Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius

Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment - a biomechanical study

Complex intraarticular distal radius fractures (DRFs), commonly managed with volar locking plates, are challenging. Combined volar and dorsal plating is frequently applied for treatment, however, biomechanical investigations are scant. The aim of this biomechanical study was to investigate volar plating versus double plating in DRFs with different degrees of lunate facet comminution.Thirty artificial radii with simulated AO/OTA 23-C2.1 and C3.1 DRFs, including dorsal defect and lunate facet comminution, were assigned to 3 groups: Group 1 with two equally-sized lunate facet fragments; Group 2 with small dorsal and large volar fragment; Group 3 with three equally-sized fragments. The specimens underwent volar and double locked plating and non-destructive ramped loading in 0° neutral position, 40° flexion and 40° extension.In each tested position, stiffness: (1) did not significantly differ among groups with same fixation method (p ≥ 0.15); (2) increased significantly after supplemental dorsal plating in Group 2 and Group 3 (p ≤ 0.02).Interfragmentary displacements between styloid process and lunate facet in neutral position were below 0.5 mm, being not significantly different among groups and plating techniques (p ≥ 0.63).Following volar plating, angular displacement of the lunate facet to radius shaft was significantly lower in Group 1 versus both Group 2 and Group 3 (p < 0.01). It decreased significantly after supplemental dorsal plating in Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not differ significantly among the three groups after double plating (p ≥ 0.74).Comminution of the lunate facet within its dorsal third significantly affected the biomechanical outcomes related to complex intraarticular DRFs treated with volar and double locked plates.Double plating demonstrates superior stability versus volar plating only for lunate facet comminution within its dorsal third. In contrast, volar plating could achieve stability comparable with double plating when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicated achievable absolute stability between the articular fragments.

Combined palmar and dorsal plating of four-part distal radius fractures: Our clinical and radiological results

OBJECTIVES

This study aims to investigate the radiological and clinical outcomes of four-part intraarticular distal radius fractures treated with a volar anatomically locked plate and 2 mm low-profile plates using both the volar and dorsal approaches.

PATIENTS AND METHODS

This retrospective study included 20 patients (8 males, 12 females; mean age 47±12.1; range, 25 to 67 years) who received open reduction and internal fixation with combined volar and dorsal plating to treat complex four-part distal radius fractures (shaft, radial styloid area, dorsal medial facet, volar medial facet) between May 2016 and January 2019. According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, all fractures were 2R3-C3. According to Melone classification, one fracture was type 1, seven fractures were type 2a, three were type 2b, three were type 3 and six were type 4. The mean follow-up time was 21±7.5 (range, 12 to 36) months.

RESULTS

Union was achieved in all fractures. The mean tourniquet time was 103±12 (range, 90 to 130) minutes. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 10±9, and the mean Visual Analog Scale score was 2.1±0.9. According to Mayo wrist score, five patients had excellent, six had good, six had satisfactory and three had poor results. The mean grip strength was 25.2±9.2 (range, 15 to 40) kg and 78% of opposite side. Mean wrist flexion was 48.7°±15.3° (range, 30° to 80°), extension was 52.2°±17.2° (range, 25° to 80°), radio-ulnar deviation arc was 40.7°±6.9° (range, 30° to 55°), and mean forearm rotation arc was 152.3°±11° (range, 130° to 170°).

CONCLUSION

Plating method with a dual approach may be an alternative for four-part intraarticular distal radius fractures given its early mobility advantage and satisfactory functional and radiological results.

Fixation Strength in Full and Limited Fixation of Osteoporotic Distal Radius Fractures

BACKGROUND

The purpose of this investigation is to determine whether osteoporotic intra-articular distal radius fractures surgically treated by filling all 7 distal screws of a volar plate will have a higher load to failure than those treated by filling only 4 distal screws.

METHODS

Ten matched pairs of fresh frozen cadaveric forearms were randomized within each pair to be treated by using either all 7 of the distal holes of a volar plate or only 4 distal screws. The distal radius fixation was performed with unicortical screws going to but not through the dorsal cortex, and the most distal screws were placed within 4 mm of the joint surface. An AO C2 type fracture was then created. All specimens were tested cyclically, with an axial load of 60 N, at 3 Hz for 1000 cycles to simulate early postoperative motion. All specimens were subsequently tested to mechanical failure.

RESULTS

There were no failures in either group during cyclic testing. There was no difference detected between groups for mean stiffness, yield load, peak load, or load to clinical failure. In both groups, the yield load, peak load, and load to clinical failure were higher than the 60- to 100-N forces encountered during postoperative rehabilitation.

CONCLUSIONS

There was no difference detected between osteoporotic intra-articular distal radius fractures treated by utilizing all 7 of the distal screws of a volar plate compared with those treated with only 4 distal screws.

Fragment-Specific Fixation for Fractures of the Distal Radius

This article summarizes the management of distal fractures utilizing Acumed fragment-specific family of plates. No single plate option can address every fracture pattern of the distal radius. These fragment-specific plates are usually adjuncts to allow the surgeon to expand the armamentarium in the management of complex volar and dorsal comminuted distal radius fracture patterns.

Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and residents

Purpose

Classification, the definition of an acceptable reduction and indications for surgery in distal radius fracture management are still subject of debate. The purpose of this study was to characterise current distal radius fracture management in Europe.

Methods

During the European Congress of Trauma and Emergency Surgery (ECTES) 2015 a 20-question multiple-choice survey was conducted among the attending surgeons and residents of the hand and wrist session. Consensus was defined as more than 50 % identical answers (moderate consensus 50–75 % and high consensus more than 75 %).

Results

A total of 46 surgeons and residents participated in the survey. High consensus was found among both surgeons and residents for defining the AO/OTA classification as the preferred classification system. For the definition of an acceptable reduction, a moderate to high consensus could be determined. Overall, high consensus was found for non-operative treatment instead of operative treatment in dislocated extra- and intra-articular distal radius fractures with an acceptable closed reduction, regardless of age. We found high (surgeons) and moderate (residents) consensus on the statement that an intra-articular gap or step-off ≥2 mm, in patients younger than 65 years, is an absolute indication for ORIF. The same applied for ORIF in dislocated fractures without an acceptable closed reduction in patients younger than 75 years of age.

Conclusion

Current distal radius fracture management in Europe is characterised by a moderate to high consensus on the majority of aspects of fracture management.

[Complex fragmentation of the distal radial articular surface. Reconstruction with subchondral Kirschner wires and bone grafts]

BACKGROUND

Complex fragmentation of the distal radial articular surface often results in three major problems: some fragments are too small for stabilisation by standard plates or screws; in addition, substantial loss of articular surfaces and metaphyseal/subchondral bony defects frequently occur.

MATERIAL AND METHODS

To solve these problems the following strategy was developed: the fixation of small articular fragments was performed by small K-wires that were placed subchondrally and countersunk in the bone. In case of lost articular surfaces a silicone foil was inserted intra-articularly to induce a cartilage-like tissue. Bony defects were replaced by iliac crest bone grafts. Additional stability was achieved by dorsal and volar plate fixation or bridge plating.

RESULTS

An average of 53° of extension, 44° of flexion, 74° of pronation, and 66° of supination were achieved. The grip strength was an average of 61% of that in the contralateral limb. The average radiographic measurements were -5° of palmar inclination, 21° of ulnar inclination, and 0 mm of positive ulnar variance. A good or excellent functional result was achieved for five of seven wrists according to the rating system of Gartland and Werley. According to the modified Mayo Wrist Score four of five wrists achieved a good and one a fair result.The DASH Score averaged 19 (6-59) points.

CONCLUSIONS

The applied treatment resulted in stable, mobile wrists with reasonable alignment and nearly even articular surfaces. The functional results were similar to those reported by other authors for less complex distal radius fractures. This strategy seems to be a rational approach to the reconstruction of severely comminuted intra-articular fractures of the distal radius.

Management of distal radius fractures: treatment protocol and functional results

Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment is controversial and still debated in the literature. For a correct management of these lesions many authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint mobilisation. We report our experience in the daily management of these lesions. The fractures are evaluated considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture stability. The best treatment option must be decided in accordance to the type of fracture, the extent of metaphyseal comminution, the quality of the bone and the medical condition of the patient.

[Combined dorsal and palmar plate osteosynthesis for intraarticular distal radius fractures]

BACKGROUND

Complex comminuted intraarticular fractures of the distal radius require anatomic restoration. In rare cases, this aim can only be achieved by a combined dorsal and volar plate fixation despite increasing experience with volar locking compression implants. This retrospective quality control study investigated functional, radiological and subjective outcomes of patients treated with this technique.

METHODS

Between March 1999 and January 2003, 30 out of 360 patients who were operated on for an unstable distal radius fracture with complex C2/C3 type distal radius fractures at the Division of Trauma Surgery of the University Hospital Zurich, had been treated with a combined dorso-palmar plate fixation (dorsal two 1/4 tubular plates, volar 3.5 mm T-plate) and were included in this study (9 female, 21 male, mean age 52 years). Of the 30 patients 25 could be evaluated at an average of 29 months after injury.

RESULTS

Anatomic reconstruction could not be achieved in all cases, 56% showed mild and 28% explicit signs of arthrosis. Flexion reached 66% and extension 75% of the contralateral wrist, whereas pronation reached 98% and supination 91%, respectively. Grip strength achieved 75% of that of the contralateral side and 10 patients (40%) developed a complex regional pain syndrome (CRPS). Return to work was possible 120 days after the injury.

CONCLUSION

With the dorso-palmar plate fixation joint reconstruction in complex intraarticular distal radius fractures can be achieved with a satisfactory subjective, functional, and radiologic result, although additional soft tissue injury was caused by the bilateral approach. The patient has to be informed of the high rate of CRPS and the long period of disability.

Retrospective comparison of percutaneous fixation and volar internal fixation of distal radius fractures

A change in the practice of a single surgeon provided an opportunity for retrospective comparison of comparable cohorts treated with percutaneous fixation (17 patients) or a volar plate and screws (23 patients) an average of 30 months after surgery. The final evaluation was performed according to the Gartland and Werley and Mayo rating systems and the DASH questionnaire. There were no significant differences on the average scores for the percutaneous and volar plating groups, respectively: Gartland and Werley, 4 vs 5; Mayo, 82 vs 83; and DASH score 13 for both cohorts. Motion, grip, and radiographical parameters were likewise comparable. Volar internal plate and screw fixation can achieve results comparable to percutaneous fixation techniques in the treatment of fractures of the distal radius.

Long-term outcome of nonsurgically treated distal radius fractures

PURPOSE

To study the long-term outcome after nonsurgically treated distal radius fractures including recovery of grip strength, mobility, and radiographic parameters.

METHODS

Eighty-seven patients, mean age 55 (range 19-78) years, treated with closed reduction and casts, were evaluated radiographically and clinically during the first 6 months and finally after 9-13 years. Fifty patients had extra-articular fractures (AO Class A), 4 had simple intra-articular fractures (AO Class B) and 33 had complete intra-articular fractures (AO Class C).

RESULTS

Fifty-two of 66 patients with unilateral fractures were, after 9-13 years, rated as excellent/good according to the Green and O'Brien score as modified by Cooney et al (GOBC score). Fracture class according to AO did not correlate to outcome. Considerable fracture displacements remained: dorsal angulation (mean 13 degrees in <60 y, 18 degrees in >/=60 y), greater radial shortening than initially (mean 2 mm in <60 y, 3 mm in >/=60 y). Five patients had remaining joint step-off (1-2 mm) after reduction, but only one developed mild osteoarthritis. Patients with an unsatisfactory outcome had sustained more displaced fractures that also healed with greater displacement. The remaining subjective complaints were pain or reduced function during heavier tasks. Outcome was not correlated to age. Wrist mobility returned notably faster than grip strength. Patients over 60 years of age recovered slower in both mobility and strength. Closed reduction and plaster improved dorsal angulation but not radial shortening.

CONCLUSIONS

Our data indicate that a number of patients with nonsurgically treated distal radius fractures still experience some hand/wrist impairment a decade after the trauma. The severity of fracture displacement seems to influence the clinical outcome in contrast to patients' age. Recovery of grip strength is slower than that of range of motion. Elderly patients recover more slowly than young patients. Dorsal angulation was improved but remained considerable (13 degrees -18 degrees ), while final radial shortening (2-3 mm) increased from the injury status.