Inadvertent retention of angled drill guides after volar locking plate fixation of distal radial fractures. A report of three cases

Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature

Flexor tendon rupture after volar plate fixation of distal radius fracture (DRF) is rare. There is no consensus as to how to prevent them. The aim of our study was to identify the pathological mechanisms, and to establish the clinical and epidemiological profile of patients suffering from this complication. We carried out a systematic review using the PubMed, Scopus and Cochrane databases. Studies were included if they described complete or partial flexor tendon rupture following volar plate fixation of DRF. Forty-six 46 were included, for a total of 145 patients were reported: 138 from the literature, and 7 from our personal experience. Etiology was usually mechanical, by impingement with either the plate or protruding screws. Plate impingement was due to positioning beyond the watershed line, consolidation with posterior tilt, plate thickness, or low palmar cortical angle. Mean patient age was 62.4 years (range, 23-89 years). Median postoperative interval was 8 months (range, 3-120 months). Flexor pollicis longus was the most frequently injured tendon. The plate should be positioned proximally to the watershed line if possible, to ensure good initial reduction. Hardware should be removed 4 months after surgery if the plate is causing impingement according to the Soong criteria or if signs of tenosynovitis appear.

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.

Restoration of the volar cortex: predicting instability after manipulation of distal radial fractures

INTRODUCTION

Distal radial fractures are one of the most common fractures that are presented to the emergency department (ed). The management of non-emergent cases often involves closed reduction and immobilisation before referral to orthopaedic services. Surgical intervention is offered based on the criteria for instability. This can be predicted from the initial and post-manipulation radiographs. The purpose of this study was to assess the role of various predictors of instability in the requirement for surgery, based on specific evidence-based criteria.

PATIENTS AND METHOD

We audited 87 consecutive distal radial fractures that had been manipulated by the ED and analysed what factors predicted instability.

RESULTS

The most significant predictor of instability and hence further surgery was the failure to anatomically restore the volar cortex (VC) (p = 0.002) during the manipulation. Other significant factors were increasing age (p = 0.006) and fracture of the ulna styloid (p = 0.028). If the VC was restored or remained intact during the manipulation, only 38% required further surgery. If the VC was displaced or not restored, 65% required further surgery.

CONCLUSION

The restoration or maintenance of volar cortical alignment during the manipulation of distal radial fractures offers patients the best chance of avoiding the need for further surgery. This factor should be taken into account in the decision-making process for these fractures.

Incidence and clinical outcomes of tendon rupture following distal radius fracture

PURPOSE

To evaluate the incidence of tendon rupture after nonoperative and operative management of distal radius fractures, report clinical outcomes after tendon repair or transfer, and examine volar plate and dorsal screw prominence as a predictor of tendon rupture.

METHODS

We performed a retrospective chart review on patients treated for tendon rupture after distal radius fracture. We evaluated active range of motion, Disabilities of Arm, Shoulder, and Hand score, grip strength, and pain score, and performed radiographic evaluation of volar plate and dorsal screw prominence in both the study group and a matched control group.

RESULTS

There were 6 tendon ruptures in 1,359 patients (0.4%) treated nonoperatively and 8 tendon ruptures in 999 patients (0.8%) treated with volar plate fixation. At the time of final follow-up, regardless of treatment, we noted that patients had minimal pain and excellent motion and grip strength. Mean Disabilities of the Shoulder, Arm, and Hand scores were 6 for patients treated nonoperatively and 4 for those treated with volar plating.

CONCLUSIONS

We were unable to verify volar plate or dorsal screw prominence as independent risk factors for tendon rupture after distal radius fractures. However, we recommend continued follow-up and plate removal for symptomatic patients who have volar plate prominence or dorsal screw prominence. In the event of tendon rupture, we report excellent clinical outcomes after tendon repair or tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of distal radius fractures from the North American perspective

In North America, the rate of nonoperative management of displaced distal radius fractures has declined as the rate of internal fixation has increased. Volar locking plate fixation has increased in popularity despite a lack of supportive level 1 evidence. Issues of cost-effectiveness are relevant because there is no best-practice treatment at this stage. Clinicians should be aware of the goals of treatment and challenges, particularly in managing elderly patients with distal radius fractures. Large, randomized controlled trials or meta-analyses may provide answers about when operative intervention is favored over nonoperative management and which operative intervention provides the best outcomes.

Avoiding and treating perioperative complications of distal radius fractures

Numerous methods of treatment are available for the management of distal radius fractures, with modern trends favoring volar fixed-angle distal radius plates. Whatever the method of fixation, recognition, management, and prevention of the known associated complications are essential to achieve a good outcome. This article reviews the common preventable complications that are associated with operative treatment of distal radius fractures, including tendon injuries, inadequate reduction, subsidence or collapse, intra-articular placement of pegs or screws, nerve injuries, complex regional pain syndrome, carpal tunnel syndrome, and compartment syndrome.

Dorsally displaced extra-articular distal radius fractures fixation: Dorsal IM nailing versus volar plating. A randomized controlled trial

INTRODUCTION

Fractures of the distal radius are very common and mainly occur in the elderly. There has been an increasing use of locked volar plate fixations which report satisfactory results. However, some authors advocate the use of nail fixation.

HYPOTHESIS

The aim of this study is to compare dorsal nail plate versus locked volar plate fixation in the treatment of distal radius fractures with dorsal tilt.

MATERIALS AND METHODS

The mean age of the patients was over 50 years. The study included extra-articular distal radius fractures with posterior tilt. We conducted a prospective randomized study between December 2007 and February 2009 including a group of 16 patients treated with a dorsal nail fixation (group 1) and a group of 15 patients managed with a locked volar plate fixation (group II). We analyzed both the clinical results (complications, Range of motion [ROM], tightening strength, Disabilities of the Arm, Shoulder and Hand [DASH] and Mayo Clinic scores) and the radiographic results from A/P and lateral radiographs in the early postoperative period and at 6-month follow-up.

RESULTS

ROM toward extension was better in the volar plating subgroup (group I, 42.5°, group II, 57.5°; P<0.05). Pronation mobility was better in the dorsal nail subgroup (group I, 85°; group II, 80°; P<0.05). The locked volar plate fixation subgroup demonstrated a better recovery of the tightening strength as compared with the uninjured side (group I, 78%, group II, 90%, P=0.03). The DASH score was similar in both groups (group I, 22.09±22.9; group II, 20.62±20.3, P>0.05). The Mayo Clinic score was better in the locked volar plate fixation subgroup (group I, 65±13.4; group II, 85.6±19.2; P=0.002). Radiographic results were good in both groups, however anatomical reduction of the volar tilt was significantly better in group II (plate) when compared with the uninjured side. Moreover, we report on two cases of tendinous damages to the long extensor muscle of the thumb in the dorsal nail fixation subgroup despite the use of a minimally invasive implant.

CONCLUSION

The management of distal radius fractures with locked volar plate fixation in active elderly patients has proved successful and leads to better results than nail fixation regarding both reduction quality and objective functional scores.

LEVEL OF EVIDENCE

Level II, prospective, randomized of low-level.

Volar locking plate implant prominence and flexor tendon rupture

BACKGROUND

Flexor tendon injury is a recognized complication of volar plate fixation of distal radial fractures. A suspected contributing factor is implant prominence at the watershed line, where the flexor tendons lie closest to the plate.

METHODS

Two parallel series of patients who underwent volar locked plating of distal radial fractures from 2005 to 2008 and with at least six months of follow-up were retrospectively reviewed. Group 1 included seventy-three distal radial fractures that were treated by three orthopaedic hand surgeons with use of a single plate design at one institution, and Group 2 included ninety-five distal radial fractures that were treated by four orthopaedic hand surgeons with use of a different plate design at another institution. On the postoperative lateral radiographs, a line was drawn tangential to the most volar extent of the volar rim, parallel to the volar cortical bone of the radial shaft. Plates that did not extend volar to this line were recorded as Grade 0. Plates volar to the line, but proximal to the volar rim, were recorded as Grade 1. Plates directly on or distal to the volar rim were recorded as Grade 2.

RESULTS

In Group 1, the average duration of follow-up was thirteen months (range, six to forty-nine months). Three cases of flexor tendon rupture were identified among seventy-three plated radii (prevalence, 4%). Grade-2 plate prominence was found in two of the three cases with rupture and in forty-six cases (63%) overall. In Group 2, the average duration of follow-up was fifteen months (range, six to fifty-six months). There were no cases of flexor tendon rupture and no plates with Grade-2 prominence among ninety-five plated radii.

CONCLUSIONS

Flexor tendon rupture after volar plating of the distal part of the radius is an infrequent but serious complication. The plate used in Group 1 is prominent at the watershed line of the distal part of the radius, which may increase the risk of tendon injury. We found no ruptures in Group 2, perhaps as a result of the lower profile of the plate. Further studies are needed before recommending one plate over another. Regardless of plate selection, surgeons should avoid implant prominence in this area.

Complications of volar plate fixation for managing distal radius fractures

Volar locking plate fixation via open reduction and internal fixation is an increasingly accepted method for managing displaced distal radius fractures. Volar plating offers biomechanically stable fixation, allows early rehabilitation, and enables fixation of comminuted or osteopenic bone. The literature reporting complications of volar plate fixation is limited primarily to case reports and small case series. The surgeon must be mindful of potential soft-tissue, neurovascular, and osseous complications, such as extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, and loss of reduction, as well as hardware failure. Increased awareness of potential complications may lead to more prompt recognition and treatment when they do arise.

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.