

Often a fracture of this nature is considered as one of the first signs of osteoporosis in a middle-aged adult. Hormone replacement therapies and use of bisphosphonate therapy have been proven to reduce the risk of osteoporotic fractures with alendronate being found to significantly reduce the risk of spine, hip and wrist fractures in postmenopausal women with a mean age of 70 years. Incorporation of other health care professionals such as physiotherapists and occupational therapists is also of vital importance to ensure osteoporotic patients are at a lower risk of sustaining falls.

Use of the radial groove view intra-operatively to prevent damage to the extensor pollicis longus tendon by protruding screws during volar plating of a distal radial fracture

The aims of this study were to assess the efficacy of a newly designed radiological technique (the radial groove view) for the detection of protrusion of screws in the groove for the extensor pollicis longus tendon (EPL) during plating of distal radial fractures. We also aimed to determine the optimum position of the forearm to obtain this view. We initially analysed the anatomy of the EPL groove by performing three-dimensional CT on 51 normal forearms. The mean horizontal angle of the groove was 17.8° (14° to 23°). We found that the ideal position of the fluoroscopic beam to obtain this view was 20° in the horizontal plane and 5° in the sagittal plane. We then intra-operatively assessed the use of the radial groove view for detecting protrusion of screws in the EPL groove in 93 fractures that were treated by volar plating. A total of 13 protruding screws were detected. They were changed to shorter screws and these patients underwent CT scans of the wrist immediately post-operatively. There remained one screw that was protruding. These findings suggest that the use of the radial groove view intra-operatively is a good method of assessing the possible protrusion of screws into the groove of EPL when plating a fracture of the distal radius.