Prospective study of distal radial fractures treated with an intramedullary nail

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE

Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome.

METHODS

The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°.

RESULTS

A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups.

CONCLUSION

According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study

Background

Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy.

Methods

We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups.

Results

All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms.

Conclusions

Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.

Minimally invasive internal fixation for extra-articular distal radius fracture: Comparison between volar plate and intramedullary nail

INTRODUCTION

There are numerous internal fixation techniques for distal radius fracture, using pins, plates or nails. Some authors have developed minimally invasive procedures. The aim of the present study was to compare two minimally invasive internal fixation techniques for unstable extra-articular distal radius fracture in women over 50 years of age: volar plate (minimally invasive plate osteosynthesis: MIPO), and intramedullary nail.

HYPOTHESES

The main study hypothesis was that the incision scar left by minimally invasive internal fixation is smaller using MIPO than an intramedullary nail. The secondary hypotheses were that the two techniques do not differ in terms of pain, functional score, strength, range of motion and radiologic indices.

MATERIAL AND METHOD

The series comprised nineteen A2.2 and one A2.1 fractures in 20 female patients with a mean age of 72 years. The first 10 (group 1) received minimally invasive internal fixation of the distal radius by MIPO, and the other 10 (group 2) by intramedullary nail locked onto the distal radius epiphysis and diaphysis.

RESULTS

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail (mean, 14.3mm vs. 32.8mm). Some of the secondary hypotheses were also confirmed: there were no differences between the two techniques in terms of pain at 6 months, QuickDASH, PRWE (Patient-Reported Wrist Evaluation), range of motion or ulnar variance; two were not confirmed: pain at 6 weeks was less with intramedullary nails, and palmar slope was better with MIPO.

DISCUSSION AND CONCLUSION

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail. In conclusion, the present findings showed that internal fixation of unstable extra-articular fracture in over 50-year-olds gave better clinical results at 6 weeks using an intramedullary nail, while MIPO required smaller incision.

LEVEL OF EVIDENCE

III, retrospective study.

Wrist Fractures and Osteoporosis

Distal radial fractures account for up to 18% of all fractures in patients over 65 years of age, and osteoporosis is a predominant factor in these fractures. Fracture treatment may include closed reduction and casting/splinting, external fixation, and open reduction and internal fixation.

Long-term results of elastic-stable intramedullary nailing (ESIN) of diaphyseal forearm fractures in children

Since its introduction by Metaizeau and Prevot, elastic-stable intramedullary nailing (ESIN) has been used for almost all diaphyseal fractures in children. Here, we present a retrospective study analyzing the long-term results of ESIN of forearm fractures in children.A total of 122 patients with diaphyseal forearm fractures and single subtypes in childhood were treated from 2000 to 2007 at our University Hospital by ESIN. At follow-up, the current conditions of the patients were evaluated using the Disabilities of Arm, Shoulder, and Hand (DASH) Score, and the Mayo Wrist score. Moreover, an individual questionnaire with 16 items was used to collect further information about the patient's condition and limitations as adults.The evaluation was performed at 12.4 years (average) after surgery. In our study population (n = 90), the average DASH scores for sports, performing arts, and work were 0.4 (standard deviation: 1.45), 0.9 (standard deviation: 5.68), and 0.3 (standard deviation: 7.39), respectively. Furthermore, 77% of our patients achieved a DASH Score of 0 (optimum outcome). The average Mayo Wrist Score was 97.64 (standard deviation: 7.39), and 82% of the study population achieved a score of 100 (optimum outcome). A correlation between the DASH and Mayo Wrist Scores was found in few patients. Overall, the DASH Score, Mayo Wrist Score, and results of our individual questionnaire demonstrated convincing point values.This study demonstrated favorable long-term results achieved by ESIN of forearm fractures in children. It seems that good outcomes, reported by various studies with short- to mid-term follow-up beforehand, do not deteriorate over time.Level of Evidence: Level III; retrospective study; therapeutic study.

Complications of Intramedullary Fixation for Distal Radius Fractures in Elderly Patients: A Retrospective Analysis Using McKay's Complication Checklist

BACKGROUND

Intramedullary fixation for distal radius fractures is reported to be free of hardware irritation and less invasive than other fixation methods. Some specific complications associated with intramedullary fixation, such as radial nerve sensory neuritis, have been reported, but no study has focused on the complication rates of intramedullary fixation for distal radius fractures in the elderly population. Furthermore, no studies have analyzed common complications, such as carpal tunnel syndrome and flexor tenosynovitis including trigger finger, among patients with distal radius fractures treated by intramedullary fixation based on a comprehensive complication checklist.

METHODS

We reviewed the medical records of 52 elderly patients with distal radius fractures treated with intramedullary nail fixation. We investigated the postoperative complications in these patients using McKay's complication checklist.

RESULTS

5 patients experienced radial nerve sensory disorder, and one patients developed carpal tunnel syndrome. All neurological symptoms resolved spontaneously, and these neurological complications were categorized as mild. Further, 3 patients developed trigger finger at the A1 pulley and needed triamcinolone injections for symptomatic relief. There were no tendinous complications around the implanted hardware. All tendinous complications were categorized as moderate complications and resolved with steroid injection therapy. Among skeletal complications, 1 case of postoperative volar displacement resolved with good functional outcome without the need for corrective osteotomy. This was considered a mild complication. The total complication rate was 19.2%. All complications were categorized as mild or moderate, and no patients experienced severe complications that needed further surgery such as hardware removal.

CONCLUSIONS

Intramedullary fixation for distal radius fractures was free from tendinous complications such as tenosynovitis and tendon ruptures around the implant, which are frequently caused by volar locking plate fixation. However, this less invasive technique could not avoid common complications such as trigger finger and carpal tunnel syndrome associated with distal radius fractures.

Volar Locking Plate versus External Fixation for Distal Radius Fractures: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Volar locking plate (VP) and external fixation (EF) are the two most commonly used methods for treating distal radius fractures. The aim of this study was to identify which of the two treatments leads to better outcomes (clinically and radiographically) with fewer complications.

MATERIALS AND METHODS

A metaanalysis was performed. All available randomized controlled trials (RCTs) which compared the clinical results of VP to EF were obtained and the reported means and standard deviations were extracted to perform data synthesis.

RESULTS

A total of 9 published RCTs with 776 patients fulfilled all inclusion criteria. Data analysis revealed that VP gives better clinical results in the early postoperative period in terms of disabilities of the arm, shoulder, and hand (DASH) scores (3 and 6 months), grip strength (3 months), flexion, extension, and supination (3 months). VP is also advantageous over EF regarding the DASH scores, maintenance of ulnar variance, and total and mild surgical complications at 12 months.

CONCLUSIONS

This meta analysis supports the use of VP in treating distal radius fractures.

Results of geriatric distal radius fractures treated by intramedullary fixation

INTRODUCTION

Distal radius fracture are common injuries but no gold standard for their therapy exists. The aim of this study was to evaluate the quality of fracture care in distal radius fractures using an intramedullary implant (Targon DR interlocking nail). The nail had been developed to minimize the surgical exposure, increase fixation strength, to prevent tendon irritations and to allow for a fast return to activity.

PATIENTS AND METHODS

Prospective study reports the result of 43 patients with an age over 70 years (range 70-91 years) treated by closed reduction and intramedullary fixation. Inclusion criteria were displaced unilateral isolated AO A or C type fractures. The Targon DR interlocking nail was used for all patients. The minimum follow up was 12 months.

RESULTS

All fractures united within 2 months. At one-year follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial abduction of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and a grip strength of 91.5 ± 4.3% compared to the contralateral wrist. Pain score measured by a Visual Analogue Scale scored 0.0 ± 0.0 at rest and in activity 0.3 ± 0.3. The mean Castaing Score was good (1.06 ± 0.30) and the Gartland & Werley Score was excellent (1.50 ± 0.57). The mean radial shortening was 0.2 ± 0.1 mm and radial inclination was 3.1 ± 1.1° (range +15° to 0°). No deep soft-tissue or chronic osseous infections were observed. One patient developed a carpal tunnel syndrome. Paraesthesia or dysaesthesia of the superficial radial nerve was registered in seven patients and fully recovered in four patients. There were two cases of single screw loosening. We also found two cases of screw overlength and consecutive contact with the ulnar head, one patient underwent implant removal. Another patient developed CRPS (2.3%). We did not observe any case of hardware failure, tendon irritation or tendon rupture.

CONCLUSION

In geriatric patients intramedullary interlocking nailing of displaced extraarticular or intraarticular distal radius fracture with the Targon DR nail represents a viable treatment option and alternative to the use of volar interlocking plating in terms of fracture reduction, maintenance of reduction and functional outcome.

Fixation of intra-articular fractures of the distal radius using intramedullary nailing: a randomized trial versus palmar locking plates

BACKGROUND

Proposed benefits of intramedullary techniques include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial was that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of intra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, prospective randomized matched-pairs trial. Patients with intraarticular distal radius fractures with metaphyseal comminution and a sagittal fracture line (AO 23 C2.1) were randomized to receive volar locking plate fixation (n = 14) or intramedullary nailing (n = 14). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain at eight weeks. At the final follow up, patients in the nail group had regained more extension than in the plate group (98% of the unaffected side vs. 94%, this however, did not reach significance). Reduction was maintained in both groups; however volar tilt and ulnar variance were significantly better in the plate group. There was no significant difference in the complication rate between groups.

CONCLUSION

The present study suggests that intramedullary nail fixation is a reasonable alternative to volar plate fixation for the treatment of intra-articular distal radius fractures and both techniques can yield reliably good results.

Intramedullary Nail Fixation for Displaced and Unstable Distal Radial Fractures in Patients Aged 65 Years or Older

BACKGROUND

Distal radius fractures in elderly patients are now commonly treated with a volar locking plate, but flexor pollicis longus dysfunction caused by stripping of the muscle and tendon irritation and rupture caused by prominence of the implant have been reported. Intramedullary implants can stabilize distal radius fractures while minimally affecting the flexor and extensor tendons and muscles around the site, but osteoporosis in elderly patients might affect the radiographic and functional results of distal radius fractures treated by intramedullary implants. We investigated the radiographic and functional results of intramedullary implants for distal radius fractures in patients ≥65 years of age.

METHODS

We reviewed medical records of 40 patients with extra-articular or simple intra-articular fractures with the sagittal fracture line treated by an intramedullary implant.

RESULTS

All fractures achieved bony union, with an average radial inclination of 24.9 degrees, volar tilt of 9.2 degrees, and ulnar variance of 0.7 mm. We encountered one case of postoperative volar displacement of the distal fragment due to the small size of the intramedullary implant. The average range of motion was 69.8 and 59.9 degrees for dorsal and palmar wrist flexion, respectively. Average percentile grip strength of the uninjured side was 97%. The average Mayo modified wrist score at final follow-up was 91.9 points, with 20 patients graded as excellent, 16 as good, and 4 as fair.

CONCLUSIONS

The findings of this study indicate that intramedullary implants for dorsally displaced extra-articular or simple intraarticular distal radius fractures may offer good radiological and functional outcomes without hardware irritation in elderly patients. Distal radius fractures with an osteoporotic, large medullary canal should be stabilized by implants of an appropriate size.

Stabilisation of distal radius fractures: Lessons learned and future directions

Our understanding of the diagnosis and management of distal radius fractures has been a long developed over centuries. There has been a shift in treatment of these very common injuries from closed reduction and casting to internal fixation. The answer to the best method of treatment has yet to be found. Today, we have a multitude of treatment options available with varying degrees of evidence to support their use. This review helps to illustrate the lessons we have learned and future directions for treatment.

Volar, Intramedullary, and Percutaneous Fixation of Distal Radius Fractures

Background The management of extra-articular distal radius fractures is highly variable, with no clear consensus regarding their optimal management. Purpose To assess comparatively the biomechanical stability of Kirschner wire (K-wire) fixation, volar plating, and intramedullary nailing for unstable, extra-articular distal radius fractures with both (1) constant and (2) cyclical axial compression, simulating forces experienced during early postoperative rehabilitation. Methods Twenty-six volar locking plate, intramedullary nail, and K-wire bone-implant constructs were biomechanically assessed using an unstable extra-articular distal radius bone model. Bone implant models were created for each type of construct. Three samples from each construct underwent compressive axial loading until fixation failure. The remaining samples from each construct underwent fatigue testing with a 50-N force for 2,000 cycles followed by repeat compressive axial loading until fixation failure. Results Axial loading revealed the volar plate was significantly stiffer than the intramedullary nail and K-wire constructs. Both the volar plate and intramedullary nail required greater than 300 N of force for fixation failure, while the K-wire construct failed at less than 150 N. Both the volar plate and intramedullary nail demonstrated less than 1 mm of displacement during cyclic loading, while the K-wire construct displaced greater than 3 mm. Postfatigue testing demonstrated the volar plate was stiffer than the intramedullary nail and K-wire constructs, and both the volar plate and intramedullary nail required greater than 300 N of force for fixation failure while the K-wire construct failed at less than 150 N. Conclusions Volar plating of unstable extra-articular distal radius fractures is biomechanically stiffer than K-wire and intramedullary fixation. Both the volar plate and intramedullary nail demonstrated the necessary stability and stiffness to maintain anatomic reduction during the postoperative rehabilitation period. Clinical Relevance Both the volar plate and intramedullary nail demonstrated the necessary biomechanical stability to maintain postoperative reduction in extra-articular distal radius fractures, warranting further clinical comparison.

Defining the role of intramedullary nailing for fractures of the distal radius

This article is a systematic review of the published literature about the biomechanics, functional outcome and complications of intramedullary nailing of fractures of the distal radius.

We searched the Medline and EMBASE databases and included all studies which reported the outcome of intramedullary (IM) nailing of fractures of the distal radius. Data about functional outcome, range of movement (ROM), strength and complications, were extracted. The studies included were appraised independently by both authors using a validated quality assessment scale for non-controlled studies and the CONSORT statement for randomised controlled trials (RCTs).

The search strategy revealed 785 studies, of which 16 were included for full paper review. These included three biomechanical studies, eight case series and five randomised controlled trials (RCTs).

The biomechanical studies concluded that IM nails were at least as strong as locking plates. The clinical studies reported that IM nailing gave a comparable ROM, functional outcome and grip strength to other fixation techniques.

However, the mean complication rate of intramedullary nailing was 17.6% (0% to 50%). This is higher than the rates reported in contemporary studies for volar plating. It raises concerns about the role of intramedullary nailing, particularly when comparative studies have failed to show that it has any major advantage over other techniques. Further adequately powered RCTs comparing the technique to both volar plating and percutaneous wire fixation are needed.

Cite this article: Bone Joint J 2015;97-B:1370–6.

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.

Randomized clinical trial on percutaneous minimally invasive osteosynthesis of fractures of the distal extremity of the radius

Objectives

the purpose of this study was to compare the postoperative radiological and clinical outcomes with minimally invasive percutaneous osteosynthesis using three implants: volar locking plate, intramedullary nail system and nonbridging external fixator for distal radius fractures.

Methods

forty-eight patients (A group, 16; B group 16; C group 16) underwent minimally invasive percutaneous osteosynthesis of reductible and unstable displaced (Type IIB by Rayhack Classification) distal radius fractures. In B group intramedullary nail system was used, in A group the patients were treated with volar locking plate and in C group the patients were treated by nonbridging external fixator from January 2011 to December 2012. The mean follow-up period was 12 months. Radiologic parameters, range of motion, grip strength, and disability of the arm, shoulder, and hand score were evaluated at each examination (3rd and 6th week, and 12th months). The visual analog scale of wrist pain and complications were assessed at the final follow-up.

Results

the groups did not differ significantly in radiological outcomes after 12 months, but the clinical results, VAS scale and dash score in group A (volar locking plate) and B (nail intramedullary) were statistically significantly better than that of C group (nonbridging external fixator). One patient underwent an osteosynthesis with nail intramedullary and another with external fixator (C group) developed persistent pain near the site of the superficial radial nerve because of the distal's screw and pins, respectively.

Conclusion

in clinical parameters, significant differences in outcomes were found between groups A and B after six weeks versus C group.

Intramedullary nail versus volar plate fixation of extra-articular distal radius fractures. Two year results of a prospective randomized trial

BACKGROUND

Intramedullary techniques for stabilization of displaced distal radius fractures are now available. Purported benefits include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial is that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of unstable dorsally displaced extra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, parallel-group trial, with unrestricted randomization. Patients with dorsally displaced extra-articular distal radius fractures were randomized to receive volar locking plate (n=72) fixation or intramedullary nailing (n=80). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks, 6 months, 1 year and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain during the entire follow-up period (p>0.05). There was no significant difference between treatment groups with respect to volar tilt or ulnar variance (p>0.05). There was no significant difference in the complication rate between groups (p>0.05).

CONCLUSIONS

The present study supports the view that intramedullary nail fixation and volar plate fixation for the treatment of displaced extra-articular distal radius fractures have equivalent radiographic and functional outcomes.

LEVEL OF EVIDENCE

Level I therapeutic study.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

Distal radius fractures: current concepts

Despite the frequency of distal radius fractures, the optimal treatment remains without consensus opinion. A trend toward increased distal radius fracture open reduction and internal fixation has been identified, with biomechanical and clinical studies suggesting treatment advantages of certain fixation methods over others. Well-controlled patient trials are still missing to lend objective findings to management algorithms. This article reviews the literature over the past 5 years to guide our management regarding this common upper-extremity injury.

Treatment of Distal Radial Fractures with an Intramedullary Nail

Introduction

This paper will describe the surgical technique for the treatment of unstable distal radial fractures with use of the MICRONAIL Intramedullary Distal Radius System (Wright Medical Technology, Arlington, Tennessee).

Step 1 Closed Reduction and Pinning

The fracture must be adequately reduced and pinned prior to nail insertion.

Step 2 Perform Exposure and Enter Canal

Protect the branches of the superficial radial sensory nerve at all times.

Step 3 Insert Nail and Distal Locking Screws

Insert the nail to a depth to place the most distal screw just proximal to the radiocarpal joint line; confirm fluoroscopically that the screw does not penetrate the articular surface.

Step 4 Insert Proximal Interlocking Screws and Close

Confirm that the proximal interlocking screws are bicortical for adequate fixation but are not too long.

Step 5 Postoperative Management

Use of a splint is followed by active and then passive range-of-motion exercises.

Results

We reported a prospective analysis of patients treated for an unstable distal radial fracture with an intramedullary nail.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.