Operative treatment of volar intra-articular fractures of the distal end of the radius

Evaluation of the Distal Extent of Visualization Using Volar Approaches for Fixation of Distal Radius Fractures

PURPOSE

Distal radius fractures may include difficult-to-treat fractures of the volar ulnar corner, colloquially termed as the "critical corner." These fragments are problematic because they are often missed, and their fixation is difficult. We aimed to compare the distal extent of the exposure of the volar surface of the distal radius between the classic Henry approach and the extended flexor carpi radialis (EFCR) approach.

METHODS

Thirteen matched-pair specimens were randomized to receive either the Henry approach or the EFCR approach to the volar distal radius. A mini Hohmann retractor provided retraction at the level of the critical corner. The force needed to attain a standardized angle of retraction at 60° was measured. A 0.062-inch Kirschner wire was placed at the most distal and most ulnar point that was visible from a position directly above the incision. Each distal radius was removed from the specimens. A digital caliper was used to measure the distance from the pin hole to the articular margin of the lunate fossa, along a line parallel to the long axis of the radius.

RESULTS

The pin was significantly closer to the articular margin in the EFCR approach (mean, 2.94 ± 1.69 mm) than in the Henry approach (mean, 9.70 ± 2.70 mm).

CONCLUSIONS

Our results demonstrated significantly more distal visualization of the volar distal radius in the EFCR approach compared to the Henry approach.

CLINICAL RELEVANCE

Adequate exposure of the volar surface of the distal radius is crucial for assessment and fixation of the volar ulnar corner. Complete visualization of the volar ulnar corner improves surgeons' ability to detect a volar marginal fragment and adequately fix this fragment.

Is Carpal Tunnel Release Necessary in High-Energy Distal Fractures of the Radius?

Purpose This study aimed to compare the clinical outcomes of patients who underwent volar plate osteosynthesis for high-energy distal radius fracture (DRFx) and carpal tunnel release (CTR) for acute or subacute carpal tunnel syndrome (CTS) with patients who did not undergo CTR. Methods This study is a retrospective evaluation of all high-energy DRFx treated with volar plate osteosynthesis in a regional hospital between January 2021 and January 2023. All adult patients (≥18 years) who underwent open reduction and internal fixation were included in the study after obtaining approval from the internal review board of our institution. Only patients who underwent plate osteosynthesis of the volar aspect through a modified Henry incision and patients who underwent CTR through a classic separate incision were included in the study. Clinical results include hand dynamometry, visual analog scale (VAS) scores, and physical examination findings of patients who underwent volar plate osteosynthesis because of high-energy DRFx and CTR due to CTS in the acute and subacute periods were retrospectively examined. Results Among the patients who underwent volar plate osteosynthesis because of high-energy DRFx, no statistically significant difference was detected between the hand grip strength and VAS scores of patients who underwent CTR because of acute CTS and subacute CTS at the sixth postoperative week (p>0.05). Conclusion Prophylactic CTR may be performed in the same session in selected cases, such as DRFx caused by a high-energy injury, to establish a scale for DRFx at a high risk of CTS and avoid delays in treatment. CTR for transient CTS detected in the subacute period during outpatient follow-up does not improve clinical outcomes.

The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction

Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.

Using Trident distal radial locking plate to fix the fracture of distal radius volar rim

BACKGROUND

The volar locking plates have been widely used in a variety of distal radius fractures, but they still have several limitations when dealing with small fragments located around the watershed line with widely reported complications. The volar rim fragments play a critical role in radiocarpal joint stability and failing to secure the volar rim fragment usually results in carpal instability, subluxation, or even dislocation. This study investigates clinical outcomes in the use of a novel implant, the Trident distal radial (TDR) locking plate to treat distal radius fracture with the intermedium column edge (lunate fossa volar rim) fragment involvement.

METHODS

A retrospective study of 25 patients was conducted, all patients had intermedium column fractures with lunate fossa volar rim involvement and treat with the TDR between January 2016 and December 2019. The clinical assessment outcomes included VAS Pain, PRWE, and DASH scores. Objective measurements included ROM of the injured wrist and grip strength. Final radiographs were used to evaluate radial inclination, volar tilt, ulnar variance, and distal radioulnar joint instability. Secondary operations related to hardware complications were also recorded.

RESULTS

The outcome revealed that the mean VAS Pain Score was 1.3, mean DASH score was 10.5, and mean PRWE score was 9.3. Objective measurements revealed good ROM recovery and an 89% gripping strength recovery compared with contralateral hand. Radiographic measurements revealed good maintenance of volar tilt, radial inclination, and mean ulnar variance. There were no complications related to the implant and all fracture sites were union.

CONCLUSION

We believe that the TDR provided more stable fixation among distal radial fractures that predominantly involved the intermedial column and volar rim fragment, and allowing early rehabilitation. We could obtain excellent results in the wrist ROM, gripping power, and Pain Score (VAS).

Persian Fixation - A Novel Surgical Method for Intra-articular Distal Radius Fractures

Background: Intra-articular distal radius fracture treatment options include Kirschner wires (K-wire) fixation, external fixation and plate fixation, however, fixation of small bone fragments in distal radius fractures in a secure and anatomical manner was a challenging issue with several limitations. In this study, we present a novel surgical method that we have called the Persian Fixation for intra-articular distal radius fracture and describe a short-term clinical result. Methods: We described the surgical procedure and clinical result of 15 patients between 2019 and 2020 in whom the Persian Fixation technique was utilised. Through clinical examination and questionnaires, objective and subjective clinical results were determined. Results: At the final follow-up, the mean Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score for our patients was 17.6 ± 12.1, the mean WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP) score was 20.7 ± 4.4 and the mean Visual Analogue Scale (VAS) score was 27.8 ± 16.5, indicating a good to excellent clinical result. Conclusions: We recommended the Persian Fixation technique for intra-articular distal radius fractures, which is a low-cost and readily accessible procedure that provides stable fixation of a tiny bone piece. Level of Evidence: Level IV (Therapeutic).

Comparison of the conventional Henry approach and trans-flexor carpi radialis approach for the treatment of distal radius fracture: A retrospective cohort study

Few studies have compared the clinical outcomes of the conventional Henry approach and trans-flexor carpi radialis (FCR) approach. The purpose of this study was to compare the clinical and radiologic outcomes of the conventional Henry approach and trans-FCR approach for the treatment of distal radius fractures. We compared 20 wrists that underwent the conventional Henry approach with 20 wrists that underwent the trans-FCR approach for open reduction and internal fixation of distal radius fracture. The clinical and radiological parameters were checked at 3 months, 6 months, and 1 year after surgery. A visual analogue scale score, the modified Mayo wrist score, range of motion, and grip strength were collected. In addition, tenderness in the area of the FCR tendon were assessed. Regarding radiologic evaluations, the radial inclination, radial height, volar tilt, and ulna variance were measured. In the trans-FCR approach group, 15 patients complained of tenderness in the area of the FCR tendon at 3 months after surgery, which was significantly higher than those of conventional Henry approach group (P < .05). In the conventional Henry approach group, the tenderness had resolved spontaneously by 1 year after surgery in 19 patients. The trans-FCR approach can cause discomfort such as tenderness to the area of the FCR tendon compared to the conventional Henry approach, but there is no significant difference in the final clinical and radiologic outcomes.

The Relation between the Radial Collapse and the Number of Metaphyseal Screws for Distal Radius Fractures

Introduction

The purpose of this study is the evaluation of radial collapse, based on the number of screws used in the metaphyseal region and by distal dorsal distance (DDD) and lunate facet distance (LFD) measurement.

Materials and methods

Between 2015 and 2019, 60 patients who were being treated with volar locking plates due to isolated distal radius fracture were evaluated. Control radiographs were taken on the first day and at 3rd-, 6th- and 12th-month follow-ups. Distal dorsal cortex distance and lunate facet distance were measured in the lateral radiographs. The number of screws used in the metaphyseal region was also evaluated. According to the number of screws, the amount of collapse was analysed based on both the LFD and the DDD.

Results

The mean age of patients was 43.5±12.7 years. Thirty-three of the patients included in the study were male and 27 were female, and the minimum follow-up period was one year. According to the mean number of screws, groups were defined as up to 6 screws or 7 screws and above. There was a statistically significant difference between the groups in terms of DDD collapse at the 6th-month and 12th-month follow-ups (p<0.005). It was observed that the radial collapse and decrease in DDD and LFD were lower in plates with seven screws and above.

Conclusion

Decreases in either DDD or LFD, or radial collapse were observed less in patients who had seven or more metaphyseal screws inserted. These findings might be useful for surgeons treating distal radius fractures to reduce radial collapse.

Growth plate injury in children: Review of literature on PubMed

Growth plate injury is a debilitating condition for children. To our knowledge, there is currently no systematic review regarding the complication of epiphyseal injury. Thus, the authors would like to conduct a systematic review regarding this topic. The following strategy was used: the terms used on the PubMed search engine were “growth plate injuries complications.” Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the comprehensive data collection. The initial PubMed search yielded 341 titles and 81 articles included according to the inclusion criteria, but 20 articles were eliminated according to the exclusion criteria. The final total number of articles was 61. The epiphyseal injury usually ends with a good functional outcome, although some serious complication risk remains.

Three-Dimensional Planning and Patient-Specific Instrumentation for the Fixation of Distal Radius Fractures

Background and Objectives: Three-dimensional planning and guided osteotomy utilizing patient-specific instrumentation (PSI) with the contralateral side used as a reference have been proven as effective in the treatment of malunions following complex fractures of the distal radius. However, this approach has not yet been described in relation to fracture reduction of the distal radius. The aim of this study was to assess the technical and logistical feasibility of computer-assisted surgery in a clinical setting using PSI for fracture reduction and fixation. Materials and Methods: Five patients with varied fracture patterns of the distal radius underwent operative treatment with using PSI. The first applied PSI guide allowed specific and accurate placement of Kirschner wires inside the multiple fragments, with subsequent concurrent reduction using a second guide. Results: Planning, printing of the guides, and operations were performed within 5.6 days on average (range of 1–10 days). All patients could be treated within a reasonable period of time, demonstrating good outcomes, and were able to return to work after a follow-up of three months. Mean wrist movements (°) were 58 (standard deviation (SD) 21) in flexion, 62 (SD 15) in extension, 73 (SD 4) in pronation and 74 (SD 10) in supination at a minimum follow-up of 6 months. Conclusions: Three-dimensional planned osteosynthesis using PSI for treatment of distal radius fractures is feasible and facilitates reduction of multiple fracture fragments. However, higher costs must be taken into consideration for this treatment.

Functional Outcome of Joshi’s External Stabilization System Fixation in Distal Radius Fractures

Background

Distal radius fractures account for almost one-sixth of all fractures in a casualty setting. The usual aim of distal radius fracture treatment is to restore the function of the wrist joint, of which the distal radius is an important part. There seems to be no consensus regarding which mode of treatment is optimal for managing distal radius fracture, particularly when it is associated with distal radioulnar joint instability.

Objective

To describe the functional outcome in patients presenting with displaced distal radius fractures who undergo Joshi’s external stabilization system (JESS) fixation.

Methods

An observational study was done among 32 working-age (18 to 55 years) patients presenting with unilateral displaced distal radius fractures (excluding volar displaced) and subsequently treated with JESS fixation. The outcomes of the patients were assessed using the Green and O’Brien Scoring System modified by Cooney et al. at six months and one year following the surgery. Radiographs were also taken postoperatively and during follow-up. The data were analyzed (using IBM SPSS software version 22 and Microsoft Excel) in terms of the proportion of patients with acceptable clinical and radiological outcomes.

Results

Acceptable functional outcomes (good and excellent scores in the Green and O’Brien Scoring System) were observed in 78.1% of the study population. Though the functional outcome scores were higher among the younger age group, a statistically significant difference was not obtained. 96.9% of the patients had acceptable radiological reductions, and infection of the pin tracts complicated 9.4% of the cases. A significant improvement in outcome scores (p-value 0.0001) was observed between the outcome scores at six months and one year after surgery.

Conclusions

JESS fixation is an easy and effective method for treating displaced distal radius fractures to achieve good to excellent clinical outcomes. The functional outcome scores were better in the younger age group and male patients, but no statistically significant difference was observed.

Extended Flexor Carpi Radialis Approach

Level V-Expert Opinion.

Fragment-specific fixation of posterior wall acetabular fractures

PURPOSE

Fractures of the posterior wall (PW) of the acetabulum have a wide variety of patterns; treating them as a single entity using the standard ilio-ischial plate would be inappropriate. We are presenting our experience with a fragment-specific fixation technique in which each PW fragment is reduced and fixed with separate buttress/anti-glide plate(s) in a tailored fashion, abandoning the use of the ilio-ischial plate.

PATIENTS AND METHODS

Fragment-specific fixation was applied to 46 patients with PW fractures (33 simple and 13 associated fracture types) with a mean follow-up of 34.9 ± 20.5 months (range: 12-72). Kocher-Langenbeck approach was utilized for all patients with dissection limited to the fracture site (a limited form of the approach was used in three patients).

RESULTS

Anatomical reduction of the fracture was achieved in 41 (89.1%) patients, imperfect reduction in four (8.7%), and poor reduction in one (2.2%) patient. Excellent to good radiological and functional results were achieved in 91.3% of cases. A single case had recurrent subluxation which was related to avascular necrosis of the highly comminuted wall fragments. Four patients developed post-traumatic arthritis and required total hip arthroplasty. None of our cases developed clinically significant heterotopic bone formation.

CONCLUSION

With a versatile yet a strong-enough construct and limited soft tissue dissection, fragment-specific fixation yielded very good results with few complications.

Fragment specific fixation with APTUS wrist system for volar rim fractures of the distal radius: a multicentric study

PURPOSE

Volar rim fractures of the distal radius are a spectrum of pathology that must be well identified and treated to achieve good outcomes and avoid surgical failures. New devices of fragment specific fixation have been developed during the last decades to fix this fragment. The purpose of this retrospective study was to evaluate the ability of APTUS^® wrist distal radius system to securely fix different types of volar rim fractures.

METHODS

Patients with at least 1 year of follow-up and a preoperative CT-scan evaluation of the fracture pattern were included in the study. Clinical, radiological and functional outcomes were assessed.

RESULTS

Sixty-eight patients with an average follow-up of 34, 1 months (12-61) were included in the study. There were no clinical and radiological complications, including loss of reduction, device failure and tendon ruptures. No patients required hardware removal. Wrist range of motion in flexion-extension averaged 96°, while in pronation-supination 144°. At final follow-up mean visual analogue scale pain was 1,8. Questionnaires, as dissabilities of the arm, shouldder and hand (DASH) score and patient-related wrist evolution (PRWE) score were 6,6 and 3 respectively. Grip strenght measured 86% compared to the normal side.

CONCLUSION

APTUS^® wrist presents a versatile set of fragment specific fixation plates able to easily and securely fix all types of volar rim fracture. The system can be used with other devices without any kind of interference between them. When correctly placed and used with the right indications, no late complications can be recorded.

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.

Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures

BACKGROUND

In the setting of intra-articular distal radius fractures, the volar lunate facet (VLF) is the only articular segment that resists volar carpal subluxation. So, it is important to achieve a stable fixation of this key fragment. The VLF, when small (also called as volar marginal fragment, VMF) is located distal to the watershed line making fixation with the conventional volar locking plates difficult or impossible.

METHODS

18 patients with either an AO: 2R3B3 or a C3 fracture consisting of a VMF underwent surgical repair through a volar approach. The VMF was stabilised using a anatomical volar hook plate. Remaining fracture components were stabilised using 2.4/ 2.0 mm locked plates. Fracture healing, ability of the hook plate to maintain reduction of the VMF and complications were assessed during follow up. Functional outcome was evaluated using Mayo score and patient rated wrist evaluation questionnaires.

RESULTS

All fractures united at follow up. Reduction of the VMF was maintained through healing with a stable radiocarpal and distal radioulnar joint. The mean flexion - extension wrist arc was 105° ± 10.2° The mean grip strength reached 74.6 ± 6% of the opposite side. The mean Mayo wrist score was 75 ± 5.3 and the mean patient rated wrist evaluation (PRWE) score was 15.2 ± 4.3 indicating recovery of wrist function.

CONCLUSION

It is important to identify VMFs in intra-articular distal radius fractures. Anatomically designed volar hook plate achieves excellent low-profile stable fixation of this key fragment to allow early mobilisation without fearing loss of reduction and volar carpal subluxation.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227-234.].

Hook Plate for Volar Rim Fractures of the Distal Radius: Review of the First 23 Cases and Focus on Dorsal Radiocarpal Dislocation

Background  Fragment-specific fixation of the distal radius is born to fix each articular fragment with limited surgical approach and low-profile devices. Over time, many devices with different designs and characteristics have been developed. However, many of them have showed the inability to securely fix marginal, small, and comminuted fragments as bony ligament avulsions and bony compression injuries. Purpose  The purpose of this study was to evaluate the clinical and radiological outcome of a new device born to treat marginal articular fractures of the distal radius. Patients and Methods  A retrospective review was conducted on 23 patients with a mean follow-up of 21 months including postoperative clinical evaluation, grip strength, computed tomography scan, and X-ray control. Results  All fragments healed and maintained reduced until the final follow-up. The carpus was aligned with the distal radius in all patients presenting with a radiocarpal dislocation. Conclusion  The volar rim fragment is an attachment site for the short radiolunate and the volar distal radioulnar ligament. Its unstable fixation can lead to articular incongruity, volar or dorsal subluxation of the carpus, and distal radioulnar instability. The involvement of this fragment on distal radius fractures is relatively common and many studies of the literature have been focused on its treatment. The Hook Plate stabilizes distal fragments at their bone-ligament interface. In addition to bony reduction, the device permits to stabilize the capsule and ligaments, as volar bony ligament avulsions, in a picture of dorsal radiocarpal dislocation. Level of Evidence  This is a Level IV, case series.

Fragment-Specific Fixation in Distal Radius Fractures

PURPOSE OF REVIEW

Fragment-specific fixation can be a useful tool in treating distal radius fractures. In order to best utilize these techniques, surgeons require an understanding of the normal anatomy, fracture patterns, approaches, and fixation strategies.

RECENT FINDINGS

Fragment-specific fixation may be appropriate for certain fracture patterns particularly when monoblock plating techniques are not sufficient. Radial styloid, volar rim, dorsal wall, dorsal-ulnar corner, and impacted intraarticular fragments may be secured with implants designed specifically for each individual fragment. Although more technically demanding, advantages include accurate articular reconstruction, minimal hardware irritation, and reliable functional outcomes.

Screw Length Optimization of a Volar Locking Plate Using Three Dimensional Preoperative Planning in Distal Radius Fractures

BACKGROUND

A three-dimensional (3D) digital pre-operative planning system for the osteosynthesis of distal radius fracture was developed. The objective of this study was to evaluate screw choices for three-dimensional (3D) digital pre-operative planning of osteosynthesis of distal radius fractures and to compare with the screw choices for the conventional method.

METHODS

Distal radius fracture patients who underwent osteosynthesis using volar locking plates were evaluated. Thirty wrists in the plan group utilized 3D preoperative planning, and nineteen wrists in the control group utilized conventional preoperative assessment. In the plan group, the 3D preoperative planning was performed prior to surgery. The reduction was simulated with 3D image, and the implant choice/placement also simulated on the 3D image. In the control group, standard preoperative planning was performed using posterior-anterior and lateral view radiographs, and CT scan. After the planning, osteosynthesis was performed. During the surgery, the operator performed the reduction and the placement of the plate while comparing images between the pre-operative plan and fluoroscopy. The distal screw lengths and the anteroposterior diameter of the radius along the axis of the distal screws were measured. The ratios of the screw length and radius diameter were evaluated. The screw/radius ratios within the range of 0.75-1.00 were considered appropriate. The screw choices less than 0.75, or greater than 1.00 were considered inappropriate. The rate of appropriate screw choices were compared between plan and control groups.

RESULTS

The results of appropriate screw choices were 86.1% and 74.8% in the plan group and the control group, respectively. The inappropriate screw choices were 14.0% and 25.2% in the plan group and the control group, respectively. The three-dimensional planning significantly increased appropriate screw choices compared to the conventional planning (p < 0.05).

CONCLUSIONS

Three-dimensional digital preoperative planning is useful for the optimization of screw lengths in osteosynthesis of distal radius fractures.

Buttress plating for volar Barton fractures in children: Salter-Harris II distal radius fractures in sagittal plane

We observed an unusual type of volar Barton fracture in the pediatric age and performed open reduction and internal fixation of the fragment, using the buttress plate in consecutive children. We report the radiological and clinical outcomes after follow-up for at least 3 years. From March 2008 to September 2014, nine consecutive children were treated by buttress plating. Their mean age at the time of injury was 13.1 years. All of the fractures were metaphyseal fractures in the coronal plane and typical Salter-Harris II fractures in the sagittal plane. After accurate reduction of the fragment, a cortical screw was inserted in the proximal area until the maximum compressive force against the fragment was obtained. Then, one or two locking screws were added adjacent to the initial cortical screw. No screw was fixed in the distal fragment. All evaluations were done at least 3 years postoperatively with a mean follow-up of 48.8 months. At final follow-up, the radial inclinations, volar tiltings, and ulnar variances were 23.2°±1.78° (98.7% of contralateral side), 9.4°±2.12° (98.4% of contralateral side), and -1.56±0.88 mm (93% of contralateral side), respectively. All radiological parameters of the distal radius were not significantly different from the contralateral values. The flexion-extension arc was 140.56°±5.27°, and the pronation-supination arc was 165.00°±8.29°. The grip strength was 26.67±5.56 kg. All clinical outcomes except the flexion-extension arc were similar to those of the normal side, with statistical significance. A volar Barton type injury can occur in the pediatric age involving the physis, and the buttress plating that is used in adults is also a useful treatment method. However, there is little information on this injury, and it was difficult to compare treatment outcomes with other methods. Because of the rarity of the injury, a larger, multicenter prospective comparative study is required to further explore appropriate treatment options, long-term outcomes, and complications. Level of Evidence: Therapeutic, Level IV.

Dual Plating Technique for Volar Rim Fracture of the Distal Radius Using DePuy-Synthes 2.0 m and 2.4 mm Locking Plates

BACKGROUND

To assess the surgical results of distal radius fractures with the involvement of a volar rim fragment using the DePuy-Synthes 2.0 mm and 2.4 mm locking plates.

METHODS

Subjects were six women and one man of average age 57 years (range, 31-83 y) and a mean follow-up period of 9 months (range, 5-19 mo) with AO B3 (volar shearing) distal radius fractures. Time of the procedure, physical examination of wrist range of motion, grip strength compared with the contralateral healthy wrist, and radiographic evaluation (volar tilt, radial inclination, and ulnar variance) were evaluated. The Visual Analog Scale (VAS: 0 points represents no pain, 100 points represents the worst pain possible) and the Quick Disability of the Arm, Shoulder, and Hand questionnaire (QuickDASH, 0 = no disability, 100 = extreme disability) were completed by patients at the final follow-up.

RESULTS

The average time of the procedure was 74 min. There were no perioperative complications. Average radiographic measures were: volar tilt, 8°; radial inclination, 23°, and ulnar variance, 0 mm. Wrist range of motion averaged 63° in wrist extension (range, 55-80°) and 55° in wrist flexion (range, 45-65°). Grip strength averaged 81% of the contralateral side at final evaluation (range, 67-100%). The mean QuickDASH score was 3.0 points (range, 0-9.1 points) and the mean VAS for pain was 9.3 at final follow-up.

CONCLUSIONS

Open reduction internal fixation with the DePuy-Synthes 2.0 mm and 2.4 mm locking plates is an effective means of fixing a distal radius fracture that includes a volar rim fragment without interfering with flexor tendon gliding.

[Design of distal radius volar locking plates : Anatomical, surgical and biomechanical aspects]

The operative treatment of unstable distal radius fractures primarily aims for the anatomical reduction of the joint while addressing accompanying injuries. Anatomical reduction, stable fixation and early functional movement of the joint are the three cornerstones of modern treatment concepts of distal radius fractures. Distal radius volar locking plates play a major role in the treatment and rehabilitation of the most commonly occurring fracture in humans. This article outlines the different principles in the current design of available distal radius volar locking plates. The biomechanical aspects, anatomical findings and clinical evaluation that have influenced current design features and trends in new developments of the latest plates are emphasized. This is an ongoing process that is supported through the investigation and feedback of clinical science.

Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data

PURPOSE

The management of distal radius fractures differs based on the nature of the fracture and the experience of the surgeon. We hypothesized that patients requiring surgical intervention would undergo different procedures when in the care of a surgeon with subspecialty training in hand surgery as compared with surgeons with no subspecialty training in hand surgery.

METHODS

We queried the ABOS database for case log information submitted for part II of the ABOS examination. Queries for all codes involved with distal radius fracture management were combined with associated codes for the management of median nerve neuropathy, triangular fibrocartilage complex tears, ulnar shaft, and styloid fractures. Hand fellowship trained orthopedic surgeons were compared with those completing other fellowships and non-fellowship trained orthopedic surgeons during their board collection period.

RESULTS

During the study period, 2,317 orthopedic surgeons reported treatment of 15,433 distal radius fractures. Of these surgeons, 411 had hand fellowship training. On a per surgeon basis, fellowship trained hand surgeons operatively treated more multifragment intra-articular distal radius fractures than their non-hand fellowship trained counterparts (5.3 vs 1.2). Additional procedures associated with the management of distal radius fractures were also associated with the fellowship training of the treating surgeon.

CONCLUSIONS

Among orthopedic surgeons taking part II of the ABOS certifying examination, differences exist in the type, management, and reporting of distal radius fractures among surgeons with different areas of fellowship training.

CLINICAL RELEVANCE

This study describes the association of hand surgery fellowship training on the choice of intervention for distal radius fractures and associated conditions.

Complications of Distal Radius Fractures Treated by Volar Locking Plate Fixation

The current study investigated the incidence of complications after surgery for distal radial fractures. This multicenter retrospective study was conducted at 11 institutions. A total of 824 patients who had distal radius fractures that were treated surgically between January 2010 and August 2012 were identified. The study patients were older than 18 years and were observed for at least 12 weeks after surgery for distal radius fractures with a volar locking plate. Sex, age, fracture type according to AO classification, implants, wrist range of motion, grip strength, fracture consolidation rate, and complications were studied. Analysis included 694 patients, including 529 women and 165 men, with a mean age of 64 years. The mean follow-up period was 27 weeks. The fracture consolidation rate was 100%. There were 52 complications (7.5%), including 18 cases of carpal tunnel syndrome, 12 cases of peripheral nerve palsy, 8 cases of trigger digit, 4 cases of tendon rupture (none of the flexor pollicis longus), and 10 others. There was no rupture of the flexor pollicis longus tendon because careful attention was paid to the relationship between the implant and the tendon. Peripheral nerve palsy may have been caused by intraoperative traction in 7 cases, temporary fixation by percutaneous Kirschner wires in 3 cases, and axillary nerve block in 1 case; 1 case appeared to be idiopathic. Tendon ruptures were mainly caused by mechanical stress. [Orthopedics.2016; 39(5):e893-e896.].

Devising for a distal radius fracture fixation focus on the intra-articular volar dislocated fragment

Introduction

Distal radius fracture (DRF) accompanied by intra-articular volar displaced fragment is difficult to reduce. This volar fragment remains when treated with a simple buttress effect alone, and V-shaped deformity may remain on the articular surface. We attempted to improve dorsal rotational deviation of volar fragment by osteosynthesis applying the condylar stabilizing technique. We report the surgical procedure and results.

Materials and methods

The subjects were 10 cases of DRF accompanied by intra-articular volar displaced fragments surgically treated (mean age: 69 years old). The fracture type based on the AO classification was B3 in 1 case, C1 in 4, C2 in 2, and C3 in 3 cases. All cases were treated with a volar locking plate. Reduction was applied utilizing the angle stability of the volar locking plate, similarly to the condylar stabilizing technique. On the final follow-up, we evaluated clinical and radiologic evaluation. To evaluate V-shaped valley deformity of the articular surface, the depth of the lunate fossa of the radius was measured using computed tomography (CT).

Results

The duration of postoperative follow-up was 11 (6–24) months. Mayo wrist score was 93 (Excellent in 10 cases). No general complication associated with a volar locking plate was noted in any case. Volar tilt on radiography were 11° (4–14). The depth of the lunate fossa on CT was 3.9 ± 0.7 mm in the patients.

Conclusion

This procedure may be useful for osteosynthesis of distal radius fracture accompanied by intra-articular volar displaced fragments.

•

We reported our devision for distal radius fractures.

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Our procedure may be useful.

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It is difficult to fix volar displaced fragment.

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.

Stabilization of Volar Ulnar Rim Fractures of the Distal Radius: Current Techniques and Review of the Literature

Background Distal radius fractures involving the lunate facet can be challenging to manage. Reports have shown the volar carpal subluxation/dislocation that can occur if the facet is not appropriately stabilized. Literature Review Recent emphasis in the literature has underscored the difficulty in managing this fracture fragment, suggesting standard volar plates may not be able to adequately stabilize the fragment. This article reviews the current literature with a special emphasis on fixation with a specifically designed fragment-specific hook plate to secure the lunate facet. Case Description An extended flexor carpi radialis volar approach was made which allows access to the distal volar ulnar fracture fragment. Once provisionally stabilized with Kirschner wire fixation, a volar hook plate was applied to capture this fragment. Additional fracture stabilization was used as deemed necessary to stabilize the remaining distal radius fracture. Clinical Relevance The volar marginal rim fragment remains a challenge in distal radius fracture management. Use of a hook plate to address the volar ulnar corner allows for stable fixation without loss of reduction at intermediate-term follow-up.

Distal Radius Volar Rim Fracture Fixation Using DePuy-Synthes Volar Rim Plate

Background To assess the results of distal radius fractures with the involvement of the volar rim fixed with the DePuy-Synthes Volar Rim Plate. Case Description We searched for the patients with volar rim fracture and/or volar rim fractures as part of a complex fracture fixed with a volar rim plate. Ten patients met the inclusion criteria: three patients with type 23B3, six patients with type 23C, and one patient with very distal type 23A. The mean follow-up was 14 months (range: 2-26). Fractures healed in all patients. Of the three patients with isolated volar rim fractures (type 23B3), two patients had no detectable deficits in motion. These patients had an average Gartland and Werley score of 9 (range: 2-14). Of the other seven patients (six with type 23C and one with type 23A fracture), three patients healed with full range of motion and four had some deficits in range of motion. Two patients had excellent results, three had good results, and two had fair results using the Gartland and Werley categorical rating. One patient healed with a shortened radius and ulnar impingement requiring a second surgery for ulnar head resection arthroplasty. Literature Review Results after nonoperative treatment of volar rim fractures are not satisfactory and often require subsequent corrective osteotomy. Satisfactory outcomes are achieved when the fragments are well reduced and secured regardless of the device type. Clinical Relevance Volar rim plates give an adequate buttress of the volar radius distal to volar projection of the lunate facet and do not interfere with wrist mobility. Furthermore, the dorsal fragments can be fixed securely through the volar approach eliminating the need for a secondary posterior incision. However, patients should be informed of the potential problems and the need to remove the plate if symptoms develop.

Fixation Options for the Volar Lunate Facet Fracture: Thinking Outside the Box

Background Fractures of the distal radius with small volar ulnar marginal fracture fragments are difficult to stabilize with standard volar locking plates. The purpose of this study is to describe alternative techniques available to stabilize these injuries. Materials and Methods Five patients were identified retrospectively with unstable volar lunate facet fracture fragments treated with supplemental fixation techniques. The demographic data, pre- and postoperative radiographic parameters, and early outcomes data were analyzed. The AO classification, preoperative and final postoperative ulnar variance, articular step-off, volar tilt, radial inclination, and teardrop angle were measured. The lunate subsidence and length of the volar cortex available for fixation were measured from the initial injury films. Description of Technique Lunate facet fixation was based on the morphology of the fragment, and stabilization was achieved with headless compression screws in three patients, a tension band wire construct in one, and two cortical screws in another. Results Five patients with a mean age of 58 years (range: 41-82) were included. There were two AO C3.2 and three B3.3 fractures. Preoperative radiographic measurements including radial inclination, tilt, and ulnar variance all improved after surgery and were maintained within normal limits at 3-month follow-up. There was no change in the teardrop angle at final follow-up (70-64 degrees; p = 0.14). None of the patients had loss of fixation or volar carpal subluxation. The mean visual analog scale pain score at 3 months was 1 (range: 0-2). Conclusions The morphology of volar lunate facet fracture fragments is variable, and fixation must be customized to the particular pattern. Small fragments may preclude the use of plates and screws for fixation. These fractures can be managed successfully with tension band wire constructs and headless screws. These low-profile implants may decrease the risk of tendon irritation that might accompany distally placed plates.

Volar Marginal Rim Fracture Fixation With Volar Fragment-Specific Hook Plate Fixation

PURPOSE

To review the outcomes of patients treated with a volar hook plate specifically designed to capture volar marginal rim fractures.

METHODS

A retrospective study was performed over 18 months of patients treated with a volar hook plate in the management of AO type B or C distal radius fractures with a volar marginal rim fragment. Clinical and radiographic outcomes were evaluated.

RESULTS

The series included 26 wrists in 25 patients, average age 55 years. Average follow-up was 9 months (range, 3-30 mo). Twenty patients had AO type C fractures and 6 had AO type B fractures. All 6 AO type B were B3 fractures. Of the AO type C, 1 had C1, 7 had C2, and 12 had C3. No patients had loss of fixation of the critical volar ulnar corner and there was no evidence of carpal subluxation. Five patients required hardware removal. Four patients experienced hardware irritation requiring removal of all hardware including the volar hook plate. One patient required partial hardware removal that did not include the volar hook plate. All patients with volar hardware irritation had hook plates that were of second-generation design that had a prominent bend, which has since been modified. There were no cases of tendon rupture.

CONCLUSIONS

Volar marginal rim fragments of intra-articular distal radius fractures are not amenable to standard volar plate fixation. Fragment-specific fixation using a volar hook plate designed specifically for these fragments allowed for stable fixation when combined with other fragment-specific fixation techniques. There was no loss of fixation of the critical corner in this series. Although hardware irritation can occur, fully seated hooks and subsequent modification of the design of the hook bend has diminished this complication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Volar locking plate fixation of distal radius fractures: use of an intra-operative 'carpal shoot through' view to identify dorsal compartment and distal radioulnar joint screw penetration

INTRODUCTION

We report our experience using a 'carpal shoot through' view of the distal radius to identify dorsal compartment screw penetration intra-operatively when performing volar plating of the distal radius.

METHODS

A prospective study of 42 patients (mean age 56 years) with acute distal radius fractures treated with open reduction internal fixation was undertaken. Surgical fixation was performed using a volar locking plate in all patients. After plate application, inclined posteroanterior and lateral radiographs were taken followed by the carpal shoot through view.

RESULTS

In six cases (14 %), the carpal shoot through view revealed dorsal screw protrusion, which was not detectable on standard PA and lateral views. In one case, a screw had penetrated the distal radioulnar joint (DRUJ), which was only apparent on the shoot through view. The overall screw exchange rate was 17 %.

CONCLUSIONS

Using the hand and carpus to minimise the contrast in X-ray penetration, the dorsal cortex of the distal radius may be imaged intra-operatively and dorsal compartment screw penetration detected in cases with significant multifragmentation when screw measurement is difficult. This view potentially reduces the risk of post-operative pain and extensor tendon injury and also provides excellent visualisation of the DRUJ.

Exposure of the forearm and distal radius

Approaches to the forearm use internervous planes to allow adequate bone exposure and prevent muscle denervation. The Henry approach utilizes the plane between muscles supplied by the median and radial nerves. The Thompson approach utilizes the plane between muscles supplied by the radial and posterior interosseous nerves. The distal radius may be approached volarly. The extended flexor carpi radialis approach is useful for intraarticular fractures, subacute fractures, and malunions. The distal radius can be approached dorsally by releasing the third dorsal compartment and continuing the dissection subperiosteally. Choice of approach depends on the injury pattern and the need for exposure.

Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study

BACKGROUND

There are relatively few studies in the literature that specifically evaluate accelerated rehabilitation protocols for distal radial fractures treated with open reduction and internal fixation (ORIF). The purpose of this study was to compare the early postoperative outcomes (at zero to twelve weeks postoperatively) of patients enrolled in an accelerated rehabilitation protocol with those of patients enrolled in a standard rehabilitation protocol following ORIF for a distal radial fracture. We hypothesized that patients with accelerated rehabilitation after volar ORIF for a distal radial fracture would have an earlier return to function compared with patients who followed a standard protocol.

METHODS

From November 2007 to November 2010, eighty-one patients with an unstable distal radial fracture were prospectively randomized to follow either an accelerated or a standard rehabilitation protocol after undergoing ORIF with a volar plate for a distal radial fracture. Both groups began with gentle active range of motion at three to five days postoperatively. At two weeks, the accelerated group initiated wrist/forearm passive range of motion and strengthening exercises, whereas the standard group initiated passive range of motion and strengthening at six weeks postoperatively. Patients were assessed at three to five days, two weeks, three weeks, four weeks, six weeks, eight weeks, twelve weeks, and six months postoperatively. Outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) scores (primary outcome) and measurements of wrist flexion/extension, supination, pronation, grip strength, and palmar pinch.

RESULTS

The patients in the accelerated group had better mobility, strength, and DASH scores at the early postoperative time points (zero to eight weeks postoperatively) compared with the patients in the standard rehabilitation group. The difference between the groups was both clinically relevant and statistically significant.

CONCLUSIONS

Patients who follow an accelerated rehabilitation protocol that emphasizes motion immediately postoperatively and initiates strengthening at two weeks after volar ORIF of a distal radial fracture have an earlier return to function than patients who follow a more standard rehabilitation protocol.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcomes and cost of care for patients with distal radius fractures

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997-2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

Comparison of treatment of unstable intra articular fractures of distal radius with locking plate versus non-locking plate fixation

INTRODUCTION

Unstable intra articular fractures of distal radius are frequently being managed with open reduction and internal fixation. Of late in some biomechanical studies locking plates have been shown to be better in terms of maintenance of radiological parameters in comparison to non-locking plates. We conducted this study to know whether this biomechanical superiority of locking plates is converted in to better clinical outcomes.

MATERIALS AND METHODS

A study was conducted in 60 patients (30 in each group) with unstable intra articular fractures of distal radius who were treated by open reduction and internal fixation with locking plates and non-locking plates. Patients were evaluated for radiological parameters (intra articular step off, radial height, radial tilt, volar tilt) and functional parameters (flexion, extension, radial deviation, ulnar deviation, pronation, supination grip strength) at two year follow up. Overall outcome was evaluated by scoring systems of Gartland and Werley and modified Green O' Brien.

RESULTS

The change in radiological parameters from immediate post op to latest at two year in locking plate group was not significant for radial height, radial tilt, volar tilt, but ulnar variance whereas in non-locking plate there was significant change in radial height, volar tilt, ulnar variance but no significant change in radial inclination. In clinical and functional outcome no significant difference was found at two year follow up.

CONCLUSIONS

Locking plates maintain the radiological parameters better than non-locking plates but functional outcome are same for both plates at two year after surgery.

Corrective distal radius osteotomy following fracture malunion using a fixed-angle volar locking plate

Post-traumatic distal radius deformity may cause severe morbidity, and corrective osteotomy is often necessary to realign the functional axis of the wrist to correct symptomatic malunion. The aim of this retrospective study was to review the short-term results of a single surgeon’s series of distalradius corrective osteotomies following fracture malunion using a fixed-angle volar locking plate for 20 patients(16 women) of an average age of 57 (range 19–83) years [corrected].At short-term follow up (average 14 months, range 12-15 months), no complications were noted and radiological union was confirmed in all cases at an average of 3 months. The average post-operative Disability of the Arm, Shoulder and Hand score was 13.48 (range 0-48.33) and an objective improvement was noted in movements at the wrist joint. A statistically significant improvement was achieved in ulnar variance, radial inclination, dorsal tilt, and supination.

Volar plate fixation failure for volar shearing distal radius fractures with small lunate facet fragments

PURPOSE

To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction.

METHODS

A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction.

RESULTS

Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups.

CONCLUSIONS

Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention

STUDY DESIGN

Descriptive cross-sectional design.

INTRODUCTION

Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research.

PURPOSE OF THE STUDY

The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF.

METHODS

Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status.

RESULTS

Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable.

CONCLUSIONS

Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients.

LEVEL OF EVIDENCE

2c.

The association of education level on outcome after distal radius fracture

BACKGROUND

Socioeconomic factors have been found to be predictors of outcome for other ailments. The purpose of this study was to evaluate the association of patient education level on pain and disability after distal radius fracture.

METHODS

A series of patients with distal radius fractures (n = 335) were enrolled into a prospective research registry. Standard demographic information was obtained from patients, including a five-value categorical education variable. After treatment with closed reduction, external fixation, or internal fixation patients were evaluated for pain, function (Disability of the Arm, Shoulder, and Hand score [DASH]), range of motion (ROM), and grip strength at standard intervals until 12 months post-injury. A series of linear mixed effects models were developed to evaluate the relationship between time from injury and education level with each of the outcomes measured.

RESULTS

Complete demographic and 12-month follow-up data were available on 227 patients (75 %). There were neither group differences in mode of injury, severity, nor treatment modality after stratification by education level. Mixed effects model analyses revealed a significant linear association between level of education and measured outcomes at each follow-up point. Overall, each increase in education level demonstrated a doubling of improvement in pain, ROM, grip strength, and DASH score.

CONCLUSIONS

Outcome of distal radius fracture depends on acute care and follow-up rehabilitation; however, patient-related factors indicative of socioeconomic status are becoming increasingly relevant as predictors of outcome and should be considered by the orthopaedist.

Volar plate fixation of intra-articular distal radius fractures: a retrospective study

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

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

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

Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius

PURPOSE

To evaluate whether there was a difference in complication rates in our patients treated with external fixation versus volar plating of distal radius fractures. We also looked for a difference in radiographic results; in the clinical outcomes of flexion, extension, supination, pronation, and grip strength; and in scores on the visual analog scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

METHODS

We reviewed 115 patients with comminuted intrarticular distal radius fractures. Of those patients, 59 were treated with external fixation and 56 with volar plate fixation. Postoperative radiographs, range of motion, and grip strength were measured; DASH and VAS pain questionnaires were administered; and complications were documented.

RESULTS

The external fixation group had a significantly higher overall complication rate. In the volar plate group, there were more tendon and median nerve complications, but this difference was not significant. Radiographically, the external fixator group demonstrated radial shortening of 0.7 mm, whereas the volar plate group demonstrated 0.3 mm of radial shortening during the postoperative period. There were no significant differences between the groups in the measurement of scapholunate angle or palmar tilt. The mean DASH score at final follow-up was 32 in the external fixation group and 17 in the volar plate group, which was statistically significant. The final VAS scores were statistically different at 3.1 for the external fixation group and 1.1 for the volar plate group. On physical examination, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.

CONCLUSIONS

In the patients we studied, volar plate fixation has an overall decreased incidence of complications and significantly better motion in flexion-extension and supination-pronation compared to external fixation. Volar plate fixation also has less radial shortening than the external fixation group, yet the absolute difference in magnitude of ulnar variance was only 1.4 mm, calling into question the clinical significance of this difference. Patients with volar plating also have better pain and functional outcomes and better grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Dorsal screw penetration following implant removal after volar locked plating of distal radius fracture

Complications while removing implants are quite common. In rare cases screw shanks must be left in situ. We present a case of a 38-year-old patient who was treated using a palmar locking plate for a distal radius fracture. After implant removal, one of the screw shanks left in situ penetrated the dorsal cortex of the distal radius into the third extensor tendon compartment and led to irritation of the extensor pollicis longus tendon. We report the unexpected complication and analysis of possible errors of this case to avoid this kind of complication.

The surgical treatment of unstable distal radius fractures by angle stable implants: a multicenter prospective study

OBJECTIVES

The goal of this study is to document the 2-year outcome after surgical treatment of distal radius fractures using an angle stable implant.

DESIGN

Prospective case-series.

SETTING

Multicenter study in nine trauma units with recruitment between December 2001 and May 2003.

PATIENTS

One hundred eight patients with the same number of distal radius fractures.

INTERVENTION

Open reduction and internal fixation with the LCP DR 3.5 mm (Synthes GmbH, Oberdorf, Switzerland).

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand, Gartland and Werley, SF-36 scores, radiologic assessment, and return to work status at 2 years.

RESULTS

At 2 years, the mean range of motion (relative to the contralateral wrist) was 83% for palmar flexion, 91% for extension, 94% for radial deviation, 92% for ulnar deviation, and 98%/94% for pronation/supination angles. Grip strength was 90% of the mean uninjured side. The average radiographic measurements were 23.6° for radial inclination angle, 6.1° for palmar (volar) tilt angle, and 0 mm for ulnar variance. The proportion of fractures for which the Gartland and Werley score was categorized as either good or excellent was 89%. Minor complications occurred in 14 patients, although none of these events were considered to be directly related to the implant.

CONCLUSION

After a 2-year follow-up period, the use of an angle stable implant for unstable distal radius fractures provides adequate fixation with minimal loss of reduction. This device is associated with good functional and radiologic outcome for the patient and is indicated for distal radius fractures classified as Orthopaedic Trauma Association (OTA) Type 23-A2/A3, OTA Type 23-B2/B3, and OTA Type 23-C.