Management of distal radial fractures

Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients?

INTRODUCTION

Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing.

MATERIALS AND METHODS

From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device.

RESULTS

212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%.

CONCLUSION

The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus.

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.

Machine Learning Improves Functional Upper Extremity Use Capture in Distal Radius Fracture Patients

Current outcome measures, including strength/range of motion testing, patient-reported outcomes (PROs), and motor skill testing, may provide inadequate granularity in reflecting functional upper extremity (UE) use after distal radius fracture (DRF) repair. Accelerometry analysis also has shortcomings, namely, an inability to differentiate functional versus nonfunctional movements. The objective of this study was to evaluate the accuracy of machine learning (ML) analyses in capturing UE functional movements based on accelerometry data for patients after DRF repair. In this prospective study, six patients were enrolled 2-6 weeks after DRF open reduction and internal fixation (ORIF). They all performed standardized activities while wearing a wrist accelerometer, and the data were analyzed by an ML algorithm. These activities were also videotaped and evaluated by visual inspection. Our novel ML algorithm was able to predict from accelerometry data whether the limb was performing a movement rated as functional, with accuracy of 90.4% ± 3.6% for within-subject modeling and 79.8% ± 8.9% accuracy for between-subject modeling. The application of ML algorithms to accelerometry data allowed for capture of functional UE activity in patients after DRF open reduction and internal fixation and accurately predicts functional UE use. Such analyses could improve our understanding of recovery and enhance routine postoperative rehabilitation in DRF patients.

Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial

OBJECTIVE

To assess wrist function, quality of life, and complications in adult patients with a dorsally displaced fracture of the distal radius, treated with either a moulded cast or surgical fixation with K-wires.

DESIGN

Multicentre randomised clinical superiority trial, SETTING: 36 hospitals in the UK National Health Service (NHS).

PARTICIPANTS

500 adults aged 16 or over with a dorsally displaced fracture of the distal radius, randomised after manipulation of their fracture (255 to moulded cast; 245 to surgical fixation).

INTERVENTIONS

Manipulation and moulded cast was compared with manipulation and surgical fixation with K-wires plus cast. Details of the application of the cast and the insertion of the K-wires were at the discretion of the treating surgeon, according to their normal clinical practice.

MAIN OUTCOME MEASURES

The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) score at 12 months (five questions about pain and 10 about function and disability; overall score out of 100 (best score=0 and worst score=100)). Secondary outcomes were PRWE score at three and six months, quality of life, and complications, including the need for surgery due to loss of fracture position in the first six weeks.

RESULTS

The mean age of participants was 60 years and 417 (83%) were women; 395 (79%) completed follow-up. No statistically significant difference in the PRWE score was seen at 12 months (cast group (n=200), mean 21.2 (SD 23.1); K-wire group (n=195), mean 20.7 (22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66), P=0.87). No difference was seen at earlier time points. In the cast group, 33 (13%) of participants needed surgical fixation for loss of fracture position in the first six weeks compared with one revision surgery in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10).

CONCLUSIONS

Among patients with a dorsally displaced distal radius fracture that needed manipulation, surgical fixation with K-wires did not improve patients' wrist function at 12 months compared with a cast.

TRIAL REGISTRATION

ISRCTN registry ISRCTN11980540.

Influence of volar margin of the lunate fossa fragment fixation on distal radius fracture outcomes: A retrospective series

BACKGROUND

Distal radius fractures accompanied by the volar margin of the lunate fossa (VMLF) lesions are often overlooked or inadequately reduced in clinical practice.

AIM

To investigate the impact of VMLF fragment in distal radius fractures on the stability and function of the wrist joint.

METHODS

This was a retrospective study of patients with distal radius fractures who underwent surgical treatment between January 2013 and December 2017. The patients were divided into two groups according to whether the VMLF fragments were fixed or not. X-rays and computed tomography were performed before surgery, immediately postoperatively, and at 1, 3, and 6 mo to measure the scapholunate angle, radiolunate angle, capitolunate angle, and effective radiolunate flexion (ERLF). The Mayo wrist score and disabilities of the arm, shoulder, and hand (DASH) score were determined at 1 year.

RESULTS

Thirty-five patients were included. There were 15 males and 20 females. Their mean age was 52.5 ± 14.3 (range: 19-70) years. There were 38 wrists (17 on the left side, 15 on the right, and three bilateral; 16 in the fixed group, and 22 in the unfixed group). The interval between trauma and surgery was from 1 h to 1 mo. The incidence of postoperative wrist instability in the unfixed group (86.4%) was higher than in the fixed group (25.0%) (P ≤ 0.001). Ten patients had ERLF > 25° in the unfixed group and none in the fixed group (P = 0.019). The Mayo wrist score was 94 ± 5.7 in the fixed group and 68 ± 15.1 in the unfixed group (P < 0.001). The DASH score was 4.6 ± 2.5 in the fixed group and 28.5 ± 19.5 in the unfixed group (P < 0.001).

CONCLUSION

Injuries of VMLF, even small fractures, might damage the radial-lunar ligament, leading to postoperative wrist instability, sagittal force line imbalance, and poor recovery of wrist joint function.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures

Introduction:

Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups.

Materials and Methods:

Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated.

Results:

Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts.

Discussion/Conclusions:

The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care.

Level of evidence:

Prognostic Level III

The treatment of complex intra-articular distal radius fractures with turning radius and distal volaris radius plate fixation

BACKGROUND

Although distal radius fractures (DRFs) are clinically common, intra-articular DRFs accompanied by dorsally displaced free fragments are much less so. At present, it is very difficult to fix and stabilize the intra-articular distal radius fractures accompanying dorsally displaced free fragments with a plate. Our aim was to investigate the clinical effect of DRFs with distally displaced dorsal free mass treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach.

METHODS

From 2015 to 2019, 25 patients with intra-articular distal radius fractures associated with dorsally displaced free fragments were selected and treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. This study involved 14 males and 11 females, with an average age of 34.5 years (ranging from 21 to 50 years). The mean follow-up period was 16.5 months (ranging from 12 to 22 months). The dorsal displacement of the free fragments was analyzed by X-ray and three-dimensional computed tomography, allowing characterization of postoperative recovery effects by radial height, volar tilt and radial inclination. For the follow-up, we evaluated effects of the surgery by analyzing range of motion (ROM); Modified Mayo Wrist Score (MMWS); and Disabilities of Arm, Shoulder and Hand (DASH) score. Postoperative wound recovery and complications were also monitored to evaluate the clinical therapeutic effects of the surgical procedures.

RESULTS

X-ray showed that all patients showed reduced fractures, well-healed wounds and recovered function with no obvious complications. Based on the follow-up, patients had a mean radial height of 10.5 mm (ranging from 8.1 to 12.6 mm), mean MMWS of 78.8° (ranging from 61° to 90°), mean DASH score of 16.25 (ranging from 11 to 21), mean ROM for volar flexion of 76.5° (ranging from 62° to 81°), mean ROM for dorsiflexion of 77.1° (ranging from 59 to 83) and mean VAS score of 1.4 (ranging from 1 to 3).

CONCLUSION

Treatment of the intra-articular distal radius fractures accompanying dorsally displaced free fragments with turning of the radius and the DVR plate system via the distal palmar approach is effective and has no obvious complications.

Age-Related Variations in Volar Cortical Angle of the Distal Radius

Background: The ideal volar locking plate for the treatment of distal radius fracture should anatomically fit the volar surface of the distal radius. The purpose of this study was to measure the volar cortical angle (VCA) of uninjured adult distal radii to determine how well the VCA matches that of modern volar locking plates and whether variations in the VCA are related to demographic factors. Methods: A retrospective radiographic analysis of 273 uninjured adult distal radii was performed. Patients were stratified into age quintiles: less than 27 years, 27 to 43 years, 44 to 51 years, 52 to 64 years, and 65 years or older. The VCA was measured on lateral wrist radiographs, and patient demographics, including age and sex, were collected. Multivariable linear regression analyses were performed to determine the relationship between VCA and demographic factors. Results: The VCA ranged from 23.2° to 42.6°, with a mean of 32.2° (SD = 3.79). Mean VCA was 32.8 (SD = 4.17) in the youngest cohort (<27 years) and 30.4 (SD = 3.63) in the oldest cohort (>65 years). Mean VCA decreased with age, approximately 0.04° per year after adjusting for sex. Men had a 1.6° greater VCA than women after adjusting for age. Conclusion: Mean VCA was greater than the VCA of modern volar locking plates. The VCA decreased with age in both men and women, and men had a greater VCA than women. Such differences must be taken into account to avoid malreduction, tendon irritation, or intra-articular screw placement using current volar plate designs.

When a volar locking plate is not the right choice in fractures of the distal radius: Case based technical considerations

A volar approach is commonly used for fixation of distal radius fractures with a volar locking plate. There are certain fracture patterns for which volar locked plating is not suitable. This case based review outlines such case examples.

Medial anatomical buttress plate in treating displaced femoral neck fracture a finite element analysis

BACKGROUND

Displaced femoral neck fractures in young adults are most likely to result from high energy trauma that causes a vertically-oriented shearing injury through the femoral neck. The optimal strategy for treatment of displaced femoral neck fractures remains an unsolved challenge in orthopedic surgery.

METHODS

our group has previously designed a medial anatomical buttress plate (MABP) based on the analysis of the computed tomography (CT) data of anatomical structures derived from a large sample population. In this study, finite element analyses (FEA) were carried out to compare the outcomes of the combination of our MABP with cannulated screws to those of the combination of tubular plate with cannulated screws, and to those of using cannulated screws alone.

RESULTS

MABP resulted in a more stable fixation as compared to the other two approaches, with respect to the femur and the stress distributions, stress peaks, and Z axis displacements.

CONCLUSIONS

The FEA encouraged us that addition of a medial buttress plate not only achieved superior medial buttress stability but also achieves superior performance because it perfectly fits with the existing anatomic structure of medial femoral neck. The results from our study may provide references for clinical decision making in dealing with such patients.

Biomechanical considerations for strategies to improve outcomes following volar plating of distal radius fractures

This article is a systematic review of the recent published literature on the biomechanics of volar locking plate fixation of distal radius fractures. PUBMED/MEDLINE and EMBASE databases were searched on 13th Sep 2018. Biomechanical papers on volar locking plate fixation of distal radius fractures since 2010 were included. Papers were analysed and included studies were appraised by the author using the validated quality assessment GRADE tool. The search revealed 456 papers between January 2010 and the present day whose abstracts were reviewed for relevance and 21 papers were included for full paper review. The aim of this systematic review was to evaluate the evidence to determine the surgical techniques and strategies that are associated with the best biomechanical outcomes of volar plating for distal radius fractures. Review of the literature revealed that it was not necessary to fill all available distal locking screws, there was little evidence to support the use of 2 rows of screws distally over 1 row. Screws of 75% length of the distal cortex are sufficient to withstand standard postoperative regimes in extrarticular fractures. The was a paucity of evidence to conclude multidirectional locking plates were superior to fixed angle plates or that one brand of plate was superior to another.

A Comparison of Radiographic Outcomes between 3D Preoperative Planning and Conventional Planning in the Osteosynthesis of Distal Radius Fractures

Background: To assess the usefulness of three-dimensional (3D) digital pre-operative planning, we compared the radiographic parameters of the distal radius from 3D planning and conventional planning after osteosynthesis of distal radius fractures. We hypothesized that the use of 3D digital planning may improve radiographic outcomes for reduction and decrease the risk of correction loss. Methods: Sixty wrists of 60 distal radius fracture patients were randomly divided into two groups according to the order of hospital visits. Thirty wrists were treated with 3D preoperative planning as the plan group. Another thirty wrists were treated with conventional preoperative planning as the control group. Both groups were treated with volar locking plates. In the plan group, 3D digital preoperative planning and a surgical simulation were performed in order to determine the reduction and placement of the implants in addition to the plate/screw size prior to surgery. In the control group, conventional preoperative planning was performed. Ulnar variance, volar tilt, and radial inclination were measured at one week, three and six months after surgery. Difference of the measurement of radiographic parameters between operated and healthy side wrists were compared between plan and control groups at one week after surgery. Loss of corrections for radiographic parameters were compared between plan and control groups. Results: The differences between the operated and healthy side wrists were significantly smaller in the plan group compared to the control group for the volar tilt and radial inclination (p < 0.05).The loss of corrections for ulnar variance and volar tilt were significantly smaller in the plan group compared to the control group at six months after surgery (p < 0.05). Conclusions: 3D preoperative planning offers better reduction accuracy and reduces correction loss in the osteosynthesis of distal radius fractures.

Management of High Energy Distal Radius Injuries

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The use of dorsal distraction plating for severely comminuted distal radius fractures: A review and comparison to volar plate fixation

INTRODUCTION

Optimal fixation for highly comminuted distal radius fractures remains a major treatment challenge for orthopaedic surgeons. Dorsal distraction plating can serve as an improved fixation technique by allowing reduction under ligamentotaxis, providing a dorsal buttress, addressing proximal comminution, and allowing for early weightbearing in polytrauma patients. The aim of this study was to review current literature regarding treatment of distal radius fractures treated with dorsal distraction plating.

METHODS

We performed a literature search in Pubmed and EMBASE databases to identify all studies analyzing use of dorsal distraction plating. Case reports, biomechanical and anatomic cadaver studies were excluded from analysis. Primary outcome measures were range of motion (ROM) at final follow up, grip strength, and radiographic parameters.

RESULTS

Eight studies were included in the final analysis. Pooled mean ROM after dorsal distraction plating was found to be 47.6° of flexion, 50.5° of extension, 76.0° of pronation, and 74.2° of supination. Pooled mean grip strength was 79.1% compared to the uninjured contralateral limb. Pooled mean volar tilt was 3.6°. Overall radial height was maintained at an average of 10.5 mm with a pooled mean loss of only 3.8 mm in length. Mean radial inclination was found to be 19.4 mm with patients having a mean ulnar variance of 0.5 mm.

DISCUSSION & CONCLUSION

Treatment of comminuted intra-articular distal radius fractures with dorsal distraction plating yielded excellent outcomes with very low complication rates, and has several advantages over volar plating and/or external fixation for these fractures. Necessity of plate removal remains a negative feature of this technique.

Carpal Translocation Following Dorsal Bridge Plate Fixation of Distal Radius Fractures: A Cadaveric Study

Background  Dorsal bridge plate fixation is an effective technique for stabilization of highly comminuted, complex distal radius fractures. However, it is unknown whether fixation to the second or third metacarpal is optimal. Given dorsal bridge plating spans the radiocarpal joint, it is unclear if the dorsal spanning plate affects carpal position. This study investigates differences in carpal translocation resulting from bridge plate distal fixation to either the second or third metacarpal. Methods  Ten paired cadaveric upper extremities without evidence of gross deformity or prior surgery distal to the elbow were evaluated with three-view wrist fluoroscopic images for baseline radiographic measurements. An unstable distal radius fracture model was created via a volar approach using a 1-cm osteotomy. Following fracture creation, a dorsal bridge plate was applied with random to the second metacarpal on one limb, and the third metacarpal on the contralateral limb. Laterality for distal fixation was chosen randomly. Fluoroscopic images were repeated and radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, radial rotation index, and carpal translocation were measured. Results  Radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, and radioscaphoid angle were not statistically different before and after fixation, or when comparing the second or third metacarpal fixation. Additionally, there was no difference in Taleisnik's ulnar translocation index, Chamay's ulnar translation index, or McMurtry's carpal translation index based on which metacarpal was used for distal fixation. Conclusions  Dorsal bridge plate fixation of distal radius fractures restores preoperative physiologic measures of the radius, ulna, and carpus. Carpal translocation was similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a bridge plate. Level of Evidence  This is a Level V, therapeutic study.

A Meta-analysis of Studies of Volar Locking Plate Fixation of Distal Radius Fractures: Conventional versus Minimally Invasive Plate Osteosynthesis

Background

Open reduction and internal fixation using a volar locking plate has been increasingly performed for distal radius fractures. Both conventional and minimally invasive plate osteosynthesis (MIPO) techniques are widely used to treat distal radius fractures. However, it is unclear which of the techniques yields better outcomes after surgery for distal radius fractures. The purpose of this meta-analysis was to compare the benefits of conventional and MIPO techniques for distal radius fractures in terms of clinical outcomes.

Methods

Medline, Embase, and the Cochrane Central Register of Controlled Trials electronic databases were searched for articles comparing the outcomes of the conventional and MIPO techniques and published up until July 2017. Data search, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated using various outcome measures.

Results

Four clinical studies were included in the analysis. No significant clinical differences were found between the techniques in clinical hand scoring, grip strength, and range of motion. However, patient satisfaction after surgery was significantly higher in the MIPO group than that in the conventional group (standard mean difference, −0.54; 95% confidence interval [CI], −0.79 to −0.29; I² = 0%). Furthermore, although there were no significant differences in volar tilt and ulnar variance between the two groups, radial inclination revealed a significant difference between the two groups (radial inclination: weighted mean difference, 1.20; 95% CI, 0.25 to 2.15; I² = 19%).

Conclusions

Both conventional and MIPO techniques were effective for patients with distal radius fractures. Despite limited high quality evidence to compare osteosynthesis with a volar locking plate via the conventional and MIPO techniques, the present study showed that the MIPO technique was associated with more favorable patient satisfaction.

Surgical fixation with K-wires versus plaster casting in the treatment of dorsally displaced distal radius fractures: protocol for Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT 2)

INTRODUCTION

Optimal management of distal radius fractures in adults remains controversial. Previous evidence and current clinical guidelines tell us that, if a closed reduction of a dorsally displaced fracture is possible, Kirschner wires (K-wires) are the preferred form of surgical fixation. However, the question remains whether there is any need to perform surgical fixation following a successful closed reduction, or is a simple plaster cast as effective? This is the protocol for a randomised controlled trial of manipulation and surgical fixation with K-wires versus manipulation and casting in the treatment of dorsally displaced distal radius fractures.

METHODS AND ANALYSIS

Adult patients with an acute dorsally displaced fracture of the distal radius are potentially eligible to take part. Prior to surgery, baseline demographic data, radiographs, data on pain/function using the Patient-Rated Wrist Evaluation Score (PRWE) and health-related quality of life (HRQoL) using the EuroQoL 5-dimension 5-level (EQ-5D-5L) will be collected. A randomisation sequence, stratified by centre, intra-articular extension of the fracture and age, will be administered via a secure web-based service. Each patient will be randomly allocated to either 'manipulation and surgical fixation with K-wires' or 'manipulation and plaster casting'. A clinical assessment, radiographs and records of early complications will be recorded at 6 weeks. PRWE and HRQoL outcome data will be collected at 3, 6 and 12 months post-randomisation. Further information will be requested with regard to healthcare resource use and any complications.

ETHICS AND DISSEMINATION

The National Research Ethic Committee approved this study on 6 October 2016 (16/SC/0462).The National Institute for Health Research Health Technology Assessment monograph and a manuscript to a peer-reviewed journal will be submitted on completion of the trial. The results of this trial will substantially inform clinical practice on the clinical and cost-effectiveness of the treatment of this injury.

TRIAL REGISTRATION NUMBER

ISRCTN11980540; Pre-results.

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.

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.

Is volar locking plate superior to external fixation for distal radius fractures? A comprehensive meta-analysis

Objective

The aim of this meta-analysis of randomized controlled trials (RCT) and retrospective cohort studies (CS) regarding the use of volar locking plate (VLP) and external fixation (EF) in distal radius fractures was to determine whether there was any evidence that one treatment was superior to the other.

Methods

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electrical databases (PubMed, EMBASE and the Cochrane library) were retrieved to find RCTs and CSs met the eligibility criteria. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis with RevMan 5.1. The publication bias was test by Stata 14.0. The Begg's and Egger's test were performed by Stata 14.0. The quality of evidence was graded according to the criteria of GRADE. We ultimately included ten RCTs and eleven CSs.

Results

A total of 1590 subjects were reported. Publication bias was detected by funnel plot in RCTs. VLP could provide better results such as DASH scores (RCT: MD = −6.12, 95%CI = −12.07–0.17; CS: MD = −6.43, 95%CI = −12.53–0.3), ulnar variance (RCT: MD = −0.81, 95%CI = −1.25–0.37) and infection rate (RCT: RR = 0.25, 95%CI = 0.10–0.65; CS: RR = 0.15, 95%CI = 0.06–0.40). There were no significant differences for G-W scores, VAS and grip strength between the VLP group and EF group. There was significantly greater loss of volar tilt (P = 0.01) and radial inclination (P = 0.02) in patients receiving EF, basing on the CSs.

Conclusions

VLP could provide better results, such as DASH scores, ulnar variance, volar tilt, radial inclination and infection rate. The use of VLP appear to be associated with better results of ROM (flexion, pronation, supination and radial deviation), radiographic parameters (volar tilt and radial inclination) and lower total complication rate and CRPS rate in CSs.

Level of evidence

Level 1, Therapeutic study.

The diagnostic accuracy of ultrasonography in determining the reduction success of distal radius fractures

Objective

We evaluated the sensitivity and specificity of bedside ultrasound (US) for determining the success of reduction of displaced distal radius fractures. In addition, we determined the ability of US to diagnose causes of unsuccessful reduction.

Methods

In a prospective, double-blind fashion, patients over 18 of age whose acute distal radius fracture was to be reduced were approached for inclusion. The closed reductions were performed by orthopedics residents. Post-reduction, the fracture was checked by an Emergency Medicine (EM) resident by US. Ultrasound images were evaluated by an EM attending physician blinded to X-ray findings and post-reduction X-ray images were evaluated by an orthopedic surgeon blinded to the US findings.

Results

Sixty patients agreed to participate in the study. Of these, reduction was deemed successful by X-ray in 40 (66.7%). Of these 40, 39 (97.5%) were found to be successful reductions by US. In the 20 of 60 (33.3%) patients with unsuccessful reduction by X-ray, 19 (95%) were considered unsuccessful reductions by US. In evaluating the success of distal radius fracture reduction, compared to X-rays, US was 97.5% (95% CI 86.8 to 99.9) sensitive and 95% (95% CI 75.1 to 99.9) specific; its positive predictive value was 97.5% (95% CI 85.2 to 99.6) and negative predictive value 95% (95% CI 73.2 to 99.2).

Conclusions

Ultrasonography is highly sensitive and specific in determining the success of distal radius fracture reduction.

Volar Locking Plate Fixations for Displaced Distal Radius Fractures: An Evaluation of Complications and Radiographic Outcomes

BACKGROUND

A volar locking plate (VLP) is the most frequently used form of implant used for open reduction and internal fixation of distal radius fractures. They are known to have a complication rate of up to 27%. We hypothesized that plate design could influence complication rates.

METHODS

We performed a review of patients undergoing VLP fixation for distal radius fracture. A total of 228 patients underwent fixation with the Distal Volar Radial Anatomical (DVR) plate; 388 patients underwent fixation with the VariAx plate. Independent observers performed blinded case note and radiographic review, to assess for the quality of reduction, and complications for the inserted VLP.

RESULTS

Mean time to surgery was 6.0 days; mean follow-up was 17.5 weeks. Mean age was 56.5 years. The quality of reduction was classified as anatomical (46%), good (36.3%), moderate (13.0%), or poor (3.9%). Complications were identified in 109 patients (17%). Plate prominence was seen in 133 patients (21%). The DVR plate was less prominent ( P < .001) and had better overall radiographic appearances ( P = .025). Flexor tendon complications were related to plate prominence ( P = .005). Inferior reduction was associated with increased time to surgery ( P = .020).

CONCLUSIONS

This study highlights the importance of prompt surgery, effective fracture reduction, and careful plate positioning to avoid volar prominence.

Treatment of the distal radius fractures with percutaneous pinning: evolution to the HK2 system

Displaced fractures of the distal radius often require reduction and fixation to improve outcome in active patients. The volar locking plate gained ground over pinning, which was the first surgical solution described. But pinning methods have since evolved with fewer complications. The authors present a clinical study of distal radius fracture fixation using the HK2 technique, where subchondral pins are connected to intra-focal pins. The results are satisfactory with a lower complication rate compared to other pinning methods. This technical improvement relaunches the pinning technique, with its two advantages, being faster and significantly cheaper than locking plates, with similar long-term functional results.

The Cost-Effectiveness of Surgical Fixation of Distal Radial Fractures: A Computer Model-Based Evaluation of Three Operative Modalities

BACKGROUND

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value: closed reduction and percutaneous pinning, open reduction and internal fixation, or external fixation.

METHODS

We developed a Markov model that projected short-term and long-term health benefits and costs in patients undergoing a surgical procedure for a distal radial fracture. Simulations began at the patient age of 50 years and were run over the patient's lifetime. The analysis was conducted from health-care payer and societal perspectives. We estimated transition probabilities and quality-of-life values from the literature and determined costs from Medicare reimbursement schedules in 2016 U.S. dollars. Suboptimal postoperative outcomes were determined by rates of reduction loss (4% for closed reduction and percutaneous pinning, 1% for open reduction and internal fixation, and 11% for external fixation) and rates of orthopaedic complications. Procedural costs were $7,638 for closed reduction and percutaneous pinning, $10,170 for open reduction and internal fixation, and $9,886 for external fixation. Outputs were total costs and quality-adjusted life-years (QALYs), discounted at 3% per year. We considered willingness-to-pay thresholds of $50,000 and $100,000. We conducted deterministic and probabilistic sensitivity analyses to evaluate the impact of data uncertainty.

RESULTS

From the health-care payer perspective, closed reduction and percutaneous pinning dominated (i.e., produced greater QALYs at lower costs than) open reduction and internal fixation and dominated external fixation. From the societal perspective, the incremental cost-effectiveness ratio for closed reduction and percutaneous pinning compared with open reduction and internal fixation was $21,058 per QALY and external fixation was dominated. In probabilistic sensitivity analysis, open reduction and internal fixation was cost-effective roughly 50% of the time compared with roughly 45% for closed reduction and percutaneous pinning.

CONCLUSIONS

When considering data uncertainty, there is only a 5% to 10% difference in the frequency of probability combinations that find open reduction and internal fixation to be more cost-effective. The current degree of uncertainty in the data produces difficulty in distinguishing either strategy as being more cost-effective overall and thus it may be left to surgeon and patient shared decision-making.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of Computed Tomography in Determining the Occurrence of Dorsal and Intra-articular Screw Penetration in Volar Locking Plate Osteosynthesis of Distal Radius Fracture

Background: The use of volar locking plate in distal radius fracture can lead to extensor tendon rupture due to dorsal screw penetration. The aim of our study was to investigate the occurrence of dorsal and intra-articular screw penetration using CT scan after volar distal radius osteosynthesis for distal radius fractures.

Methods: Thirty patients who underwent distal volar locking plate for distal radius fracture were included in a retrospective study. In all 30 patients no dorsal and intra-articular screw penetration were detected on standard AP and lateral views of a plain radiograph. CT scan of the operated wrist was performed to determine the number of intra-articular and dorsal screw penetrations. Clinical examination was performed to determine the wrist functions in comparison to the normal wrist.

Results: Nineteen wrists were noted to have screw penetration either dorsally or intraarticularly. The highest incidence is in the 2nd extensor compartment where 13 screws had penetrated with a mean of 2.46 mm. Six screws penetrated into the distal radial ulnar joint and five screws into the wrist joint with a mean of 2.83 mm and 2.6 mm, respectively. However, there was no incidence of tendon irritation or rupture.

Conclusions: This study demonstrated a high incidence of dorsal and intra-articular screw penetration detected by CT scan which was not apparent in plain radiograph. We recommend that surgeons adhere to the principle of only near cortex fixation and downsizing the locking screw length by 2 mm.

Volar Plate Fixation in Patients Older Than 70 Years with AO Type C Distal Radial Fractures: Clinical and Radiologic Outcomes

Introduction  Treatment of unstable distal radial fractures (DRFs) in elderly patients is controversial, and considering the increasing life expectancy, their appropriate treatment is of growing importance. Our aim was to analyze the clinical and radiologic outcomes in the elderly patients with AO type C DRF treated with volar locking plate (VLP). Materials and Methods  Between 2007 and 2011, 572 DRFs were operated on in our hospital with open reduction and internal fixation with VLP. Of these, only 64 patients (66 DRFs) met the selection criteria (AO type C DRF, age > 70 years, minimum 12-month follow-up). Mean follow-up was 28 months. Outcome assessment included range of motion, grip strength, VAS pain, Mayo Clinic Score, and DASH score. Analysis of pre- and postoperative radiographs was performed. Complications were recorded. Statistical analysis was performed comparing the results with the contralateral side. Results  Mean postoperative range of motion of the injured wrist compared with the control contralateral side was 86% for flexion ( p  < 0.001), 92% for extension ( p  < 0.001). The average DASH was 12. Mayo Clinic Wrist Score showed 43 excellent results, 15 good, 4 satisfactory, and 4 poor. Articular step-offs were reduced in 34 of 38 wrists. Five (7%) patients required plate removal. Conclusion  The treatment of articular DRF (AO type C) with VLP in the elderly patients achieved greater than 90% of the wrist range of motion and grip strength with no residual pain in greater than 90% of the patients. Level of Evidence  Therapeutic IV, case series.

A comparative study of functional outcome of treatment of intra articular fractures of distal radius fixed with percutaneous Kirschner's wires vs T-plate

BACKGROUND & OBJECTIVE

Fractures of the distal radius are common with a variable prognosis in case of intra articular extension. The available options include Plaster, External fixation, Prefabricated Splintage using Ligamentotaxis, K-wire fixation, and open reduction internal fixation with T-plate without an as yet clear advantage of one over the others. If these fractures are allowed to collapse, radial shortening, angulation and articular incongruity may cause permanent deformity and loss of function. This limited small scale study was intended to compare the functional results of treatment of these fractures with a T plate and K-wires.

METHODS

This was a prospective experimental study conducted at department of Orthopedics of PGMI/Lahore General Hospital, Lahore. Total 30 patients were included and randomized into two groups of 15 patients each. Group-A patients were treated with Krischner's wires and Group-B patients were treated with a T-Plate with open reduction. Informed consent was taken. Post operative follow up was done for 12 weeks for the outcome parameters (Green and O'Brien score).

RESULTS

Mean age of patients in Group-A and B was 36.13±9.81 and 44.73±7.86 years respectively. In Group-A there were 10 male and 5 female patients and in Group-B there were 8 male and seven female patients respectively. In Group-A nine patients presented with Fernandez type-II and six patients presented with Fernandez type-III fracture. While in Group-B 10 patients presented with Fernandez type-II and five patients presented with Fernandez type-III fracture. Among Group-A patient's final outcome was excellent in 86.67% patients while in Group-B only 53.33% patients had excellent outcome at three months follow up.

CONCLUSION

Percutaneous Kirschner's wires appeared to be more effective as compared to T-Plate fixation in terms of functional outcome for treating intra-articular distal radius fractures.

Functional Outcome of Fixation of Complex Intra-articular Distal Radius Fractures with a Variable-Angle Distal Radius Volar Rim Plate

Aim To evaluate the outcome of these complex fractures using a volar approach and the DePuy Synthes variable-angle 2.4-mm distal radius rim plate. This plate is precontoured to the volar rim for placement distal to the watershed line allowing purchase of the rim fragment of the lunate facet. Its low profile and smooth edges are designed to minimize flexor tendon irritation. Method We report on a consecutive series of far distal AO-23B3 and AO-23C3 fractures treated using this plate in a tertiary hand center between November 2011 and May 2014. Range of motion, grip strength, and complications were assessed at the final clinical review. Disabilities of the arm, shoulder, and hand (DASH) and patient evaluation measure (PEM) scores were assessed at 12 months after surgery. Results Twenty-six patients were included in this review. Six patients were lost to follow-up at 3 months. This plate was used in isolation in 17 cases, and in combination with a dorsal plate, in cases of dorsal instability after volar plating, in 10 patients. DASH and PEM scores 1 year after surgery were 17.6 and 27%, respectively. Visual analog scores for patient treatment satisfaction and severity of pain showed good satisfaction with treatment and mild intermittent pain on activity. Postoperative range of motion was variable and grip strength was of 71% of the uninjured contralateral side. There were no cases of flexor or extensor tendon rupture. Tendon irritation was noted in two patients. Removal of metal was performed in four patients. Loss of reduction occurred in one case and neurologic complications in two cases. Conclusion This implant is specifically designed for the management of far distal complex intra-articular fractures of the distal radius. Despite the complexity of these fracture patterns and the challenge they pose to accurate reduction and stable fixation, outcomes were satisfactory in this small series. There were no cases of tendon rupture. Removal of metal is not necessary in all cases, but prompt removal should be performed in cases of tendon irritation in view of the risk of tendon rupture.

Volar locking distal radius plates show better short-term results than other treatment options: A prospective randomised controlled trial

AIM

To compare the outcomes of displaced distal radius fractures treated with volar locking plates and with immediate postoperative mobilisation with the outcomes of these fractures treated with modalities that necessitate 6 wk wrist immobilisation.

METHODS

A prospective, randomised controlled single-centre trial was conducted with 56 patients who had a displaced radius fracture were randomised to treatment either with a volar locking plate (n = 29), or another treatment modality (n = 27; cast immobilisation with or without wires or external fixator). Outcomes were measured at 12 wk. Functional outcome scores measured were the Patient-Rated Wrist Evaluation (PRWE) Score; Disabilities of the Arm, Shoulder and Hand and activities of daily living (ADLs). Clinical outcomes were wrist range of motion and grip strength. Radiographic parameters were volar inclination and ulnar variance.

RESULTS

Patients in the volar locking plate group had significantly better PRWE scores, ADL scores, grip strength and range of extension at three months compared with the control group. All radiological parameters were significantly better in the volar locking plate group at 3 mo.

CONCLUSION

The present study suggests that volar locking plates produced significantly better functional and clinical outcomes at 3 mo compared with other treatment modalities. Anatomical reduction was significantly more likely to be preserved in the plating group. Level of evidence: 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.

Intramedullary nailing for correction of post-traumatic deformity in late-diagnosed distal radius fractures

Background

Post-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius.

Materials and methods

From July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months.

Results

All fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8.

Conclusion

Surgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius.

Level of evidence

IV.

1-Year outcome of concomitant intracarpal lesions in patients with dislocated distal radial fractures: a systematic assessment of 78 distal radial fractures

INTRODUCTION

Ligamentous lesions are concomitant to dislocated distal radius fractures in a high percentage. The purpose of this study was to evaluate the relevance of intracarpal lesions.

METHODS

Seventy eight of an original cohort of 104 distal radius fractures (74%) were studied over a follow-up period of one year after surgery with complete data (X-rays, CT, MRI, follow-up X-rays and questionnaire).

RESULTS

Most of our radius fractures (AO 23 type: A 39, B 9, C 30) present additional lesions: 97%. One-year evaluation showed an average Castaing score of 4.5 ± 2.5 points, means a "good" result of a scale of 0-27. Fifty five of seventy eight had an "excellent" or "good" result (<6 points). No patient had more than 12 points ("fair").

CONCLUSIONS

The dislocated distal radial fracture implies severe and complex injury to the whole wrist, mostly concerning intracarpal concomitant lesions (MRI). Surgical therapy of dislocated radius fractures followed by 6 weeks relief through thermoplastic splint seems to be sufficient to achieve good 1-year results. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance.

Ultrasonic Evaluation of the Flexor Pollicis Longus Tendon Following Volar Plate Fixation for Distal Radius Fractures

PURPOSE

To evaluate with ultrasound the thickness of the flexor pollicis longus (FPL) tendon and its relationship to the volar locking plate after the fixation of distal radius fractures.

METHODS

We evaluated 27 type C2 and C3 distal radius fractures with ultrasound to evaluate damage to the FPL tendon after volar plate fixation. The thickness of the FPL tendon and its distance to the volar plate in the involved wrists and to the volar rim in the contralateral uninjured wrist were measured on sonograms taken 12 months postoperatively. Measurements of the involved wrists were compared with those of the intact wrists.

RESULTS

The mean plate-tendon distance in the involved wrist was considerably shorter than the mean volar rim-tendon distance in the intact wrist, and the FPL tendon was considerably thicker in the involved wrist than in the intact wrist.

CONCLUSIONS

In distal radial fractures treated with volar locking plates, increases in the thickness of the FPL tendon and a consequent decrease in the distance between the tendon and the plate can be determined with ultrasonography. This finding is a warning that asymptomatic tenosynovitis may eventually cause tendon ruptures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Optimal Positioning for Volar Plate Fixation of a Distal Radius Fracture: Determining the Distal Dorsal Cortical Distance

Distal radius fractures are currently among the most common fractures of the musculoskeletal system. With a population that is living longer, being more active, and the increasing incidence of osteoporosis, these injuries will continue to become increasingly prevalent. When operative fixation is indicated, the volar locking plate has recently become the treatment of choice. However, despite its success, suboptimal position of the volar locking plate can still result in radiographic loss of reduction. The distal dorsal cortical distance is being introduced as an intraoperative radiographic tool to help optimize plate position and minimize late loss of fracture reduction.

Treatment of unstable distal radius fractures: non-invasive dynamic external fixator versus volar locking plate - functional and radiological outcome in a prospective case-controlled series

Introduction: Distal radius fracture (DRF) is a common injury and various treatment modalities including open reduction and internal fixation (ORIF) with volar locking plate are available. More recently, a non-invasive external fixator has been used.

Aims: To prospectively compare the use of a non-invasive external fixator with early dynamisation for DRF against ORIF with volar locking plate control group.

Methods: Consecutive patients with closed DRF were included in a prospective case-controlled study. Patients were assigned to non-invasive external fixator or ORIF. Minimum follow-up was two years. Follow-up was at weeks 2, 4, 6, 8, 12, 26 and at one and two-year post-operatively. The outcome measures included demographic details, injury mechanism, AO fracture type, risk factors, body mass index (BMI), ulnar styloid fracture and dorsal comminution, radiographs, grip strength and DASH score.

Results: Consecutive 50 patients were treated either with non-invasive external fixator (25/50) or with ORIF (25/50) and the mean age of the two groups was 53 years (SD 17.1) and 49 years (SD 19.5), respectively. Demographics were matched in two groups. In the non-invasive external fixator group, there were 10 AO Type-A, 5 Type-B and 10 Type-C fractures. The ORIF group included 8 Type-A, 6 Type-B and 11 Type-C fractures. The mean DASH score at three-months and one-year post-injury in non-invasive fixator group was 12.2 (SD 3.1) and 3.5 (SD 0.7), respectively, significantly greater than those of ORIF group 14.5 (SD 5.6) and 11.2 (SD 4.4), respectively (p < 0.05).

Conclusion: DRF treated with non-invasive external fixator can give functional results superior to ORIF at three-months and the trend is maintained at one and two-year post-operatively.

Minimally invasive plate osteosynthesis in distal radius fractures with metaphyseal extension: A series of 13 cases

To evaluate objective and subjective outcomes after minimally invasive volar locked plate fixation of distal radius fractures with metaphyseal extension, we retrospectively evaluated 13 patients with unstable distal radius fractures with metaphyseal extension, treated by minimally invasive volar locked plating. Patients' average age was 41 years. Two volar incisions, 2 to 3cm long, were made; indirect reduction was performed and a volar locked T-plate was placed submuscularly under fluoroscopy guidance. Twelve fractures healed after an average of 2.46 months; one patient needed revision due to a new injury. The plate had to be removed in one patient. On X-rays, radial height averaged 12.78mm, radial inclination averaged 21.34° and volar tilt averaged 8.22°. Flexion averaged 75°, extension 71.5°, pronation 82.08° and supination 83.08°. Grip strength averaged 83.75% of the contralateral wrist. The DASH score averaged 13.91 points and pain assessed on VAS averaged 0.92 points. In unstable distal radius fractures with metaphyseal extension, minimally invasive plate osteosynthesis using volar locked plates led to good reduction and stable fixation, with low pain levels, and good functional and esthetic results. Indirect reduction techniques, fluoroscopy, and restoration of radial length, rotation and alignment, are necessary to achieve these outcomes.

LEVEL OF EVIDENCE

IV.

Hemiarthroplasty for Complex Distal Radius Fractures in Elderly Patients

Background In elderly patients, distal radius fractures frequently occur in osteoporotic bone and may be nonreconstructable. It is our hypothesis that a hemiarthroplasty replacment of the articular surface can provide satisfactory results in terms of range of motion, pain, and function for immediate salvage of a fracture that is not amenable to internal fixation. Methods Between July 2009 and January 2012, eight elderly patients were treated with insertion of a Sophia distal radius implant (Biotech, Paris, France). Inclusion criteria consisted of an isolated AO type C2 distal radius fracture in patients over 70 years old. All patients were reviewed by an independent surgeon. Results The mean follow-up was 25 months (range, 17-36 months). Mean wrist range of motion (ROM) was 45° (40-50°) of flexion, 44° (40-50°) of extension, and a mean pronation-supination arc of 160°. Mean grip force was 18 kgf. The mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) was 18.2/100 (6.82-29.55), and the mean visual analog scale (VAS) was 2.33 (0-4). X-ray images did not demonstrate implant loosening or ulnar translation of the carpus. Conclusions The Sophia hemiarthroplasty provided rapid recovery of independence in elderly patients with a nonreconstructable comminuted distal radius fracture.

Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures

The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

Randomized comparison of volar locking plates and intramedullary nails for unstable distal radius fractures

PURPOSE

To compare minimally invasive intramedullary nails (IMN) and volar locking plates (VLP) for the treatment of unstable distal radius fractures by evaluating postoperative subjective, radiographic, and functional outcomes. The hypothesis was that IMN patients would have less pain and required less pain medication in the early postoperative period and returned to work earlier than VLP patients.

METHODS

Sixty patients with closed, displaced, unstable, extra-articular, metaphyseal fractures of the distal radius were randomized to receive a VLP or an IMN for internal fixation. Functional outcomes (Quick Disabilities of the Arm, Shoulder, and Hand, Michigan Hand Questionnaire), radiographic measurements (ulnar variance, radial height, inclination, and volar tilt), and range of motion were assessed until final follow-up at 2 years after surgery. Narcotic pain medication use was documented for 5 weeks following surgery.

RESULTS

There were 2 groups of 30 patients with IMN (mean age, 55 ± 14 y) or VLP (mean age, 55 ± 16 y) with similar demographics and comorbidities. Patients with IMN regained extension earlier but had similar range of motion to patients with VLP at final follow-up. There was similar improvement in Michigan Hand Questionnaire, Quick Disabilities of the Arm, Shoulder, and Hand, and strength between groups. Five weeks after surgery, fewer IMN patients required narcotic pain medication (13%) than VLP patients (33%). Radiographic outcomes were similar at final follow-up. There were 3 failures with IMN versus 1 failure with VLP. All 10 employed patients with IMN returned to previous work compared with 10 of the 12 employed patients with VLP. Time to return to work was similar for both groups.

CONCLUSIONS

In a cohort of similar patients, IMN and VLP provided comparable improvement in functional and radiographic outcomes. Patients with IMN required less narcotic pain medication after surgery than VLP patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

[Carpal lesions associated with dislocated fractures of the distal radius. A systematic screening of 104 fractures using preoperative CT and MRI]

BACKGROUND

The functional outcome of surgically treated dislocated fractures of the distal radius is limited and does not correlate with radiographic results. Additional carpal lesions are assumed to be the cause. This study has evaluated which carpal lesions are associated with dislocated fractures of the distal radius.

MATERIAL AND METHODS

A total of 104 consecutive patients with dislocated fractures of the distal radius were included in the study. The injured wrist was examined by radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine additional carpal lesions.

RESULTS

Radiographically 51 of the 104 fractures presented as type A according to the AO classification, 10 as type B and 39 as type C. The CT scan detected that only 5 of the 51 type A fractures were exclusively metaphyseal fractures. All type A fractures were associated with ligamental lesions in MRI.

CONCLUSIONS

The results of the study confirm the hypothesis that every dislocated fracture of the distal radius is a combined carpal trauma associated with additional osseous and/or ligamental lesions.

Volar morphology of the distal radius in axial planes: a quantitative analysis

To investigate the cause of rupture of the flexor pollicis longus (FPL) after volar plate fixation of distal radius fractures, previous studies have examined the shape of the distal radius in the sagittal plane or in the lateral view. However, there are no reports on the anatomical shape of the volar surface concavity of the distal radius in the axial plane. We hypothesized that this concavity might contribute to the mismatch between the plate and the surface of the radius. To test this hypothesis, we constructed three-dimensional models of the radius and FPL based on computed tomography scans of 70 normal forearms. We analyzed axial cross-sectional views with 2 mm intervals. In all cases, the volar surface of the distal radius was concave in the axial plane. The concavity depth was maximum at 6 mm proximal to the palmar edge of the lunate fossa and progressively decreased toward the proximal radius. FPL was closest to the radius at 2 mm proximal to the palmar edge of the lunate fossa. The volar surface of the distal radius was externally rotated from proximal to distal. These results may help to develop new implants which fit better to the radius and decrease tendon irritation.

Early functional postoperative therapy of distal radius fracture with a dynamic orthosis: results of a prospective randomized cross-over comparative study

Introduction

This study was conducted according to GCP criteria as a prospective randomized cross-over study. The primary goal of the study was to determine clinical findings and patient satisfaction with postoperative treatment. 29 patients with a distal radius fracture that was surgically stabilized from volar and who met the inclusion criteria were enrolled over a 12-month period. Each patient randomly received either a dorsal plaster splint or a vacuum-fit flexible but blocked orthosis applied postoperatively in the operating theatre to achieve postoperative immobilization. After one week all patients were crossed over to the complementary device maintaining the immobilization until end of week 2. After week 2 both groups were allowed to exercise wrist mobility with a physiotherapist, in the orthosis group the device was deblocked, thus allowing limited wrist mobility. After week 4 the devices were removed in both groups. Follow-up exams were performed after postoperative weeks 1, 2, 4 and 12.

Results and Discussion

Results were determined after week 1 and 2 using SF 36 and a personally compiled questionnaire; after weeks 4 and 12 with a clinical check-up, calculation of ROM and the DASH Score. Comparison of the two groups showed a significant difference in ROM for volar flexion after 4 weeks, but no significant differences in DASH Score, duration of disability or x-ray findings. With regard to satisfaction with comfort and hygiene, patients were significantly more satisfied with the dynamic orthosis, and 23 of the 29 patients would prefer the flexible vacuum orthosis in future.

Trial Registration

German Clinical Trials Register (DRKS) DRKS00006097

Risk of tendon entrapment under a dorsal bridge plate in a distal radius fracture model

PURPOSE

To determine the risk of iatrogenic damage to the extensor tendons and sensory nerves under a bridge plate along the second versus third metacarpal.

METHODS

Using 6 paired (left-right) cadaver forearms-wrists and via a volar approach, we created a distal radius fracture with metaphyseal comminution. We then applied a dorsal distraction plate to either the second or third metacarpal. We next performed dorsal dissection of the hand and wrist over the zone of injury to determine the position of the plate relative to the extensor tendons and sensory nerves.

RESULTS

The bridge plate on the third metacarpal entrapped tendons of the first and third compartment in all 6 specimens. When the plate was applied to the second metacarpal there were no cases of tendon entrapment. There were no instances of nerve entrapment in plating to either the second or third metacarpal.

CONCLUSIONS

Distraction plating has been proposed for use in the second and third metacarpals for unstable comminuted distal radius fractures. We recommend formal exposure of the extensor tendons over the zone of injury when applying a distraction bridge plate to the third metacarpal.

CLINICAL RELEVANCE

Plating to the second metacarpal decreases the risk of entrapment of extensor tendons compared with plating to the third metacarpal.

UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius

BACKGROUND

In high-income countries, 6% of all women will have sustained a fracture of the wrist (distal radius) by the age of 80 years and 9% by the age of 90 years. Advances in orthopaedic surgery have improved the outcome for patients: many such fractures can be treated in a plaster cast alone, but others require surgical fixation to hold the bone in place while they heal. The existing evidence suggests that modern locking-plate fixation provides improved functional outcomes, but costs more than traditional wire fixation.

METHODS

In this multicentre trial, we randomly assigned 461 adult patients having surgery for an acute dorsally displaced fracture of the distal radius to either percutaneous Kirschner-wire fixation or locking-plate fixation. The primary outcome measure was the Patient-Rated Wrist Evaluation© (PRWE) questionnaire at 12 months after the fracture. In this surgical trial, neither the patients nor the surgeons could be blind to the intervention. We also collected information on complications and combined costs and quality-adjusted life-years (QALYs) to assess cost-effectiveness.

RESULTS

The baseline characteristics of the two groups were well balanced and over 90% of patients completed follow-up. Both groups of patients recovered wrist function by 12 months. There was no clinically relevant difference in the PRWE questionnaire score at 3 months, 6 months or 12 months [difference at 12 months: -1.3; 95% confidence interval (CI) -4.5 to 1.8; p=0.398]. There was no difference in the number of complications in each group and small differences in QALY gains (0.008; 95% CI -0.001 to 0.018); Kirschner-wire fixation represents a cost-saving intervention (-£727; 95% CI -£588 to -£865), particularly in younger patients.

CONCLUSIONS

Contrary to the existing literature, and against the increasing use of locking-plate fixation, this trial shows that there is no difference between Kirschner wires and volar locking plates for patients with dorsally displaced fractures of the distal radius. A Kirschner-wire fixation is less expensive and quicker to perform.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN31379280.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 17. See the NIHR Journals Library website for further project information.

Is minimally invasive application by intramedullary osteosynthesis in comparison with volar plating real benefit in the treatment of distal radius fractures?

PURPOSE OF THE STUDY

Can minimally invasive intramedullary osteosynthesis of distal radius fractures provide better therapeutic results than multidirectional locking plates. Retrospective study of 68 patients operated for distal radius fractures, 18 were treated with intramedullary X-screw (XSCR) fixation and 50 with the multidirectional angle-stable plate system (APTUS). The evaluation at 1-year follow-up included functional status of the wrist and hand, and radiographic findings. In the XSCR group, the functional outcomes of the treated extremity did not achieve values comparable with those of the uninjured side in any of the parameters measured. The radiographic findings did not meet the requirements of successful healing due to failure to restore an anatomical volar tilt in 22.2% cases. In the APTUS group, comparable values of the injured and the uninjured side were achieved in radial deviation, ulnar deviation, pronation, supination and grip strength. The radiographic criteria of successful healing were met by all fractures treated by locking plate osteosynthesis. Implant migration associated with secondary displacement of bone fragments was recorded in 33.3 % of the XSCR patients and only in 4.0 % of the APTUS patients. The overall evaluation show that intramedullary osteosynthesis does not produce better treatment outcomes compared with plate osteosynthesis in indicated types of fractures.

Comparison between cast immobilization versus volar locking plate fixation of distal radius fractures in active elderly patients, the Asian perspective

Displaced distal radius fractures in active elderly patients with high functional demand present a clinical dilemma because current evidence is equivocal in the recommendation of treatment. Internal fixation is an increasingly popular option with proposed superior results. Our study aims to evaluate the results among a population of active elderly patients with displaced fractures managed with either cast immobilization or internal fixation with volar locking plate. Seventy-five patients (35 cast immobilization and 40 internal fixation) with mean age of 74 ± 7.5 years with minimum of 12 months follow-up were studied. The radiological and clinical parameters were assessed at three, six, and 12 months. Functional outcomes (DASH, Green-O'Brien) were assessed at 12 months. Patients who underwent surgery regain wrist motion and grip strength earlier, but this was not statistically significant after six months.

Manipulation of displaced distal radial fractures in the superelderly: prediction of malunion and the degree of radiographic improvement

Superelderly patients (≥80 years old) account for 20% of all distal radial fractures and are at an increased risk of malunion. The primary aim of this study was to identify predictors of malunion and the degree of improvement in the fracture position offered by closed manipulation of displaced distal radial fractures in the superelderly. We retrospectively identified 228 displaced distal radial fractures in superelderly patients from a prospective database of 4024 distal radial fractures. The inclusion criterion was a patient that underwent closed manipulation as their primary intervention. The majority of patients (n = 196, 86%) were defined as having a malunion. A premanipulation dorsal angulation of greater than 25 degrees (P = 0.047) and an ulnar variance of 6 mm or more (P = 0.02) significantly increased the risk of malunion. The premanipulation dorsal angulation was a significant independent predictor of the degree of improvement in the final dorsal angulation (P < 0.001) and ulnar variance (P = 0.01). Patients with a high risk of malunion or poor improvement in the fracture position can be identified before manipulation and these patients may benefit from primary surgical intervention.